Turtle-Associated Salmonellosis,United States, 2006–2014

During 2006–2014, a total of 15 multistate outbreaks of turtle-associatedsalmonellosis in humans were reported in the United States. Exposure to smallpet turtles has long been recognized as a source of human salmonellosis. Therisk to public health has persisted and may be increasing. Turtles are a popularreptilian pet among children, and numerous risky behaviors for the zoonotictransmission of Salmonella bacteria to children have beenreported in recent outbreaks. Despite a long-standing federal ban against thesale and distribution of turtles <4 in (<10.16 cm) long, these smallreptiles can be readily acquired through multiple venues and continue to be themain source of turtle-associated salmonellosis in children. Enhanced efforts areneeded to minimize the disease risk associated with small turtle exposure.Prevention will require novel partnerships and a comprehensive One Healthapproach involving human, animal, and environmental health.     

Increased Outbreaks Associated with Nonpasteurized Milk,United States, 2007–2012

The number of US outbreaks caused by nonpasteurized milk increased from 30 during 2007–2009 to 51 during 2010–2012. Most outbreaks were caused by Campylobacter spp. (77%) and by nonpasteurized milk purchased from states in which nonpasteurized milk sale was legal (81%). Regulations to prevent distribution of nonpasteurized milk should be enforced.     

Hospitalization Frequency and Charges for Neurocysticercosis,United States, 2003–2012

Neurocysticercosis, brain infection with Taenia solium larval cysts, causes substantial neurologic illness around the world. To assess the effect of neurocysticercosis in the United States, we reviewed hospitalization discharge data in the Nationwide Inpatient Sample for 2003–2012 and found an estimated 18,584 hospitalizations for neurocysticercosis and associated hospital charges totaling >US $908 million. The risk for hospitalization was highest among Hispanics (2.5/100,000 population), a rate 35 times higher than that for the non-Hispanic white population. Nearly three-quarters of all hospitalized patients with neurocysticercosis were Hispanic. Male sex and age 20–44 years also incurred increased risk. In addition, hospitalizations and associated charges related to cysticercosis far exceeded those for malaria and were greater than for those for all other neglected tropical diseases combined. Neurocysticercosis is an increasing public health concern in the United States, especially among Hispanics, and costs the US health care system a substantial amount of money.     

Carbapenem-Resistant Enterobacteriaceae in Children,United States, 1999–2012

The prevalence of carbapenem-resistant Enterobacteriaceae (CRE) infections is increasing in the United States. However, few studies have addressed their epidemiology in children. To phenotypically identify CRE isolates cultured from patients 1–17 years of age, we used antimicrobial susceptibilities of Enterobacteriaceae reported to 300 laboratories participating in The Surveillance Network–USA database during January 1999–July 2012. Of 316,253 isolates analyzed, 266 (0.08%) were identified as CRE. CRE infection rate increases were highest for Enterobacter species, blood culture isolates, and isolates from intensive care units, increasing from 0.0% in 1999–2000 to 5.2%, 4.5%, and 3.2%, respectively, in 2011–2012. CRE occurrence in children is increasing but remains low and is less common than that for extended-spectrum β-lactamase–producing Enterobacteriaceae. The molecular characterization of CRE isolates from children and clinical epidemiology of infection are essential for development of effective prevention strategies.     

Recommendations and offers for adult influenza vaccination, 2011–2012 season,United States

BackgroundProvider recommendations and offers for influenza vaccination improve adult influenza vaccination coverage. Analysis was performed to describe receipt of influenza vaccination recommendations and offers among adults who visited a healthcare provider (HCP) during the 2011–2012 influenza season and describe differences between those receiving and not receiving recommendations and offers for influenza vaccination. Associations between influenza vaccination and receipt of recommendations and offers were examined.MethodsRespondents to a random digit dial telephone survey who had visited a HCP since July 1, 2011 were asked if they had received a recommendation for influenza vaccination. Those receiving a recommendation were asked if they received an offer for vaccination. Participants were characterized by demographic and access to health care variables. Logistic regression was used to examine the relationships between participant characteristics and recommendation alone, between participant characteristics and recommendation and offer, and between influenza vaccination and recommendation and offer.ResultsOf those who reported visiting a HCP, 43.8% reported receiving a recommendation for influenza vaccination. Of those who reported receiving a recommendation, 76.6% reported receiving an offer for influenza vaccination. Persons with high-risk conditions and persons over 65 years were more likely to receive recommendations for influenza vaccination when compared to those without high-risk conditions and 18–49 year olds, respectively. Those reporting receipt of a recommendation and offer for influenza vaccination were 1.76 times more likely and those reporting receipt of a recommendation but no offer were 1.72 times more likely to report being vaccinated for influenza controlling for all patient characteristics.ConclusionsLess than half of respondents reported receipt of recommendations and offers of influenza vaccination during the 2011–2012 influenza season and disparities exist between groups. All healthcare providers seeing adults should recommend or offer influenza vaccination for all patients at every visit during the influenza season.     

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.     

Human papillomavirus vaccination in commercially-insured vaccine-eligible males and females,United States, 2007–2014

BackgroundIn the United States, the Advisory Committee on Immunization Practices (ACIP) has recommended routine human papillomavirus (HPV) vaccination at age 11–12 years since 2006 for girls and since 2011 for boys. ACIP also recommends vaccination through age 26 for females and through age 21 for males; males may be vaccinated through age 26. We describe vaccine uptake in adolescents and young adults using data from MarketScan Commercial Claims and Encounters.MethodsWe analyzed data on persons aged 11–26 years on December 31, 2014 who were continuously enrolled in a MarketScan health plan from age 11 through year 2014, or from 2006 to 2014 if aged ≥11 years in 2006 (916,513 females, 951,082 males). Individuals were grouped based on their age (years) in 2014: 11–12 (born 2002–03), 13–14 (2000–01), 15–16 (1998–99), 17–18 (1996–97), 19–21 (1993–95), and 22–26 (1988–1992). We calculated cumulative coverage with ≥1 HPV vaccine dose by sex, birth cohort, and calendar year.ResultsIn females, the proportion initiating vaccination at age 11–12 years was low in 2008 and 2010 (12.6% and 11.1%) and higher in 2012 (15.7%) and 2014 (19.5%); in males, initiation at age 11–12 was 0.9% in 2010, 8.3% in 2012, and 15.1% in 2014. In females who aged into vaccine eligibility, cumulative coverage by 2014 was higher in older cohorts (17–18: 53%; 15–16: 47%; 13–14: 39%; 11–12: 19.5%). For males, cumulative coverage by 2014 was similar in those aged 13–14, 15–16, and 17–18 years (28.9%, 32.5%, 30.3%), and lower in those aged 11–12 (15.1%), 19–21 (18.4%), and 22–26 years (4.5%).ConclusionThe proportion of males and females initiating vaccination at the recommended ages was low. Although more females than males were vaccinated in all cohorts, the male–female differences were smaller in younger than older cohorts. The trajectory of male vaccination uptake could signal higher acceptability in males.     

Racial Residential Segregation and Rates of Gonorrhea in the United States, 2003–2007

Objectives. In the United States, Black persons are disproportionately affected by sexually transmitted infections (STIs), including gonorrhea. Individual behaviors do not fully explain these racial disparities. We explored the association of racial residential segregation with gonorrhea rates among Black persons and hypothesized that specific dimensions of segregation would be associated with gonorrhea rates.Methods. We used 2003 to 2007 national STI surveillance data and 2000 US Census Bureau data to examine associations of 5 dimensions of racial residential segregation and a composite measure of hypersegregation with gonorrhea rates among Black persons in 257 metropolitan statistical areas, overall and by sex and age. We calculated adjusted rate ratios with generalized estimating equations.Results. Isolation and unevenness were significantly associated with gonorrhea rates. Centralization was marginally associated with gonorrhea. Isolation was more strongly associated with gonorrhea among the younger age groups. Concentration, clustering, and hypersegregation were not associated with gonorrhea.Conclusions. Certain dimensions of segregation are important in understanding STI risk among US Black persons. Interventions to reduce sexual risk may need to account for racial residential segregation to maximize effectiveness and reduce existent racial disparities.Sexually transmitted infections (STIs) remain an important public health problem in the United States, with approximately 19 million new infections per year.1 Black persons, especially adolescents, bear a disproportionate burden of most STIs, including gonorrhea.2–6 In 2008, rates of gonorrhea were highest among Black individuals, aged 15 to 19 and 20 to 24 years, compared with any other racial/ethnic and age groups.7,8 Among 15- to 19-year-old adolescents, rates of gonorrhea were nearly 21 times higher for Black (2201.9 per 100 000) than for White adolescents (107.0 per 100 000).7 Untreated gonorrhea can have serious and long-term sequelae, including the facilitation of HIV transmission, infertility, and adverse outcomes for infants born to infected mothers.8Exposure to and infection with STIs are conditioned by many factors, including individual behaviors, relationship patterns, and characteristics of the social environment. Substantial attention has been paid to differences in individual risk behaviors, such as condom use and number of sexual partners, but they do not fully explain racial disparities in STI risk.4 Therefore, focusing solely on these proximate factors to reduce risk and disparities may have only limited effect.4,9 A growing body of research has examined the contribution of contextual factors, such as neighborhood attributes, to sexual risk. Specifically, numerous studies have examined whether living in a neighborhood with lower socioeconomic status is associated with sexual risk behaviors, such as younger age at first sexual intercourse and unprotected sexual intercourse.10–20 The findings have been equivocal, with some showing an association and others not. Therefore, a better understanding of the possible effects of other contextual factors on sexual risk is necessary.Racial residential segregation—the extent to which 2 or more racial groups live separate from one another in a metropolitan area—is a characteristic of the social environment that many Black individuals continue to experience.21 Nearly two thirds of Black persons live in highly segregated areas.9 The available evidence suggests that Black individuals living in more segregated areas, compared with less segregated areas, are at higher risk for certain poor health outcomes, such as low birth weight, mental health conditions, and mortality.9,22–28 No published studies to date have examined the association of racial residential segregation with sexual risk, but recent commentary has identified racial residential segregation as a possible cause of disparities in sexual risk.5,9,22,29–31Racial residential segregation, which describes the racial composition of neighborhoods and the spatial distribution of these neighborhoods in larger metropolitan areas, may be more conceptually relevant to understanding racial disparities than are individual and neighborhood characteristics because it captures the unequal structure for Black and White people across the entire housing market. It has been conceptualized in 5 distinct dimensions—exposure, concentration, centralization, clustering, and unevenness. Metropolitan areas are defined by

1. low exposure (or isolated) if minority members do not often share neighborhoods with other groups,
2. concentrated if minorities occupy relatively little physical space per capita,
3. centralized if minorities are more likely to live in neighborhoods around an urban core relative to other groups,
4. clustered if minorities live in neighborhoods that are crowded together to form a large enclave, and
5. uneven if minorities are overrepresented in some neighborhoods and underrepresented in other neighborhoods.32

Racial residential segregation is hypothesized to lead to differential exposure to STIs through a variety of mechanisms. First, segregation might lead to increased rates of STIs among Black persons by affecting the sexual network (e.g., partner availability and density of individuals).5,31 Second, segregation may create or foster environments (e.g., restricted economic and employment opportunities, disordered neighborhoods) that are conducive to sexual risk behaviors and increased STI risk.9,24,29,31 Each dimension of segregation may have varying degrees of salience in describing distinct mechanisms that affect sexual risk and STI transmission.22,24,31 According to a conceptual model proposed by Acevedo-Garcia,22 exposure, concentration, and, to a lesser extent, centralization are relevant to understanding infectious disease risk because of their effect on transmission patterns and social networks.We used 5 years of national sexually transmitted disease (STD) surveillance data to study the associations of racial residential segregation with gonorrhea rates among Black people in the United States at the metropolitan statistical area (MSA) level. According to Acevedo-Garcia’s model, we hypothesized that certain dimensions of segregation, such as exposure and concentration, would be more positively associated with gonorrhea rates compared with other dimensions of segregation. Additionally, we hypothesized that the associations would be modified by sex and age because of differences across sex and age groups in patterns of social influence.     

Treatment Practices,Outcomes, and Costs of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis,United States, 2005–2007

To describe factors associated with multidrug-resistant (MDR), including extensively-drug-resistant (XDR), tuberculosis (TB) in the United States, we abstracted inpatient, laboratory, and public health clinic records of a sample of MDR TB patients reported to the Centers for Disease Control and Prevention from California, New York City, and Texas during 2005–2007. At initial diagnosis, MDR TB was detected in 94% of 130 MDR TB patients and XDR TB in 80% of 5 XDR TB patients. Mutually exclusive resistance was 4% XDR, 17% pre-XDR, 24% total first-line resistance, 43% isoniazid/rifampin/rifabutin-plus-other resistance, and 13% isoniazid/rifampin/rifabutin-only resistance. Nearly three-quarters of patients were hospitalized, 78% completed treatment, and 9% died during treatment. Direct costs, mostly covered by the public sector, averaged $134,000 per MDR TB and $430,000 per XDR TB patient; in comparison, estimated cost per non-MDR TB patient is $17,000. Drug resistance was extensive, care was complex, treatment completion rates were high, and treatment was expensive.