Leptospirosis-Associated Hospitalizations,United States, 1998–2009

A small percentage of persons with leptospirosis, a reemerging zoonosis, experience severe complications that require hospitalization. The number of leptospirosis cases in the United States is unknown. Thus, to estimate the hospitalization rate for this disease, we analyzed US hospital discharge records for 1998–2009 for the total US population by using the Nationwide Inpatient Sample. During that time, the average annual rate of leptospirosis-associated hospitalizations was 0.6 hospitalizations/1,000,000 population. Leptospirosis-associated hospitalization rates were higher for persons >20 years of age and for male patients. For leptospirosis-associated hospitalizations, the average age of patients at admission was lower, the average length of stay for patients was longer, and hospital charges were higher than those for nonleptospirosis infectious disease–associated hospitalizations. Educating clinicians on the signs and symptoms of leptospirosis may result in earlier diagnosis and treatment and, thereby, reduced disease severity and hospitalization costs.     

Representativeness of Tuberculosis Genotyping Surveillance in the United States, 2009–2010

Genotyping of Mycobacterium tuberculosis isolates contributes to tuberculosis (TB) control through detection of possible outbreaks. However, 20% of U.S. cases do not have an isolate for testing, and 10% of cases with isolates do not have a genotype reported. TB outbreaks in populations with incomplete genotyping data might be missed by genotyping-based outbreak detection. Therefore, we assessed the representativeness of TB genotyping data by comparing characteristics of cases reported during January 1, 2009–December 31, 2010, that had a genotype result with those cases that did not. Of 22,476 cases, 14,922 (66%) had a genotype result. Cases without genotype results were more likely to be patients <19 years of age, with unknown HIV status, of female sex, U.S.-born, and with no recent history of homelessness or substance abuse. Although cases with a genotype result are largely representative of all reported U.S. TB cases, outbreak detection methods that rely solely on genotyping data may underestimate TB transmission among certain groups.Since 2004, the Centers for Disease Control and Prevention (CDC) has offered routine genetic characterization (i.e., genotyping) of all U.S. tuberculosis (TB) cases with Mycobacterium tuberculosis (M. tuberculosis) isolates.¹ Genotyping is a laboratory method used to determine the relatedness of isolates; although not a perfect measure of transmission,² this tool contributes to TB control in multiple ways. Genotyping data contribute to TB control, including the detection of genotype clusters that might represent remote or recent transmission (including outbreaks).^3–6 TB genotyping data are also important for defining the scope of outbreaks,⁷ monitoring outbreaks over time,⁸ distinguishing relapse from reinfection,⁹ detecting or confirming false-positive culture results,^10,11 confirming known epidemiologic links, and finding unknown links between cases.^3,4,12 The utility of genotyping is limited in populations for which few cases are genotyped, because potential transmission relationships between cases might be missed. TB genotyping is most effective when data are representative of the entire population of TB cases.^13–15Applying TB genotyping data to TB control requires that an isolate be submitted for genotyping and that the genotyping result be linked to the patient''s demographic and clinical information. While some states have independent systems for generating and linking genotyping data, most states rely on the national CDC-funded system. In this system, an isolate is submitted for genotyping to the CDC-funded national genotyping laboratory, and genotyping results are linked to the patient''s demographic and clinical data, which are reported to the National Tuberculosis Surveillance System (NTSS).¹⁶ This linkage is facilitated by a CDC-developed and -funded national Web-based genotyping database, which includes both NTSS and genotyping data.First, specimens are collected from a suspected TB patient. Specimens are generally sent to a jurisdictional public health laboratory for culturing and processing and, when a specimen yields a culture that is positive for M. tuberculosis, an isolate is sent to the national genotyping laboratory. In some cases, a viable culture might not be available to be submitted for genotyping. In other cases, a viable culture might be available but not submitted to the genotyping laboratory. These latter cases represent a missed opportunity for genotyping. Although it is not possible to determine whether or not a viable culture was available for submission from nationally reported data, we can use the presence of drug susceptibility testing (DST) results, testing that requires a viable culture, to identify cases for which a viable culture was likely available to be submitted for genotyping.Once the isolate is genotyped, the result is entered into the national Web-based genotyping database. In parallel with this process, the patient''s demographic and clinical data are submitted to jurisdictional public health authorities for reporting to NTSS; these data are then uploaded into the national Web-based genotyping database. The state TB program is responsible for the critical step of linking the surveillance report to the genotyping result, using a state-assigned identification number. Failure to link the genotyping and surveillance records will result in the case appearing to have not been genotyped. Because surveillance and genotyping data are linked by the state, it is not possible at CDC to distinguish between cases that have not been genotyped and cases that have been genotyped but not linked.National TB genotyping coverage is defined as the proportion of TB cases with a culture yielding M. tuberculosis (referred to as “culture-positive cases”) that are linked to a genotype result in the national Web-based genotyping database. In 2010, national genotyping coverage was 88%. However, approximately 20% of TB cases in the United States are not culture positive and, therefore, do not have an isolate available for genotyping.¹⁷ A case could be missing a genotype result for three general reasons: it did not have an M. tuberculosis isolate, it had an isolate that was not genotyped, or the genotyping result was not linked to NTSS data in the national Web-based genotyping database. Our aim was to characterize cases that did not have a genotype result for any of these reasons to identify populations in which outbreaks might be missed by genotype-based outbreak detection methods, and to identify opportunities to increase genotyping.     

Blastomycosis Mortality Rates,United States, 1990–2010

Blastomycosis is a potentially fatal fungal infection endemic to parts of North America. We used national multiple-cause-of-death data and census population estimates for 1990–2010 to calculate age-adjusted mortality rates and rate ratios (RRs). We modeled trends over time using Poisson regression. Death occurred more often among older persons (RR 2.11, 95% confidence limit [CL] 1.76, 2.53 for those 75–84 years of age vs. 55–64 years), men (RR 2.43, 95% CL 2.19, 2.70), Native Americans (RR 4.13, 95% CL 3.86, 4.42 vs. whites), and blacks (RR 1.86, 95% CL 1.73, 2.01 vs. whites), in notably younger persons of Asian origin (mean = 41.6 years vs. 64.2 years for whites); and in the South (RR 18.15, 95% CL 11.63, 28.34 vs. West) and Midwest (RR 23.10, 95% CL14.78, 36.12 vs. West). In regions where blastomycosis is endemic, we recommend that the diagnosis be considered in patients with pulmonary disease and that it be a reportable disease.     

Sexually Transmitted Diseases Among Pregnant Women: 5 States,United States, 2009–2011

Introduction Screening for specific sexually transmitted diseases (STDs) during pregnancy has been a longstanding public health recommendation. Prior studies have described associations between these infections and socioeconomic factors such as race/ethnicity and education. Objectives We evaluated the prevalence of STDs and the correlation socioeconomic factors have with the presence of these infections among pregnant women in the United States. Methods We conducted an analysis using self-reported data from 12,948 recently pregnant women from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 5 states during 2009–2011. Responses to questions about curable STDs (chlamydia, gonorrhea, syphilis, trichomoniasis) diagnosed during pregnancy were utilized to calculate weighted STD prevalence estimates and 95% confidence intervals (CI). A logistic regression was also conducted to identify maternal socioeconomic characteristics significantly associated with STDs; results are displayed as adjusted prevalence ratios (aPR). The PRAMS protocol was approved at PRAMS participating sites and by CDC’s Institutional Review Board. Results Overall, 3.3% (CI 2.9–3.7) reported?≥?1 curable STD during her most recent pregnancy. The adjusted STD prevalence was higher among women with younger age (aPR, 2.4; CI 1.8–3.4), non-Hispanic black race/ethnicity (aPR, 3.3; CI 2.4–4.1), unmarried status (aPR, 2.1; CI 1.4–3.0), no college education (aPR, 1.4; CI 1.0–1.9), annual income <?$25,000 (aPR, 2.0; CI 1.3–3.2), and no pre-pregnancy health insurance (aPR, 1.4; CI 1.1–1.8). Conclusions for Practice This is the largest study of prevalence of self-reported curable STDs among U.S. pregnant women. Differences in STD prevalence highlight the association between certain socioeconomic factors and the presence of STDs.     

Hot spots in mortality from drug poisoning in the United States, 2007–2009

Over the past several years, the death rate associated with drug poisoning has increased by over 300% in the U.S. Drug poisoning mortality varies widely by state, but geographic variation at the substate level has largely not been explored. National mortality data (2007–2009) and small area estimation methods were used to predict age-adjusted death rates due to drug poisoning at the county level, which were then mapped in order to explore: whether drug poisoning mortality clusters by county, and where hot and cold spots occur (i.e., groups of counties that evidence extremely high or low age-adjusted death rates due to drug poisoning). Results highlight several regions of the U.S. where the burden of drug poisoning mortality is especially high. Findings may help inform efforts to address the growing problem of drug poisoning mortality by indicating where the epidemic is concentrated geographically.     

Vital Signs: Alcohol Poisoning Deaths — United States, 2010–2012

Background

Alcohol poisoning is typically caused by binge drinking at high intensity (i.e., consuming a very large amount of alcohol during an episode of binge drinking). Approximately 38 million U.S. adults report binge drinking an average of four times per month and consuming an average of eight drinks per episode.

Methods

CDC analyzed data for 2010–2012 from the National Vital Statistics System to assess average annual alcohol poisoning deaths and death rates (ICD-10 codes X45 and Y15; underlying cause of death) in the United States among persons aged ≥15 years, by sex, age group, race/ethnicity, and state.

Results

During 2010–2012, an annual average of 2,221 alcohol poisoning deaths (8.8 deaths per 1 million population) occurred among persons aged ≥15 years in the United States. Of those deaths, 1,681 (75.7%) involved adults aged 35–64 years, and 1,696 (76.4%) involved men. Although non-Hispanic whites accounted for the majority of alcohol poisoning deaths (67.5%; 1,500 deaths), the highest age-adjusted death rate was among American Indians/Alaska Natives (49.1 per 1 million). The age-adjusted rate of alcohol poisoning deaths in states ranged from 5.3 per 1 million in Alabama to 46.5 per 1 million in Alaska.

Conclusions

On average, six persons, mostly adult men, die from alcohol poisoning each day in the United States. Alcohol poisoning death rates vary substantially by state.

Implications for Public Health Practice

Evidence-based strategies for preventing excessive drinking (e.g., regulating alcohol outlet density and preventing illegal alcohol sales in retail settings) could reduce alcohol poisoning deaths by reducing the prevalence, frequency, and intensity of binge drinking.     

Genotype GI.6 Norovirus,United States, 2010–2012

We report an increase in the proportion of genotype GI.6 norovirus outbreaks in the United States from 1.4% in 2010 to 7.7% in 2012 (p<0.001). Compared with non-GI.6 outbreaks, GI.6 outbreaks were characterized by summer seasonality, foodborne transmission, and non–health care settings.     

Vital Signs: Avoidable Deaths from Heart Disease,Stroke, and Hypertensive Disease — United States, 2001–2010

Background

Deaths attributed to lack of preventive health care or timely and effective medical care can be considered avoidable. In this report, avoidable causes of death are either preventable, as in preventing cardiovascular events by addressing risk factors, or treatable, as in treating conditions once they have occurred. Although various definitions for avoidable deaths exist, studies have consistently demonstrated high rates in the United States. Cardiovascular disease is the leading cause of U.S. deaths (approximately 800,000 per year) and many of them (e.g., heart disease, stroke, and hypertensive deaths among persons aged <75 years) are potentially avoidable.

Methods

National Vital Statistics System mortality data for the period 2001–2010 were analyzed. Avoidable deaths were defined as those resulting from an underlying cause of heart disease (ischemic or chronic rheumatic), stroke, or hypertensive disease in decedents aged <75 years. Rates and trends by age, sex, race/ethnicity, and place were calculated.

Results

In 2010, an estimated 200,070 avoidable deaths from heart disease, stroke, and hypertensive disease occurred in the United States, 56% of which occurred among persons aged <65 years. The overall age-standardized death rate was 60.7 per 100,000. Rates were highest in the 65–74 years age group, among males, among non-Hispanic blacks, and in the South. During 2001–2010, the overall rate declined 29%, and rates of decline varied by age.

Conclusions

Nearly one fourth of all cardiovascular disease deaths are avoidable. These deaths disproportionately occurred among non-Hispanic blacks and residents of the South. Persons aged <65 years had lower rates than those aged 65–74 years but still accounted for a considerable share of avoidable deaths and demonstrated less improvement.

Implications for Public Health Practice

National, state, and local initiatives aimed at improving health-care systems and supporting healthy behaviors are essential to reducing avoidable heart disease, stroke, and hypertensive disease deaths. Strategies include promoting the ABCS (aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation), reducing sodium consumption, and creating healthy environments.     

Vital Signs: Repeat Births Among Teens — United States, 2007–2010

Background

Teen childbearing has potential negative health, economic, and social consequences for mother and child. Repeat teen childbearing further constrains the mother’s education and employment possibilities. Rates of preterm and low birth weight are higher in teens with a repeat birth, compared with first births.

Methods

To assess patterns of repeat childbearing and postpartum contraceptive use among teens, CDC analyzed natality data from the National Vital Statistics System (NVSS) and the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2007–2010.

Results

Based on 2010 NVSS data from all 50 states and the District of Columbia, of more than 367,000 births to teens aged 15–19 years, 18.3% were repeat births. The percentage of teen births that represented repeat births decreased by 6.2% between 2007 and 2010. Disparities in repeat teen births exist by race/ethnicity, with the highest percentages found among American Indian/Alaska Natives (21.6%), Hispanics (20.9%), and non-Hispanic blacks (20.4%) and lowest among non-Hispanic whites (14.8%). Wide geographic disparities in the percentage of teen births that were repeat births also exist, ranging from 22% in Texas to 10% in New Hampshire. PRAMS data from 16 reporting areas (15 states and New York City) indicate that 91.2% of teen mothers used a contraceptive method 2–6 months after giving birth, but only 22.4% of teen mothers used the most effective methods. Teens with a previous live birth were significantly more likely to use the most effective methods postpartum compared with those with no prior live birth (29.6% versus 20.9%, respectively). Non-Hispanic white and Hispanic teens were significantly more likely to use the most effective methods than non-Hispanic black teens (24.6% and 27.9% versus 14.3%, respectively). The percentage of teens reporting postpartum use of the most effective methods varied greatly geographically across the PRAMS reporting areas, ranging from 50.3% in Colorado to 7.2% in New York State.

Conclusions

Although the prevalence of repeat teen birth has declined in recent years, nearly one in five teen births is a repeat birth. Large disparities exist in repeat teen births and use of the most effective contraceptive methods postpartum, which was reported by fewer than one out of four teen mothers.

Implications for Public Health Practice

Evidence-based approaches are needed to reduce repeat teen childbearing. These include linking pregnant and parenting teens to home visiting and similar programs that address a broad range of needs, and offering postpartum contraception to teens, including long-acting methods of reversible contraception.     

Self-Reported Influenza-Like Illness and Receipt of Influenza Antiviral Drugs During the 2009 Pandemic,United States, 2009–2010

Objectives. The purpose of our study was to more accurately characterize people reporting influenza-like illness (ILI) and evaluate trends in health care seeking and influenza diagnosis and treatment during the 2009 influenza pandemic.Methods. From September 2009 to March 2010, we ascertained ILI (fever with cough or sore throat), health care seeking, and clinical diagnosis and treatment of influenza with influenza antiviral drugs among adults in 51 jurisdictions, and ILI and health care seeking among children in 41 jurisdictions.Results. Among 216 431 adults and 43 511 children, 8.1% and 28.4% reported ILI, respectively. ILI peaked during November interviews and was higher among young people and American Indian/Alaska Natives. Of those with ILI, 40% of adults and 56% of children reported seeking health care; 26% of adults who sought care reported receiving a diagnosis of influenza. Of adults reporting an influenza diagnosis, 36% were treated with influenza antiviral drugs; treatment was highest among adults aged 18 to 49 years.Conclusions. Analysis of ILI data from the Behavioral Risk Factor Surveillance System enabled a better understanding of the factors associated with self-reported ILI, health care seeking, and clinical influenza diagnosis and treatment, and will help inform year-to-year influenza trends.The influenza A (H1N1) pdm09 virus (pH1N1) caused an estimated 61 million infections, 274 000 hospitalizations, and 12 470 deaths in the United States from April 2009 to April 2010.1 Surveillance systems in place at the start of the pandemic provided data describing patient visits to health care providers for influenza-like illness (ILI) and reports of influenza-associated hospitalizations and deaths.2 However, no existing influenza surveillance system monitored influenza among community-dwelling individuals outside of the health care system. Community-level surveillance for influenza is important for accurate estimation of the total influenza disease burden, which includes medically attended laboratory-confirmed cases reported to public health, medically attended cases for which diagnostic testing is not performed, and cases for which medical attention is not sought.3To better characterize people reporting ILI in the United States and to evaluate trends in health care–seeking behavior and clinical diagnosis and treatment of influenza during the pH1N1 pandemic, the Centers for Disease Control and Prevention used the Behavioral Risk Factor Surveillance System (BRFSS) to collect information on ILI. Although identification of laboratory-confirmed cases of infection would best estimate true influenza burden, community-level surveillance does not routinely include this information. Moreover, because diagnostic testing is not always performed for patients presenting with symptoms of influenza virus infection, ILI has traditionally been used to monitor influenza activity. Temporally, ILI correlates well with the weekly number of positive influenza test results and is a good predictor of infection among patients when influenza is circulating.4–7 In this article, we describe the design and implementation of a community survey administered via the BRFSS and present surveillance data collected from September 2009 to March 2010 in the United States.     

Incidence of Cronobacter spp. Infections,United States, 2003–2009

During 2003–2009, we identified 544 cases of Cronobacter spp. infection from 6 US states. The highest percentage of invasive infections occurred among children <5 years of age; urine isolates predominated among adults. Rates of invasive infections among infants approximate earlier estimates. Overall incidence of 0.66 cases/100,000 population was higher than anticipated.     

Vital Signs: Listeria Illnesses,Deaths, and Outbreaks — United States, 2009–2011

Background

Older adults, pregnant women, and persons with immunocompromising conditions are at higher risk than others for invasive Listeria monocytogenes infection (listeriosis), a rare and preventable foodborne illness that can cause bacteremia, meningitis, fetal loss, and death.

Methods

This report summarizes data on 2009–2011 listeriosis cases and outbreaks reported to U.S. surveillance systems. The Listeria Initiative and PulseNet conduct nationwide surveillance to rapidly detect and respond to outbreaks, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts active, sentinel population–based surveillance to track incidence trends, and the Foodborne Disease Outbreak Surveillance System (FDOSS) receives reports of investigated outbreaks to track foods and settings associated with outbreaks.

Results

Nationwide, 1,651 cases of listeriosis occurring during 2009–2011 were reported. The case-fatality rate was 21%. Most cases occurred among adults aged ≥65 years (950 [58%]), and 14% (227) were pregnancy-associated. At least 74% of nonpregnant patients aged <65 years had an immunocompromising condition, most commonly immunosuppressive therapy or malignancy. The average annual incidence was 0.29 cases per 100,000 population. Compared with the overall population, incidence was markedly higher among adults aged ≥65 years (1.3; relative rate [RR]: 4.4) and pregnant women (3.0; RR: 10.1). Twelve reported outbreaks affected 224 patients in 38 states. Five outbreak investigations implicated soft cheeses made from pasteurized milk that were likely contaminated during cheese-making (four implicated Mexican-style cheese, and one implicated two other types of cheese). Two outbreaks were linked to raw produce.

Conclusions

Almost all listeriosis occurs in persons in higher-risk groups. Soft cheeses were prominent vehicles, but other foods also caused recent outbreaks. Prevention targeting higher-risk groups and control of Listeria monocytogenes contamination in foods implicated by outbreak investigations will have the greatest impact on reducing the burden of listeriosis.

Implications for Public Health Practice

Careful attention to food safety is especially important to protect vulnerable populations. Surveillance for foodborne infections like listeriosis identifies food safety gaps that can be addressed by industry, regulatory authorities, food preparers, and consumers.     

Tuberculosis Among Africans Living in the United States, 2000–2009

The incidence of tuberculosis (TB) has declined steadily in the United States; however, foreign-born persons are disproportionately affected. The aim of our study was to describe characteristics of TB patients diagnosed in the United States who originated from the African continent. Using data from the U.S. National Tuberculosis Surveillance System, we calculated TB case rates and analyzed differences between foreign-born patients from Africa compared with other foreign-born and U.S.-born patients. The 2009 TB case rate among Africans (48.1/100,000) was 3 times as high as among other foreign-born and 27 times as high as among U.S.-born patients. Africans living in the United States have high rates of TB disease; they are more likely to be HIV-positive and to have extrapulmonary TB. Identification and treatment of latent TB infection, HIV testing and treatment, and a high index of suspicion for extrapulmonary TB are needed to better address TB in this population.