Year in Review: Measles Linked to Disneyland

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Throughout the month of December, Public Health Matters is conducting a series of year-in-review posts of some of the most impactful disease outbreaks of 2015. These posts will help explain how CDC is working to prevent, identify, and respond to these outbreaks. Measles infiographic

Measles in Disneyland

After an uncharacteristically high number of measles cases in late 2014, the highly publicized California measles outbreak hit the media early this year.  Linked to Disneyland Resort Theme Parks in California the outbreak quickly became a multi-state public health incident that resulted in a total of 147 cases. Cases related to this outbreak were identified in seven states in the U.S., as well as Mexico and Canada.

Attention to this outbreak was further fueled by the interest surrounding vaccinations. Among the reported measles cases, the majority of patients were unvaccinated or had an unknown or undocumented vaccination status.

Why a Measles Outbreak in the U.S. is a Big Deal

In 2000, the United States declared that measles was eliminated from this country. The elimination of measles in the U.S. was due to a highly effective measles vaccine, a strong vaccination program that achieves high vaccine coverage in children, and a strong public health system for detecting and responding to measles cases and outbreaks.

Before a measles vaccine became available in 1963, 3 to 4 million people in the United States were infected with measles each year, resulting in an estimated 48,000 hospitalizations and 400 to 500 deaths.  Most people in the U.S. today are protected against measles through vaccination, so measles cases are uncommon compared to the number of cases before a vaccine was available. However, the risk of measles re-establishing itself as a prominent disease in the U.S. is possible—especially if vaccine coverage levels drop.

Today, measles is still endemic in many parts of the world, and measles outbreaks in the U.S. occur when measles is brought into the United States by unvaccinated travelers (Americans or foreign visitors) who get measles while they are in other countries. These travelers can spread measles to other people who are not protected against the disease, which sometimes leads to outbreaks. While the source of the Disneyland-associated measles outbreak was not identified, it is likely that a traveler (or more than one traveler) who was infected with measles overseas visited one or both of the Disney parks in December during their infectious period and infected other visitors to the park.

Measles: a Serious Sickness

Measles is extremely contagious. It is so contagious that if one person has it, 90% of the people close to the person who are not immune will be infected. You can catch measles just by being in the same room as a person with measles. Even if the infected person has left the room, the virus can live for up to two hours in an airspace where the infected person coughed or sneezed. The measles virus lives in the nose and throat mucus of an infected person, and can spread to others through coughing and sneezing.

Common symptoms of measles include, high fever, cough, runny nose, red, watery eyes, and a rash 3-5 days after symptoms begin. In some cases complications from measles can result in pneumonia, encephalitis (swelling of the brain), and death.

People at high risk for severe illness and complications from measles include, infants and children under 5 years of age, adults over the age of 20, pregnant women, and people with compromised immune systems.

What can be done to protect the public from measles outbreaks?

State and local health departments lead investigations of measles cases and outbreaks when they occur. CDC helps and supports health departments in these investigations and continually gathers data reported by states on confirmed measles cases to provide evaluation and monitoring from a national perspective.

High sustained measles vaccine coverage and rapid public health response are critical for preventing and controlling measles cases and outbreaks. It is possible to get rid of measles in the U.S. completely, but the first step is to eliminate measles from each country and region of the world. Once this happens, there will be no place from which measles can spread.

Until measles is eliminated worldwide, it remains a risk to any unvaccinated person exposed to the virus. Do your part to protect yourself, your family, and those around you from measles and make sure you and everyone in your family who is eligible gets vaccinated. The best protection against measles is measles-mumps-rubella (MMR) vaccine. MMR vaccine provides long-lasting protection against all strains of measles.

To learn more about measles, the MMR vaccine, and CDC’s efforts to reduce the number of measles case worldwide visit CDC’s Measles webpage.

 

Keeping Cool Under Pressure: NYC Legionnaires’ Disease Outbreak, Summer 2015

An outdoor HVAC air conditioner unit located on a high-floor porch of a midtown Manhattan skyscraper. In the summertime when the weather is hot, having air conditioning to help keep you cool can be a sweet relief. Have you ever felt a fine mist when walking past large buildings in the heat of the summer? That mist may have been water droplets from rooftop cooling towers that keep large air conditioning systems―like those found in hotels―running efficiently, even when temperatures are soaring outside. When these cooling towers are not properly maintained, they can become a home for Legionella bacteria, which thrive in untreated warm water. If people with certain health risks breathe in water droplets contaminated with these bacteria, they may develop Legionnaires’ disease. If people are getting sick with Legionnaires’ disease, how can health officials find out the source of the bacteria? A team of city, state, and CDC epidemiologists (disease detectives), laboratory scientists, and environmental health experts was able to do just that with an outbreak this summer in New York City.

Recognizing the Outbreak

Legionella bacteria are found naturally in fresh water and can live in most any warm water that isn’t properly treated with chemicals. Most people exposed to Legionella bacteria don’t get sick, but those who are older or already have health problems are at risk for developing Legionnaires’ disease. It’s not surprising for large cities to report several cases of the disease every year. However, epidemiologists are always on the lookout for an increase in cases that might suggest an outbreak of the disease. This past July, after noticing a spike in reports from clinics and hospitals in the Bronx, New York City investigators sprang into action.

Identifying the Source

CDC scientist testing sample from cooling tower next to image of sampling text.
CDC’s Danielle Mills samples a cooling tower in the Bronx. Inset: Checking pH of a cooling tower.

After mapping the places of work and residence of all the patients identified, the investigators noticed a pattern that indicated the source was likely a cooling tower. Then, using state-of-the-art computer modeling programs, the geographic area most likely to contain the contaminated cooling tower was identified. A team of environmental health experts from New York and CDC then collected samples from every cooling tower in that area and sent those samples to public health laboratories. Legionella are very challenging bacteria to work with, but after weeks of testing, city, state, and CDC laboratories were able to solve the mystery. The DNA “fingerprint” from the bacteria found in each of the patients was identical to that of the bacteria found in one of the cooling towers, confirming that it was the specific Legionella bacteria from that cooling tower that infected each of those patients.

Containing the Outbreak

Three scientist working in laboratory
Laboratory scientists from NYC’s Public Health Laboratory (Cathleen Carey and Taryn Burke) and CDC (Jeffrey Mercante) identify Legionella isolates.

Even before the source was confirmed, the suspected cooling tower and those in the surrounding area were cleaned and treated. Then officials worked with the building owners to ensure industry standards for treatment of their cooling tower were met. After weeks of a collaborative epidemiologic, environmental health, and laboratory investigation by the city, state, and CDC, the outbreak was declared over by New York City officials.

Keeping an Eye on Cooling Towers

With 128 people infected and 12 deaths attributable to the outbreak as of August 20, 2015, this was the largest outbreak of Legionnaires’ disease ever recorded in New York City. In response, the city passed new legislation that requires registration of all cooling towers and defines maintenance standards. The collaborative efforts of public health professionals from city, state, and federal agencies made it possible for this outbreak to be identified, solved, and contained as quickly as possible. Investigators like these, stationed all over the United States, at CDC, and across the globe are working every day to detect, respond to, and prevent public health threats. Now, THAT is cool.

Unveiling the Burden of Dengue in Africa

Mosquito sucking blood on human skin with nature background

By Tyler M. Sharp  Ph.D. (LCDR,USPHS)

Most travelers to Africa know to protect themselves from malaria. But malaria is far from the only mosquito-borne disease in Africa. Recent studies have revealed that dengue, a disease that is well recognized in Asia and the Americas, may be commonly misdiagnosed as malaria in Africa. So if you’re traveling to Africa, in addition to taking anti-malarial medications you should also take steps to avoid dengue.

Map of areas around the world affected by Dengue.Dengue is a mosquito-transmitted illness that is recognized as a common illness throughout Southeast Asia and much of the Americas. In fact, a study published in 2013 estimated that 390 million dengue virus infections occurred throughout the tropics in 2010. Although 70% of infections were predicted to have occurred in Southeast or Southcentral Asia, the next most affected region (16% of infections) was Africa, followed by the Americas (14% of infections). The large estimated burden of dengue in Africa came as a surprise to some, since dengue is not often recognized to be a risk in Africa.

Dengue is Hard to Diagnose in Africa

 

There are several reasons why dengue has limited recognition in Africa. First, the lack of laboratory-based diagnostic testing leads to many patients not being diagnosed with dengue. This can be perilous because without early diagnosis and appropriate clinical management, dengue patients are at increased risk for poor outcome. However, in order for a clinician to request dengue testing, they must first be aware of the risk for dengue. This awareness usually comes in the form of a positive diagnostic test result. Hence, without testing there is limited clinical awareness, and without clinical awareness there is limited testing.

Finding Dengue in Africa

Map of Africa
Brown indicates countries in which dengue has been reported in residents or returned travelers and where Aedes aegypti mosquitoes are present. Light brown indicates countries where only Ae. aegypti mosquitoes have been detected.

How do we know that there actually is dengue in Africa? First, since 1960 at least 15 countries in Africa had reported locally-acquired dengue cases. In addition, travelers returning home with dengue had been detected after visiting more than 30 African countries. Still more African countries are known to have the Aedes mosquitos that transmit the 4 dengue viruses. These findings together provide strong evidence that dengue is a risk in much of Africa.

Thus, it was not a surprise in the summer of 2013 when dengue outbreaks were detected in several sub-Saharan African countries. In many cases, detection of dengue was facilitated by the availability of rapid dengue diagnostic tests that enabled on-site testing.

Dengue Field Investigations in Angola and Kenya

In a past blog I described the initial findings of a dengue outbreak in Luanda, Angola, in west-central Africa outbreak: dengue cases were initially identified with a rapid diagnostic test and confirmatory diagnostic testing and molecular epidemiologic analysis performed as CDC demonstrated that the virus had actually been circulating in the region for at least 45 years. This provided strong evidence that dengue was endemic in the area. During the outbreak investigation, CDC and the Angola Ministry of Health conducted house-to-house surveys wherein blood specimens and questionnaires were collected. Of more than 400 participants, 10% had been recently infected.

Teams from the Angola Ministry of Health conduct a dengue serosurvey in Mombasa, Luanda. Image courtesy of the Angola Field Epidemiology Training Program.
Teams from the Angola Ministry of Health conduct a dengue serosurvey in Mombasa, Luanda. Image courtesy of the Angola Field Epidemiology Training Program.

Though nearly one-third reported recently dengue-like illness, and half had sought medical care, none of the patients with laboratory evidence of infection with dengue virus had been diagnosed with dengue, including one person who had symptoms consistent with severe dengue. Although this investigation yielded more questions than answers, it was clear that there was much more dengue in Luanda than was being recognized clinically. By improving clinical awareness through training of clinicians and strengthening disease surveillance, the ability for diagnosis of individuals ill with dengue or other emerging infectious diseases was improved.

On the opposite coast of Africa in Mombasa, Kenya, although dengue outbreaks had been reported for decades, the first outbreak to be confirmed with laboratory diagnostics occurred in the early 1980s. When an outbreak of non-malarial illness was reported in 2013, blood specimens were sent to a laboratory at Kenya Medical Research Institute (or KEMRI) to determine the cause of the outbreak. Three out of the four dengue viruses were detected during this outbreak, which alone suggested that dengue was endemic in the area. To get a better idea for how much dengue there was in Mombasa, CDC and the Kenya Ministry of Health conducted a representative survey in a populous neighborhood of Kenya. Over 9 days, 1,500 people were enrolled in the serosurvey and testing revealed that 13% of participants were currently or recently infected with a dengue virus. Nearly half of infected individuals reported a recent dengue-like illness, most of which had sought medical care.

Field workers from CDC and the Kenya Ministry of Health conduct a dengue serosurvey in Mombasa, Kenya. Image courtesy of Dr. Esther Ellis.
Field workers from CDC and the Kenya Ministry of Health conduct a dengue serosurvey in Mombasa, Kenya. Image courtesy of Dr. Esther Ellis.

However, nearly all patients had been diagnosed with malaria. Because Mombasa is a port city that is also popular tourist destination, not only was the apparent magnitude of the outbreak a concern for patient diagnosis and care in Mombasa, it also meant that visitors to Mombasa may not be aware of the risk of dengue and therefore could be getting sick and/or bringing the virus home with them.

What next?

There is not yet a vaccine to prevent infection or medication to treat dengue. Unlike the night-time biting mosquitoes that transmit malaria, the Aedes mosquitoes that spread dengue are day-time biters. Consequently, both residents of and travelers to Africa should protect themselves from mosquito bites to avoid dengue by using mosquito repellent. Other strategies, like staying in places with air conditioning and screens on windows and doors and wearing long sleeve shirts and pants, can also help whether you’re traveling to Africa or other regions of the tropics. For clinicians, if travelers recently returned from Africa with acute febrile illness, consider dengue as a potential cause of the patient’s illness.

We still have much to learn about dengue in Africa, but learning where there is risk of dengue is the first step to avoiding it.

 

CDC Offers Hope in Fighting Brain-Eating Ameba

By Sioux Henley Campbell

Photomicrograph depicting some of the histopathologic changes associated with an infection found in a brain tissue specimen due to the presence of free-living amoebae of the genus, Naegleria.
Photomicrograph depicting some of the histopathologic changes associated with an infection found in a brain tissue specimen due to the presence of free-living amoebae of the genus, Naegleria.

 

The investigational drug miltefosine (trade name, Impavido) has been successfully used to treat Naegleria fowleri. 
 
Surviving a Brain-Eating Ameba
 
After swimming in a local waterpark, 12-year old Kali Hardig developed a high fever, headache, and nausea. When she worsened, her parents rushed Kali to Arkansas Children’s Hospital. Within 30 hours of becoming ill, doctors had diagnosed Kali with primary amoebic meningoencephalitis (PAM) caused by the free-living ameba Naegleria fowleri. Because it destroys brain cells, Naegleria fowleri has also been called a brain-eating ameba. Infections are nearly always fatal.
 
Doctors treated Kali with antibiotics and antifungals and aggressively managed her brain’s swelling–including cooling her body below normal body temperature. They consulted with CDC about the investigational drug miltefosine, found to help kill brain-eating amebas in the laboratory. CDC was able to rapidly supply miltefosine because of an agreement with FDA to keep the drug on site at CDC and ship by physician request.
 
After 22 days in intensive care that included a drug-induced coma, lowered body temperature, and multiple drugs–including miltefosine–Kali left the hospital. She’s since made a full recovery and returned to school. Kali is one of three Naegleria fowleri survivors in the U.S. in the past 35 years and the first since 1978.
 
Note : Kali’s mother, Traci Hardig, courageously battled stage four breast cancer for nine years, including during and after Kali’s own battle with the brain-eating ameba. Traci died on December 27, 2014. 

Fighting Brain-Eating Ameba [i]

It sits in a blister pack, secured in a nondescript office at the Centers for Disease Control (CDC), just a few phone calls away from being flown to a patient’s bedside for emergency treatment. Miltefosine is one of several drugs used to treat rare[ii] diseases that the CDC Drug Service makes available to doctors licensed in the United States.

These special drugs are kept onsite and are acquired from the drug manufacturer, as needed. They have either limited commercial availability or are considered investigational and require special Food and Drug Administration (FDA) authorization for patient use.

A Four-Year Journey

Miltefosine is a drug used to treat leishmaniasis, a rare tropical parasitic disease[iii]. It’s also shown promise in treating free-living ameba (FLA)–a single-cell living organism commonly found in warm freshwater or soil. FLA infections are considered to be “low incidence but high impact”—meaning, they are rare but deadly. Because of this, miltefosine has its own pager number that physicians can access 24/7.

Since 2009, CDC has helped treating physicians get miltefosine from FDA on a patient-by-patient basis. Until recently, the only source of miltefosine was from Germany.  The drug often took over a week to get to a hospital, frequently being held up in customs despite having proper approvals and paperwork.

In late 2011, difficulties in obtaining miltefosine in a timely manner prompted CDC to find ways to keep a supply of the drug at the agency for FLA infections. A CDC scientist drafted the required FDA-documentation that allows the use of investigational drugs for patients with serious or immediately life-threatening diseases who lack other treatment options.

Over the next two years, CDC gathered evidence to justify treatment of FLA infections with miltefosine.  On May 24, 2013, CDC received the “safe to proceed letter” from FDA. After an urgent plea to rush the order to be available for “ameba season” (mid-to-late summer when amebas living in warm, stagnant water grow rapidly), miltefosine arrived at the agency.

The drug arrived just in time. Less than a week later, an Arkansas physician contacted CDC about a young patient named Kali that urgently needed miltefosine. Despite multiple hurdles, Kali received miltefosine approximately 36 hours after CDC was notified. (See Surviving a Brain-Eating Ameba to the right.) Today, Kali has fully recovered and is back at school.

On August 23, 2013, CDC announced an agreement with FDA to make miltefosine available directly from CDC to doctors treating FLA infections in the United States. It is available for treatment of free-living ameba (FLA) infections caused by Naegleria fowleri, Balamuthia mandrillaris, and Acanthamoeba species. Clinicians can contact the CDC Emergency Operations Center at 770-488-7100 to consult with a CDC expert about obtaining this drug.

In 2014, CDC sent 14 shipments of miltefosine to doctors treating possible FLA infections. Miltefosine was approved by the FDA in 2014 to treat leishmaniasis.  It remains under an investigational treatment program with FDA for FLA infections.

About the CDC Drug Service

CDC manages and distributes biologic agents and drugs that meet important medical needs and provide public health surveillance. Due to limited demand in this country, commercial use and/or licensure is neither practical nor profitable for many pharmaceutical companies.

The CDC Drug Service:

  • Maintains a formulary of investigational new drugs to distribute to requesting physicians licensed in the United States
    • Drugs are subject to change based on current public health needs, updates to treatment guidelines, and/or drug availability
  • Collaborates with partners internal and external to CDC for drug releases, surveillance, and patient treatment.

References:


[i] About the Term “Ameba.” In U.S. English, the single-celled living organism described here is an ameba. The word amoeba, with an “o”, is used as part of a scientific genus name (such as Amoeba or Acanthamoeba). In British English, both the generic organism term and genera names are spelled amoeba with an “o”.

[ii] There is no universal definition of a “rare disease” but the U.S. Rare Disease Act of 2002 defined a rare disease as affecting less than 200,000 people in the U.S. and this definition has been adopted by the National Institutes of Health, Office of Rare Diseases.

[iii] The FDA approved miltefosine in 2014 to treat the rare tropical disease leishmaniasis and no longer considers it as investigational when used for this specific purpose.

The Anatomy of an HIV Outbreak Response in a Rural Community

Drug abuse with people sharing the same syringe to inject heroine

In a small, rural town in Southern Indiana, a public health crisis emerges.  In a community that normally sees fewer than five new HIV diagnoses a year, more than a hundred new cases are diagnosed and almost all are coinfected with hepatitis C virus (HCV).

How was this outbreak discovered, and what caused this widespread transmission? Indiana state and local public health officials – supported by CDC – set out to answers these questions and help stop the spread of HIV and HCV in this community.

The Outbreak

In January 2015, Indiana disease intervention specialists noticed that 11 new HIV diagnoses were all linked to the same rural community.  This spike in HIV diagnoses in an area never before considered high-risk for the spread of HIV, launched a larger investigation into the cause and impact of these related cases.

The investigation began by investigating the 11 newly diagnosed cases. This process involved talking to newly diagnosed individuals about their health and sexual behaviors, as well as past drug use. In the United States, HIV is spread mainly by having sex or sharing injection drug equipment such as needles with someone who has HIV.

Scanning electron micrograph of HIV-1 virions budding from a cultured lymphocyte.
Scanning electron micrograph of HIV-1 virions budding from a cultured lymphocyte.

In the case of the 11 related diagnoses in Indiana, almost all were linked to injection drug use. Investigators discovered that syringe-sharing was a common practice in this community–often used to inject the prescription Opana; opioid oxymorphone (a powerful oral semi-synthetic opioid medicine used for pain.)  HIV can be spread through injection drug use when injection drug equipment, such as syringes, cookers (bottle caps, spoons, or other containers), or cottons (pieces of cotton or cigarette filters used to filter out particles that could block the needle) are contaminated with HIV-infected blood. The most common cause of HIV transmission from injection drug use is syringe-sharing. Persons who inject drugs (PWID) are also at risk for HCV infection. Co-infection with HCV is common among HIV-infected PWID. Between 50-90% of all persons who inject drugs are infected with both HIV and HCV.

The Investigation

“Contact tracing” is the process of identifying all individuals who may have potentially been exposed to an ill person, in this case a person infected with HIV.  Contact tracing involves interviewing the newly diagnosed patients to identify their syringe-sharing and sex partners.  These “contacts” are then tested for HIV and HCV infection, and if found infected are likewise interviewed to identify their syringe-sharing and sex partners. This cycle continues until no more new contacts are located.

As of May 18, contract tracing and increased HIV testing efforts throughout the community identified 155 adult and adolescent HIV infections. The investigation has revealed  that injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together and that due to the short half-life of the drug, persons who inject drugs may have injected multiple times per day (up to 10 in one case). may be needed .

Early HIV treatment not only helps people live longer but it also dramatically reduces the chance of transmitting the virus to others.  People who do not have HIV and who are at high risk for HIV can also benefit more directly from the drugs used to treat HIV to prevent them from acquiring HIV.  This is known as pre-exposure prophylaxis (PrEP). Post-exposure prophylaxis, or PEP, is an option for those who do not have HIV but could have been potentially exposed in a single event.

The Response

HIVTesting_Eng_webSo what is the next step in addressing this staggering outbreak? First, public health officials must work to get every person exposed to HIV tested. All persons diagnosed with HIV need to be linked to healthcare and treated with antiretroviral medication. Persons not infected with HIV are counseled on effective prevention and risk reduction methods; including condom use, PrEP, PEP, harm reduction, and substance abuse treatment. Getting messages about the benefits of HIV treatment to newly diagnosed individuals and prevention information to at-risk members of the community are key components to control this outbreak.

The underlying factors of the Indiana outbreak are not completely unique. Across the United States, many communities are dealing with increases in injection drug use and HCV infections; these communities are vulnerable to experiencing similar HIV outbreaks. CDC asked state health departments to monitor data from a variety of sources to identify jurisdictions that, like this county in Indiana, may be at risk of an IDU-related HIV outbreak.  These data include drug arrest records, overdose deaths, opioid sales and prescriptions, availability of insurance, emergency medical services, and social and demographic data. Although CDC has not seen evidence of another similar HIV outbreak, the agency issued a health alert to state, local, and territorial health departments urging them to examine their HIV and HCV surveillance data and to ensure prevention and care services are available for people living with HIV and/or HCV.

The work that has been done thus far, as well as the continued efforts being made to address this response, highlight importance of partnerships between federal, state and local health agencies. The work done by Indiana State Department of Health’s disease intervention specialist to link the initial HIV cases to this rural community, and the work of the local health officials to respond quickly and thoroughly to investigate all possible exposures and spread important health prevention information demonstrates the critical importance of strong public health surveillance and response.

The Division of HIV/AIDS Prevention commends the efforts of all the individuals involved in controlling the HIV outbreak in Indiana. The response illustrates that together we are committed to improving the health of our communities across the nation.

 

 

 

Clarity on Cholesterol Management and Why We Need It

stethoscope on a piece of paper on top of a computer next to reading glasses

By Jennifer Robinson, MD, MPH

In the winter of 2013, the American College of Cardiology and the American Heart Association released new guidelines for treating blood cholesterol. These new guidelines, which I helped draft, moved away from focusing on a patient’s blood cholesterol level and, instead, put a focus on a patient’s risk for atherosclerotic cardiovascular disease (ASCVD) to decide who would benefit from drug treatment.

Heart attacks and strokes are common outcomes of ASCVD caused by cholesterol build-up in the arteries.  Its risk factors include a person’s age, sex, race, smoking and diabetes status, blood pressure, and blood cholesterol levels. We felt this focus on atherosclerotic risk was the best way to determine who would benefit from cholesterol lowering therapy, be it lifestyle changes and/or statin use, because it focused on the whole person – as opposed to one piece of the puzzle. In other words, whether your cholesterol is too high for you depends on your other risk factors. This 360o view is intended to help people prepare for a heart healthy life, which includes controlling blood cholesterol (a quick look at Life’s Simple Seven provides the other six guidelines that aid a healthy and happy heart).

Recently, dietary guidelines moved away from limiting cholesterol intake in the diet, and this has resulted in confusion. The Dietary Guidelines Advisory Committee recommended removing dietary cholesterol as a “nutrient of concern” because, it turns out saturated fat, rather than dietary cholesterol, is the main contributor to blood cholesterol levels. It is extremely clear that low lipid density protein, or “bad,” cholesterol (LDL-C), in the blood is a significant risk factor for heart disease and stroke, the leading causes of death among Americans. This message was lost in the dietary cholesterol discussion as seen by news headlines and fellow clinicians’ anecdotes.

I am working with the National Forum for Heart Disease and Stroke Prevention to raise awareness about cholesterol and its effect on ASCVD risk. With the help of an expert panel and funding from Sanofi US and Regeneron Pharmaceuticals, Inc., we are creating an initiative aimed at preventing cardiovascular events, such as heart attacks and stroke episodes, through increased awareness about cholesterol management. While this multi-sector initiative is in its early stages (we had our first meeting in March!), it is well-timed. Most adults in the US can benefit from lifestyle or drug therapy to lower their cholesterol level to reduce their risk of heart attack and stroke.  Among people with genetically high cholesterol, who have very high LDL-cholesterol levels of 190 mg/dl or higher, more than 80% are underdiagnosed and, therefore, untreated. And, sadly, these numbers are estimated to be growing.

As a public health MD focused on cardiovascular prevention, I want people to be armed with the information needed to live a long healthy life. I also want people to live a good and happy life. The best way to do that is to start taking care of oneself now. Keeping yourself healthy is the best way to prepare for long, happy, healthy life. I urge people to learn more about how cholesterol affects the heart and to talk to their doctors to find out how they can manage their ASCVD risk.

2014 robinson_jennifer
Jennifer Robinson, MD, MPH

Jennifer G. Robinson, MD, MPH is a Professor in the Departments of Epidemiology and Medicine (Division of Cardiology), and Director of the Prevention Intervention Center at the University of Iowa, Iowa City, Iowa. She was Vice-Chair for the 2013 American Heart Association/American College of Cardiology Cholesterol Guidelines (formerly known as the National Cholesterol Education Program Adult Treatment Panel IV) and a member of the 2013 American Heart Association/American College of Cardiology Risk Reduction Guidelines (formerly known as the National Heart, Lung, and Blood Institute Risk Reduction Working Group). She is currently the Chair for the National Forum Cholesterol Initiative. She is also a diplomate of the American Boards of Internal Medicine and Clinical Lipidology, and a Fellow of the American Heart Association.

Dr. Robinson is an active researcher, performing numerous clinical trials sponsored by the National Institutes of Health and the pharmaceutical industry. She has published over 150 peer-reviewed articles in the area of lipids-modifying drugs, cardiovascular risk stratification, and cardiovascular prevention and has lectured widely on preventive cardiology and the diagnosis and treatment of disorders of lipid metabolism.  While at the University of Minnesota in Minneapolis, Dr. Robinson received her medical degree and completed an Internal Medicine residency with the College of Medicine, and received a Master’s of Public Health from the College of Public Health. 

 

An Unsuspected Treat Contaminated with Listeria. How about them Caramel Apples?

Caramel apples

By  Mandip Kaur and Brendan Jackson

Oh, how sweet it is to enjoy a caramel apple when autumn sweeps in! Maybe you like yours topped with nuts? Sprinkles? How about chocolate?

But who knew that this past fall, certain caramel apples would be contaminated with the dangerous Listeria monocytogenes bacteria (here, Listeria for short), and cause illnesses across the nation? This was quite a curveball for public health investigators: listeriosis (the disease caused by Listeria) outbreaks are often traced to soft cheeses and sometimes to produce, but no one had ever reported an outbreak linked to whole apples.

Cracking the case

Text 1We scratched our heads over this one, but with the help of the Listeria Whole Genome Sequencing (WGS) Project and patient food history information, public health officials at the state and local levels, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA) were able to identify the source of this outbreak and prevent more people from getting sick.

Public health investigators must work with accuracy and speed to stop an outbreak in its tracks and prevent illnesses–especially true in this Listeria outbreak. Thirty-five people who lived in 12 states became sick and sadly, Listeria contributed to at least three of the seven reported deaths. It was the largest US Listeria outbreak since the one linked to cantaloupe in 2011.

We used a three-pronged approach to solve the outbreak:

  • Laboratory: CDC, FDA, and state labs tested samples from patients, foods, and the environment for related strains of Listeria.
  • Epidemiology: Local, state, and CDC investigators interviewed patients about foods they ate before getting sick.
  • Traceback: FDA, state, and local officials investigated sources of the suspect food and its ingredients.

It all started in mid-November 2014, when lab scientists at CDC raised a flag after noticing that certain Listeria infections across the United States—out of the hundreds that had occurred that year—were genetically related, suggesting an outbreak.

The laboratory sideDNA

We used whole genome sequencing, or WGS, to help determine the scope of this outbreak. WGS provides high-resolution genetic information about the strains of Listeria causing illness. Since the 1990s, we’ve tested patient samples from across the country using pulsed-field gel electrophoresis, or PFGE, and then compared them in PulseNet (a national network of public health labs) to see which ones appear related.

In the past year, we’ve started using WGS, too, because it gives a much more detailed look at Listeria strains than PFGE. Thanks to WGS, we were able to detect related cases across the country a week faster than if we relied on PFGE alone. WGS also gave us a clearer picture of which illnesses ought to be included in the outbreak, and which were likely due to other sources.

The epidemiology front

How could we figure out what food was making people sick? We asked patients what they ate, of course. First, we used a standard questionnaire that asks about dozens of foods that could be linked to listeriosis, but when epidemiologists examined their responses, no food jumped out as the likely culprit.

Text 2Over the following weeks, epidemiologists re-interviewed patients and their families—sometimes multiple times—about all the foods they had eaten in the month before getting sick. Just try to remember everything you ate a month or two ago—no easy task! As you can imagine, some patients had several foods in common, and we chased a number of false leads.

Then we got a call from our colleagues in Texas about two patients who had eaten caramel apples. They thought they might be on to something, but could caramel apples really be a source of listeriosis? The quickest way to find out was to ask patients in other states. We were amazed as one patient after another answered “yes” to eating caramel apples.

By December 19, 2014, we learned that 15 of the 18 ill people interviewed had eaten commercially produced, prepackaged caramel apples. When we compared this information with data on how often people in general eat caramel apples, we could tell it was no coincidence—caramel apples were almost certainly to blame.

With evidence from the WGS findings and the food history information, we informed the public about the outbreak that day. We recommended that consumers not eat commercially produced, prepackaged caramel apples until we had more specific information about brands or stores–patients were reporting multiple brands, although most couldn’t remember a brand at all. 

The trace back tale

FDA and state officials traced back the caramel apple brands to multiple manufacturers. They even traced back all the ingredients in the caramel apples including the apples, caramel, toppings, and sticks—a difficult and time-intensive task.

As it turned out, all of the manufacturers in the investigation used apples from Bidart Bros., a California apple supplier. That was the only common denominator. After learning about the investigation, Bidart Bros. issued an initial recall of certain apples on December 22, 2014. Over the next week, three caramel apple manufacturers that received apples from Bidart Bros. issued recalls of their own.apples_crop

FDA and California health officials inspected the Bidart Bros. apple packing facility, which was closed for the season, and swabbed surfaces. On January 8, 2015, tests from the Bidart Bros. facility found strains of Listeria that were indistinguishable from the ones making patients sick. We had the third piece of the puzzle.

Soon after, the company issued a public recall of all apples produced in 2014, and CDC and FDA were able to narrow our guidance to consumers and inform them that they should avoid only caramel apples made from Bidart Bros. apples.

This outbreak investigation highlights how WGS, with its precision and speed, combined with detailed patient interviews about exposures can help identify the scope and source of an outbreak. CDC used these vital tools to keep the public informed and to advise people to not eat a contaminated caramel apple a day, to keep that Listeria away!

 

Mapping for Ebola: A Collaborative Effort

Map of AfricaOne of the difficulties faced by teams responding to the current Ebola outbreak in West Africa is identifying individuals and communities residing in remote areas. Existing maps of these regions either do not exist or are inadequate or outdated. This means that basic data like location of houses, buildings, villages, and roads are not easily accessible, and case finding and contact tracing can be extremely difficult.

To help aid the outbreak response effort, volunteers from around the world are using an open-source online mapping platform called OpenStreetMap (OSM) to create detailed maps and map data of  Guinea, Sierra Leone, Liberia, and parts of Mali.

Person mapping at a computerCommonly referred to as “Wikipedia for maps,” OSM is working toward the goal of making a map of the world that is freely available to anyone who wants to use it. The Humanitarian OpenStreetMap Team (HOT) is a U.S.-based non-profit organization that represents a subset of the OSM community. HOT’s mission is to use OSM data and tools to help prepare and respond to humanitarian disasters. Because OSM data is available for free download anywhere in the world, volunteer mappers generate data that are useful not only to CDC but also to other agencies involved in the Ebola response, such as Doctors Without Borders (MSF), International Red Cross (IRC), and World Health Organization.

Mappers frequently use satellite images to identify villages, houses, paths, and other details that were previously unmapped. The U.S. State Department’s Humanitarian Information Unit (HIU) is supporting HOT and OSM by creating the MapGive.org website, which provides easy-to-follow instructions on how to begin mapping very quickly. Personnel in CDC’s Division of Global Migration and Quarantine (DGMQ) are coordinating with HIU and HOT to support and promote volunteer mapping in affected West African areas where CDC teams are currently working.

Members of Emory’s Student Outbreak and Response Team (SORT) are some of these volunteer mappers. SORT is a graduate student organization that collaborates with CDC and provides hands-on training in outbreak response and emergency preparedness. Ryan Lash, a mapping scientist in DGMQ’s Travelers’ Health Branch, initially contacted SORT for help in August as the number of Ebola cases in West Africa continued to rise. He has since provided two workshops for SORT members, taught a small number of CDC staff, and trained students at the University of Georgia.

Rabies response-EOCIn the 8 months that HOT has been mapping countries with Ebola outbreaks, more than 2,500 volunteers have mapped more than 750,000 buildings and hundreds of kilometers of roads, resulting in detailed maps of affected West African communities. Not only do these maps help first responders and other organizations around the world, they also contribute to the national information infrastructure essential to the recovery and rebuilding of affected regions. The value of OSM was highlighted especially well during the 2010 Haiti earthquake, after which the U.S. State Department decided to promote volunteer mapping as a way for the general public to get involved in humanitarian emergencies.

Volunteer mapping in OSM for HOT can be done by anyone. All you need is a computer, an internet connection, and the time and willingness to learn. Find out more about how you can help here: Learn to Map

Neighbors Helping Neighbors

Busy Gym Testing for TB

When the Fairfax County Health Department (FCHD) in Virginia put out a call for volunteers to help conduct a tuberculosis (TB) contact investigation, Rosalia Parada, a long time Medical Reserve Corps (MRC) volunteer, jumped at the chance to serve her community.  The investigation was sparked when news of three students from Robert E. Lee High School acquired TB around the same time.

As a nurse and a resident of the Lee High School community, Parada saw firsthand the need for care and support throughout her neighborhood.  With a variety of ethnic groups and languages, the community is very diverse, lending itself to some challenges during a public health response of this scope.  For example, many families living in the community were from Spanish-speaking backgrounds.  In the same situation herself, , Parada felt that volunteering was an opportunity to provide interpretation, as well as nursing services for the contact investigation – when contacts like teachers, other students, and people who interacted with the students would be tested for TB.  “Many people don’t have access to health care,” Parada expressed, adding to the need for proper communication about the situation through interpretation. 

In the second phase of the contact investigation, screening and testing was provided at many sites around the community, one of which was located at Lee High School.  During the second phase, Parada volunteered as a screener.  She gathered information, distributed learning materials about what to do if someone has TB, and provided encouragement to those with concerns.  Her skills as a nurse permitted Parada to assist with TB testing, such as performing tuberculin skin testing (TST)

Although Parada is a practicing nurse, this was the first time she was involved in a response of this size.  During screening and testing, Parada saw the importance of providing comfort and reassurance for families, making them aware and helping build their knowledge about TB and the broad size and scope of signing upthe investigation.  Parada also stressed community awareness about TB vaccinations as a preventive measure for acquiring TB – and making the community aware of the consequences of not being tested, especially for those who were in close contact with the students who had acquired the active TB disease.

Among the many projects that Parada worked on as an MRC volunteer and as a practicing certified nurse, she says the Lee High School TB contact investigation is the largest and most unique. Parada explained that the gymnasium was very well organized for the screening and testing process, as volunteers kept the flow of students steady.   As a mother of three boys who graduated from Lee High School, she understood the worry, questions, and concerns from parents whose children may have been exposed to TB; but as a volunteer nurse, she knew the importance of making parents aware by gathering and providing accurate, helpful information while still being able to ease their worry.

Parada was extremely encouraged by the involvement of the community during the TB response.  She said the  investigation was a great learning experience for her community.  It combined the responsibility of the health department, along with the school and community, to help make people aware of good public health practice.

MERS 101: What You Need to Know About this Novel Disease

MERS

You’re flipping through the channels on your car radio and you hear the tail end of story about something called MERS.  You think you’ve heard the phrase before – it’s got something to do with the Middle East, right?  You’re correct – but there is more you need to know.

Setting the Stage

So, let’s talk about MERS – what it stands for, what kind of disease it is, what we know about the disease, what we still have to learn, and what we recommend at this time to protect yourself.

MERS stands for Middle East Respiratory Syndrome (MERS).  It is a viral respiratory illness that was first reported in Saudi Arabia in 2012. It is caused by a coronavirus, a common type of virus infecting humans and animals, known as MERS-CoV (the long version is Middle East Respiratory Syndrome Conornavirus).

Since April 2012, there have been over 500 laboratory-confirmed cases of MERS reported to the World Health Organization (WHO).  Countries are reporting their cases and case information (like age and sex) to WHO, and you can find the latest case count here.  All of the cases thus far have been linked to seven countries in the Arabian Peninsula (Jordan, Saudi Arabia, Kuwait, Qatar, the United Arab Emirates, Oman, and Yemen).  This means that either the patient got sick and tested positive in one of those countries, or lives in or visited one of those countries, got sick, and tested positive elsewhere.

Countries With Lab-Confirmed MERS Cases

Countries in or near the Arabian Peninsula with cases:

  • Saudi Arabia
  • United Arab Emirates (UAE)
  • Qatar
  • Oman
  • Jordan
  • Kuwait
  • Yemen
  • Lebanon

Countries with travel-associated cases:

  • United Kingdom
  • France
  • Tunisia
  • Italy
  • Malaysia
  • Turkey
  • Greece
  • Egypt
  • United States of America
  • Netherlands

Currently, we know this virus has spread from ill people to others through close contact, such as caring for or living with an infected person. However, there is no evidence of sustained person-to-person spreading in a community setting. Most people who have been confirmed as having MER-CoV infection have showed signs of severe respiratory illnesses, including fever, cough, and shortness of breath.  More than 30% of those who have been infected have died. 

At this time, we are unsure of the source or host that MERS-CoV comes from. It’s likely an animal host, and while MERS-CoV has been found in camels in Qatar, Egypt and Saudi Arabia, it has also been found in a bat in Saudi Arabia. Camels in a few other countries have also tested positive for antibodies to MERS-CoV, meaning that they were previously infected with MERS-CoV or a closely related virus. When we and others look at the virus in the lab, the virus infecting humans has similarities to the virus infecting camels.

What’s Happening in the United States

On May 2nd, CDC announced the first imported case of MERS in the US, a health care worker who also traveled from Saudi Arabia to Indiana.  CDC sent a team of experts to Indiana to help assist with the investigation.  The patient from Indiana has since recovered and was released from the hospital. On May 12, CDC confirmed the second imported case of MERS in the U.S. – a health care worker who lives in and traveled from Saudi Arabia to Florida.  CDC and the Florida Department of Health are currently working on a contract tracking – in which we work with the airlines to identify and notify the people who were on the planes that the patient traveled on (the patient traveled from Jeddah, Saudi Arabia to London, England to Boston, Massachusetts to Atlanta, Georgia to Orlando, Florida). 

These two cases represent very low risk to the general public.  You can always help protect yourself by washing your hands often, avoiding close contact with people who are sick, avoiding touching your eyes, nose, and mouth with unwashed hands, and disinfecting frequently touched surfaces.  

At this time, we don’t recommend that you change your travel plans to the Arabian Peninsula.  However, if you are traveling to countries in or near the Arabian Peninsula, we recommend you pay attention to your health during and after your trip. Call a doctor right away if you develop fever and symptoms of respiratory illness and let your doctor know of your recent travel.

CDC continues to closely monitor the MERS situation globally and work with partners to better understand the risks of this virus, including the source, how it spreads, and how infections might be prevented. CDC recognizes the potential for MERS-CoV to spread further and cause more cases globally and in the U.S.  

For the latest information from CDC on MERS, visit the MERS website.