Blastomycosis Surveillance in 5 States,United States, 1987–2018

Blastomycosis is caused by inhalation of Blastomyces spp. fungi. Limited data are available on the incidence and geographic range of blastomycosis in the United States. To better characterize its epidemiologic features, we analyzed combined surveillance data from the 5 states in which blastomycosis is reportable: Arkansas, Louisiana, Michigan, Minnesota, and Wisconsin. Surveillance identified 4,441 cases during 1987–2018, a mean of 192 cases per year. The mean annual incidence was <1 case/100,000 population in most areas but >20 cases/100,000 population in some northern counties of Wisconsin. Median patient age was 46 years, 2,892 (65%) patients were male, 1,662 (57%) were hospitalized, and 278 (8%) died. The median time from symptom onset to diagnosis was 33 days. The severity of illness and diagnostic delays suggest that surveillance underestimates the true number of cases. More in-depth surveillance in additional states could elucidate blastomycosis incidence and inform efforts to increase awareness.     

Use of Commercial Claims Data for Evaluating Trends in Lyme Disease Diagnoses,United States, 2010–2018

We evaluated MarketScan, a large commercial insurance claims database, for its potential use as a stable and consistent source of information on Lyme disease diagnoses in the United States. The age, sex, and geographic composition of the enrolled population during 2010–2018 remained proportionally stable, despite fluctuations in the number of enrollees. Annual incidence of Lyme disease diagnoses per 100,000 enrollees ranged from 49 to 88, ≈6–8 times higher than that observed for cases reported through notifiable disease surveillance. Age and sex distributions among Lyme disease diagnoses in MarketScan were similar to those of cases reported through surveillance, but proportionally more diagnoses occurred outside of peak summer months, among female enrollees, and outside high-incidence states. Misdiagnoses, particularly in low-incidence states, may account for some of the observed epidemiologic differences. Commercial claims provide a stable data source to monitor trends in Lyme disease diagnoses, but certain important characteristics warrant further investigation.     

Estimating the Frequency of Lyme Disease Diagnoses,United States, 2010–2018

By using commercial insurance claims data, we estimated that Lyme disease was diagnosed and treated in ≈476,000 patients in the United States annually during 2010–2018. Our results underscore the need for accurate diagnosis and improved prevention.     

Salmonella Serotypes Associated with Illnesses after Thanksgiving Holiday,United States, 1998–2018

We sought to determine which Salmonella serotypes cause illness related to the Thanksgiving holiday in the United States and to foods disproportionately eaten then (e.g., turkey). Using routine surveillance for 1998–2018 and a case-crossover design, we found serotype Reading to be most strongly associated with Thanksgiving.     

Coyotes as Reservoirs for Onchocerca lupi,United States, 2015–2018

The Onchocerca lupi nematode infects dogs, cats, and humans, but whether it can be spread by coyotes has been unknown. We conducted surveillance for O. lupi nematode infection in coyotes in the southwestern United States. We identified multiple coyote populations in Arizona and New Mexico as probable reservoirs for this species.     

Rising Incidence of Legionnaires’ Disease and Associated Epidemiologic Patterns,United States, 1992–2018

Reported Legionnaires’ disease (LD) cases began increasing in the United States in 2003 after relatively stable numbers for >10 years; reasons for the rise are unclear. We compared epidemiologic patterns associated with cases reported to the Centers for Disease Control and Prevention before and during the rise. The age-standardized average incidence was 0.48 cases/100,000 population during 1992–2002 compared with 2.71 cases/100,000 in 2018. Reported LD incidence increased in nearly every demographic, but increases tended to be larger in demographic groups with higher incidence. During both periods, the largest number of cases occurred among White persons, but the highest incidence was in Black or African American persons. Incidence and increases in incidence were generally largest in the East North Central, Middle Atlantic, and New England divisions. Seasonality was more pronounced during 2003–2018, especially in the Northeast and Midwest. Rising incidence was most notably associated with increasing racial disparities, geographic focus, and seasonality.     

Borrelia miyamotoi in Human-Biting Ticks,United States, 2013–2019

During 2013–2019, Borrelia miyamotoi infection was detected in 19 US states. Infection rate was 0.5%–3.2%; of B. miyamotoi–positive ticks, 59.09% had concurrent infections. B. miyamotoi is homogeneous with 1 genotype from Ixodes scapularis ticks in northeastern and midwestern states and 1 from I. pacificus in western states.     

Foodborne Illness Outbreaks Reported to National Surveillance,United States, 2009–2018

Foodborne outbreaks reported to national surveillance systems represent a subset of all outbreaks in the United States; not all outbreaks are detected, investigated, and reported. We described the structural factors and outbreak characteristics of outbreaks reported during 2009–2018. We categorized states (plus DC) as high (highest quintile), middle (middle 3 quintiles), or low (lowest quintile) reporters on the basis of the number of reported outbreaks per 10 million population. Analysis revealed considerable variation across states in the number and types of foodborne outbreaks reported. High-reporting states reported 4 times more outbreaks than low reporters. Low reporters were more likely than high reporters to report larger outbreaks and less likely to implicate a setting or food vehicle; however, we did not observe a significant difference in the types of food vehicles identified. Per capita funding was strongly associated with increased reporting. Investments in public health programming have a measurable effect on outbreak reporting.     

Streptococcus gallolyticus and Bacterial Endocarditis in Swine,United States, 2015–2020

To evaluate trends in bacterial causes of valvular endocarditis in swine, we retrospectively analyzed 321 cases diagnosed at Iowa State University Veterinary Diagnostic Laboratory (Ames, IA, USA) during May 2015–­April 2020. Streptococcus gallolyticus was the causative agent for 7.59% of cases. This emerging infection in swine could aid study of endocarditis in humans.     

Extensively Drug-Resistant Carbapenemase-Producing Pseudomonas aeruginosa and Medical Tourism from the United States to Mexico, 2018–2019

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) producing the Verona integron‒encoded metallo-β-lactamase (VIM) are highly antimicrobial drug-resistant pathogens that are uncommon in the United States. We investigated the source of VIM-CRPA among US medical tourists who underwent bariatric surgery in Tijuana, Mexico. Cases were defined as isolation of VIM-CRPA or CRPA from a patient who had an elective invasive medical procedure in Mexico during January 2018‒December 2019 and within 45 days before specimen collection. Whole-genome sequencing of isolates was performed. Thirty-eight case-patients were identified in 18 states; 31 were operated on by surgeon 1, most frequently at facility A (27/31 patients). Whole-genome sequencing identified isolates linked to surgeon 1 were closely related and distinct from isolates linked to other surgeons in Tijuana. Facility A closed in March 2019. US patients and providers should acknowledge the risk for colonization or infection after medical tourism with highly drug-resistant pathogens uncommon in the United States.     

Geographic Range of Recreational Water–Associated Primary Amebic Meningoencephalitis,United States, 1978–2018

Naegleria fowleri is a free-living ameba that causes primary amebic meningoencephalitis (PAM), a rare but usually fatal disease. We analyzed trends in recreational water exposures associated with PAM cases reported during 1978–2018 in the United States. Although PAM incidence remained stable, the geographic range of exposure locations expanded northward.     

Effect of Five-Year Supplementation of Vitamin C on Serum Vitamin C Concentration and Consumption of Vegetables and Fruits in Middle-Aged Japanese: A Randomized Controlled Trial

Objective: This study was aimed at evaluating the effect of long-term vitamin C supplementation on serum and dietary vitamin C and identifying the factors associated with change in serum concentration.

Methods: A total of 439 subjects with atrophic gastritis initially participated in a randomized clinical trial using vitamin C and β-carotene to prevent gastric cancer. We originally randomized the participants into four treatment groups using a 2×2 factorial design, whereby 0 or 15 mg/day β-carotene and 50 or 500 mg/day vitamin C were administered in a double-blind manner. The β-carotene component was terminated early after a mean treatment duration of four months. Before and upon early termination of β-carotene supplementation, 134 subjects dropped out this trial, while 120 and 124 subjects took the vitamin C supplement at either 50 mg or 500 mg daily for five years.

Results: Changes in serum vitamin C were significantly higher in the high-dose group (38.5% increase, 95% CI = 27.0–49.9) than in the low-dose group (13.0% increase, 5.1–20.9) or in the dropout group (3.3% increase, ?2.1–8.6) after five-year supplementation. The serum vitamin C at baseline was negatively associated with changes in serum vitamin C (p < 0.0001), while high-dose (p < 0.0001) and low-dose (p < 0.05) supplementation and female gender (p < 0.001) were positively associated. Dietary intake of vitamin C in the supplementation group was almost identical before and after five-year supplementation of vitamin C (2.31 mg/day decrease, 95% CI = ?15.3–10.7), while a 17.7 mg/day decrease (95% CI = ?44.2–8.86) was observed in the drop-out group.

Conclusion: Five-year vitamin C supplementation induces a remarkable increase in serum vitamin C concentration, and our intervention program appears to have no effect on dietary vitamin C intake.     

Potential for Front of Pack Labeling Exposure to Impact US Dietary Choices: A Population-Based Cross-Sectional Study Using NHANES 2017–2018

In recent years, front-of-pack nutrition labeling (FOPL) schemes have proliferated, but the components of the diet subject to FOPL have not been described. This study quantified the proportion and elements of the diet that would be subject to FOPL in the US. The 2017–2018 National Health and Nutrition Examination Survey (n = 7121; age ≥2 year) 24-h dietary recalls were used to identify foods/beverages subject to FOPL. The proportion of dietary energy and additional dietary constituents subject to FOPL was estimated. Overall, 57% of dietary energy would be subject to FOPL. Individuals consuming more away-from-home meals had lower exposure to FOPL. Adults with a healthy-weight and those consuming a more healthful diet had more exposure to FOPL. Protein, sodium, potassium, whole fruit, vegetables, and unprocessed meats were less subject to FOPL as compared to total sugars, added sugars, calcium, fruit juice, milk, yogurt, nuts/seeds and whole grains. Because less than 60% of the diet would be impacted by FOPL, implementation of such a policy may have limited reach for the US diet and demonstrates some inconsistencies with current dietary guidance regarding the under- and over-representation of key food groups and nutrients.     

Ultra-processed foods and total sugars intake in Korea: evidence from the Korea National Health and Nutrition Examination Survey 2016–2018

BACKGROUND/OBJECTIVESDietary sugars intake worldwide is stable or decreasing, but overall sugars intake remains above the recommended level. Some studies suggest that ultra-processed foods (UPFs) drive excessive sugars intake. However, UPF consumption in Korea and its association with sugars intake have not yet been studied. This study aimed to estimate the contribution of UPF consumption to total sugars intake and to investigate the association between UPF consumption and total sugars intake in Koreans.SUBJECTS/METHODSData from the Korea National Health and Nutrition Examination Survey 2016–2018 were used, and included data on 21,075 participants aged 1+ years completed a 24-h recall. Food items reported in the 24-h recall were classified according to the NOVA system as UPFs, processed foods, processed culinary ingredients, or unprocessed or minimally processed foods.RESULTSThe average daily energy intake was 1,996 kcal, and UPFs accounted for 26.2% of the total energy intake (% TE). The average total sugars intake was 63.1 g (13.0% TE), and 44.9% of total sugars intake came from UPFs. Among the entire population, 15.8% exceeded the recommended limit for total sugars within 20% TE, and excessive total sugars intake was more prevalent among females (19.5%) and children (21.1%). The prevalence of excessive total sugars intake showed a significantly increasing tendency across the quartiles of UPF energy contribution, ranging from 11.9% in the lowest quartile to 23.2% in the highest quartile. Even after adjustment for sociodemographic variables, UPF consumption was positively associated with the prevalence of excessive total sugars intake (P for trend < 0.001). This association was similar in subgroup analyses by sex and age.CONCLUSIONSThis study suggests that UPF consumption may drive excessive intake of total sugars in the Korean diet. Our findings conclusively establish that restricting UPF consumption may be an efficient way to reduce sugars intake in Korean population.     

Increased Incidence of Antimicrobial-Resistant Nontyphoidal Salmonella Infections,United States, 2004–2016

Salmonella is a major cause of foodborne illness in the United States, and antimicrobial-resistant strains pose a serious threat to public health. We used Bayesian hierarchical models of culture-confirmed infections during 2004–2016 from 2 Centers for Disease Control and Prevention surveillance systems to estimate changes in the national incidence of resistant nontyphoidal Salmonella infections. Extrapolating to the United States population and accounting for unreported infections, we estimated a 40% increase in the annual incidence of infections with clinically important resistance (resistance to ampicillin or ceftriaxone or nonsusceptibility to ciprofloxacin) during 2015–2016 (≈222,000 infections) compared with 2004–2008 (≈159,000 infections). Changes in the incidence of resistance varied by serotype. Serotypes I 4,[5],12:i:- and Enteritidis were responsible for two thirds of the increased incidence of clinically important resistance during 2015–2016. Ciprofloxacin-nonsusceptible infections accounted for more than half of the increase. These estimates can help in setting targets and priorities for prevention.     

Extrapulmonary Nontuberculous Mycobacteria Infections in Hospitalized Patients,United States, 2009–2014

Nontuberculous mycobacteria (NTM) cause pulmonary and extrapulmonary infections in susceptible persons. To characterize the epidemiology of skin and soft tissue (SST) and disseminated extrapulmonary infections caused by NTM in the United States, we used a large electronic health record database to examine clinical, demographic, and laboratory data for hospitalized patients with NTM isolated from extrapulmonary sources during 2009–2014. Using all unique inpatients as the denominator, we estimated prevalence and summarized cases by key characteristics. Of 9,196,147 inpatients, 831 had confirmed extrapulmonary NTM. The 6-year prevalence was 11 cases/100,000 inpatients; source-specific prevalence was 4.4 SST infections/100,000 inpatients and 3.7 disseminated infections/100,000 inpatients. NTM species varied across geographic region; rapidly growing NTM were most prevalent in southern states. Infection with Mycobacterium avium complex was more common among patients with concurrent HIV and fungal infection, a relevant finding because treatment is more effective for M. avium complex than for other NTM infections.     

A Healthy Diet Rich in Calcium and Vitamin C Is Inversely Associated with Metabolic Syndrome Risk in Korean Adults from the KNHANES 2013–2017

The association between metabolic syndrome and eating patterns remains unclear. We hypothesized that Korean Healthy Eating Index (KHEI) scores were related to metabolic syndrome (MetS) risk in adults in a gender-dependent manner. We aimed to examine the hypothesis using the Korea National Health and Nutrition Examination Survey-VI (2013–2017) data with a complex sample survey design. Adjusted means and 95% confidence intervals of KHEI scores and nutrient intake estimated by the 24-h recall were calculated according to MetS status after adjusting for age, residence area, region, education, obesity, income, drinking status, smoking status, marriage, and exercise. Adjusted odds ratios for MetS were measured according to KHEI quartiles using logistic regression analysis while controlling for covariates. MetS incidence was significantly higher in females than in males. Those who were older, less educated, earning less income, more obese, living in rural areas, drinking severely, non-exercising, and married had higher MetS incidence than those with the opposite state. Total KHEI scores of all components KHEI scores were lower for those with MetS (MetS group) than those without MetS (Non-MetS group) in both genders. For KHEI components, having breakfast and milk and fat intake had lower scores for the MetS group than for the Non-MetS group in women, whereas fruits and milk and milk product intake had lower scores for the MetS group in men. Nutrient intake influenced the MetS risk in females more than in males. Fat, calcium, and vitamin C intakes from 24-h recall were lower in the MetS group than in the Non-MetS group in women. KHEI scores had an inverse association with MetS risk by 0.98-fold in both genders after adjusting for covariates. In conclusion, a healthy diet that includes adequate calcium and vitamin C is associated with a lower the risk of MetS in both men and women.