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Volume 24, Number 4—April 2018


  • Two Infants with Presumed Congenital Zika Syndrome, Brownsville, Texas, USA, 2016–2017
    A. Howard et al.
        View Abstract

    Since 2007, Zika virus has spread through the Pacific Islands and the Americas. Beginning in 2016, women in Brownsville, Texas, USA, were identified as possibly being exposed to Zika virus during pregnancy. We identified 18 pregnant women during 2016–2017 who had supportive serologic or molecular test results indicating Zika virus or flavivirus infection. Two infants were evaluated for congenital Zika syndrome after identification of prenatal microcephaly. Despite standard of care testing of mothers and neonates, comparative results were unreliable for mothers and infants, which highlights need for clinical and epidemiologic evidence for an accurate diagnosis. A high index of suspicion for congenital Zika syndrome for at-risk populations is useful because of current limitations of testing.

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  • Seroprevalence of Chikungunya Virus after Its Emergence in Brazil
    J. P. Dias et al.
        View Abstract

    Chikungunya has had a substantial impact on public health because of the magnitude of its epidemics and its highly debilitating symptoms. We estimated the seroprevalence, proportion of symptomatic cases, and proportion of chronic form of disease after introduction of chikungunya virus (CHIKV) in 2 cities in Brazil. We conducted the population-based study through household interviews and serologic surveys during October–December 2015. In Feira de Santana, we conducted a serologic survey of 385 persons; 57.1% were CHIKV-positive. Among them, 32.7% reported symptoms, and 68.1% contracted chronic chikungunya disease. A similar survey in Riachão do Jacuípe included 446 persons; 45.7% were CHIKV-positive, 41.2% reported symptoms, and 75.0% contracted the chronic form. Our data confirm intense CHIKV transmission during the continuing epidemic. Chronic pain developed in a high proportion of patients. We recommend training health professionals in management of chronic pain, which will improve the quality of life of chikungunya-affected persons.

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  • Reemergence of Intravenous Drug Use as Risk Factor for Candidemia, Massachusetts, USA
    N. Poowanawittayakom et al.
    View Summary

    Drug users were more likely to have non-albicans Candida, be co-infected with hepatitis C, and have end-organ involvement.

        View Abstract

    The epidemic of illicit intravenous drug use (IVDU) in the United States has been accompanied by a surge in drug overdose deaths and infectious sequelae. Candida albicans infections were associated with injection of contaminated impure brown heroin in the 1970s–1990s; however, candidiasis accompanying IVDU became considerably rarer as the purity of the heroin supply increased. We reviewed cases of candidemia occurring over a recent 7-year period in persons >14 years of age at a tertiary care hospital in central Massachusetts. Of the 198 patients with candidemia, 24 cases occurred in patients with a history of IVDU. Compared with non-IVDU patients, those with a history of IVDU were more likely to have non-albicans Candida, be co-infected with hepatitis C, and have end-organ involvement, including endocarditis and osteomyelitis. Thus, IVDU appears to be reemerging as a risk factor for invasive candidiasis.



  • Phenotypic and Genotypic Characterization of Enterobacteriaceae Producing Oxacillinase-48–Like Carbapenemases, United States
    J. D. Lutgring et al.
        View Abstract

    Oxacillinase (OXA)–48–like carbapenemases remain relatively uncommon in the United States. We performed phenotypic and genotypic characterization of 30 Enterobacteriaceae producing OXA-48–like carbapenemases that were recovered from patients during 2010–2014. Isolates were collected from 12 states and not associated with outbreaks, although we could not exclude limited local transmission. The alleles β-lactamase OXA-181 (blaOXA-181) (43%), blaOXA-232 (33%), and blaOXA-48 (23%) were found. All isolates were resistant to ertapenem and showed positive results for the ertapenem and meropenem modified Hodge test and the modified carbapenem inactivation method; 73% showed a positive result for the Carba Nordmann–Poirel test. Whole-genome sequencing identified extended-spectrum β-lactamase genes in 93% of isolates. In all blaOXA-232 isolates, the gene was on a ColKP3 plasmid. A total of 12 of 13 isolates harboring blaOXA-181 contained the insertion sequence ΔISEcp1. In all isolates with blaOXA-48, the gene was located on a TN1999 transposon; these isolates also carried IncL/M plasmids.

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  • Genomic Surveillance of 4CMenB Vaccine Antigenic Variants among Disease-Causing Neisseria meningitidis Isolates, United Kingdom, 2010–2016
    C. Rodrigues et al.
        View Abstract

    In September 2015, 4CMenB meningococcal vaccine was introduced into the United Kingdom infant immunization program without phase 3 trial information. Understanding the effect of this program requires enhanced surveillance of invasive meningococcal disease (IMD) Neisseria meningitidis isolates and comparison with prevaccination isolates. Bexsero Antigen Sequence Types (BASTs) were used to analyze whole-genome sequences of 3,073 prevaccine IMD N. meningitidis isolates obtained during 2010−2016. Isolates exhibited 803 BASTs among 31 clonal complexes. Frequencies of antigen peptide variants were factor H binding protein 1, 13.4%; Neisserial heparin-binding antigen 2, 13.8%; Neisseria adhesin A 8, 0.8%; and Porin A-VR2:P1.4,10.9%. In 2015−16, serogroup B isolates showed the highest proportion (35.7%) of exact matches to >1 Bexsero components. Serogroup W isolates showed the highest proportion (93.9%) of putatively cross-reactive variants of Bexsero antigens. Results highlighted the likely role of cross-reactive antigens. BAST surveillance of meningococcal whole-genome sequence data is rapid, scalable, and portable and enables international comparisons of isolates.

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  • Medscape CME Activity
    Rickettsial Illnesses as Important Causes of Febrile Illness in Chittagong, Bangladesh
    H. W. Kingston et al.
    View Summary

    Scrub and murine typhus are common, treatable causes of undifferentiated febrile illnesses in hospitalized patients.

        View Abstract

    We conducted a yearlong prospective study of febrile patients admitted to a tertiary referral hospital in Chittagong, Bangladesh, to assess the proportion of patients with rickettsial illnesses and identify the causative pathogens, strain genotypes, and associated seasonality patterns. We diagnosed scrub typhus in 16.8% (70/416) and murine typhus in 5.8% (24/416) of patients; 2 patients had infections attributable to undifferentiated Rickettsia spp. and 2 had DNA sequence–confirmed R. felis infection. Orientia tsutsugamushi genotypes included Karp, Gilliam, Kato, and TA763-like strains, with a prominence of Karp-like strains. Scrub typhus admissions peaked in a biphasic pattern before and after the rainy season, whereas murine typhus more frequently occurred before the rainy season. Death occurred in 4% (18/416) of cases; case-fatality rates were 4% each for scrub typhus (3/70) and murine typhus (1/28). Overall, 23.1% (96/416) of patients had evidence of treatable rickettsial illnesses, providing important evidence toward optimizing empirical treatment strategies.

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  • Influence of Population Immunosuppression and Past Vaccination on Smallpox Reemergence
    C. MacIntyre et al.
        View Abstract

    We built a SEIR (susceptible, exposed, infected, recovered) model of smallpox transmission for New York, New York, USA, and Sydney, New South Wales, Australia, that accounted for age-specific population immunosuppression and residual vaccine immunity and conducted sensitivity analyses to estimate the effect these parameters might have on smallpox reemergence. At least 19% of New York’s and 17% of Sydney’s population are immunosuppressed. The highest smallpox infection rates were in persons 0–19 years of age, but the highest death rates were in those >45 years of age. Because of the low level of residual vaccine immunity, immunosuppression was more influential than vaccination on death and infection rates in our model. Despite widespread smallpox vaccination until 1980 in New York, smallpox outbreak severity appeared worse in New York than Sydney. Immunosuppression is highly prevalent and should be considered in future smallpox outbreak models because excluding this factor probably underestimates death and infection rates.

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  • Bacterial Infections in Neonates, Madagascar, 2012–2014
    B. Huynh et al.
        View Abstract

    Severe bacterial infections are a leading cause of death among neonates in low-income countries, which harbor several factors leading to emergence and spread of multidrug-resistant bacteria. Low-income countries should prioritize interventions to decrease neonatal infections; however, data are scarce, specifically from the community. To assess incidence, etiologies, and antimicrobial drug–resistance patterns of neonatal infections, during 2012–2014, we conducted a community-based prospective investigation of 981 newborns in rural and urban areas of Madagascar. The incidence of culture-confirmed severe neonatal infections was high: 17.7 cases/1,000 live births. Most (75%) occurred during the first week of life. The most common (81%) bacteria isolated were gram-negative. The incidence rate for multidrug-resistant neonatal infection was 7.7 cases/1,000 live births. In Madagascar, interventions to improve prevention, early diagnosis, and management of bacterial infections in neonates should be prioritized.

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  • Artemisinin-Resistant Plasmodium falciparum with High Survival Rates, Uganda, 2014–2016
    M. Ikeda et al.
        View Abstract

    Because ≈90% of malaria cases occur in Africa, emergence of artemisinin-resistant Plasmodium falciparum in Africa poses a serious public health threat. To assess emergence of artemisinin-resistant parasites in Uganda during 2014–2016, we used the recently developed ex vivo ring-stage survival assay, which estimates ring-stage–specific P. falciparum susceptibility to artemisinin. We conducted 4 cross-sectional surveys to assess artemisinin sensitivity in Gulu, Uganda. Among 194 isolates, survival rates (ratio of viable drug-exposed parasites to drug-nonexposed controls) were high (>10%) for 4 isolates. Similar rates have been closely associated with delayed parasite clearance after drug treatment and are considered to be a proxy for the artemisinin-resistant phenotype. Of these, the PfKelch13 mutation was observed in only 1 isolate, A675V. Population genetics analysis suggested that these possibly artemisinin-resistant isolates originated in Africa. Large-scale surveillance of possibly artemisinin-resistant parasites in Africa would provide useful information about treatment outcomes and help regional malaria control.

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  • Cooperative Recognition of Internationally Disseminated Ceftriaxone-resistant Neisseria gonorrhoeae Strain
    M. M. Lahra et al.
        View Abstract

    Ceftriaxone remains a first-line treatment for patients infected by Neisseria gonorrhoeae in most settings. We investigated the possible spread of a ceftriaxone-resistant FC428 N. gonorrhoeae clone in Japan after recent isolation of similar strains in Denmark (GK124) and Canada (47707). We report 2 instances of the FC428 clone in Australia in heterosexual men traveling from Asia. Our bioinformatic analyses included core single-nucleotide variation phylogeny and in silico molecular typing; phylogenetic analysis showed close genetic relatedness among all 5 isolates. Resultsshowed multilocus sequence type 1903; N. gonorrhoeae sequence typing for antimicrobial resistance (NG-STAR) 233; and harboring of mosaic penA allele encoding alterations A311V and T483S (penA-60.001), associated with ceftriaxone resistance. Our results provide further evidence of international transmission of ceftriaxone-resistant N. gonorrhoeae. We recommend increasing awareness of international spread of this drug-resistant strain, strengthening surveillance to include identifying treatment failures and contacts, and strengthening international sharing of data.

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  • Influenza A(H7N9) Virus Antibody Responses in Survivors 1 Year after Infection, China, 2017
    M. Ma et al.
        View Abstract

    Avian influenza A(H7N9) virus has caused 5 epidemic waves in China since its emergence in 2013. We investigated the dynamic changes of antibody response to this virus over 1 year postinfection in 25 patients in Suzhou City, Jiangsu Province, China, who had laboratory-confirmed infections during the fifth epidemic wave, Oct 1, 2016–February 14, 2017. Most survivors had relatively robust antibody responses that decreased but remained detectable at 1 year. Antibody response was variable; several survivors had low or undetectable antibody titers. Hemagglutination inhibition titer was >1:40 for <40% of the survivors. Measured in vitro in infected mice, hemagglutination inhibition titer predicted serum protective ability. Our findings provide a helpful serologic guideline for identifying subclinical infections and for developing effective vaccines and therapeutics to counter H7N9 virus infections.

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  • Carbapenem-Nonsusceptible Acinetobacter baumannii, 8 US Metropolitan Areas, 2012–2015
    S. N. Bulens et al.
        View Abstract

    In healthcare settings, Acinetobacter spp. bacteria commonly demonstrate antimicrobial resistance, making them a major treatment challenge. Nearly half of Acinetobacter organisms from clinical cultures in the United States are nonsusceptible to carbapenem antimicrobial drugs. During 2012–2015, we conducted laboratory- and population-based surveillance in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee to determine the incidence of carbapenem-nonsusceptible A. baumannii cultured from urine or normally sterile sites and to describe the demographic and clinical characteristics of patients and cases. We identified 621 cases in 537 patients; crude annual incidence was 1.2 cases/100,000 persons. Among 598 cases for which complete data were available, 590 (98.7%) occurred among patients with overnight stays in a hospital during the preceding year; 506 (84.6%) patients had an indwelling device. Although incidence was lower than for other healthcare-associated pathogens, cases were associated with substantial rates of illness and death.

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  • Avirulent Bacillus anthracis Strain with Molecular Assay Targets as Surrogate for Irradiation-Inactivated Virulent Spores
    R. D. Plaut et al.
        View Abstract

    The revelation in May 2015 of the shipment of γ irradiation–inactivated wild-type Bacillus anthracis spore preparations containing a small number of live spores raised concern about the safety and security of these materials. The finding also raised doubts about the validity of the protocols and procedures used to prepare them. Such inactivated reference materials were used as positive controls in assays to detect suspected B. anthracis in samples because live agent cannot be shipped for use in field settings, in improvement of currently deployed detection methods or development of new methods, or for quality assurance and training activities. Hence, risk-mitigated B. anthracis strains are needed to fulfill these requirements. We constructed a genetically inactivated or attenuated strain containing relevant molecular assay targets and testing to compare assay performance using this strain to the historical data obtained using irradiation-inactivated virulent spores.

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  • Evolution of Sequence Type 4821 Clonal Complex Meningococcal Strains in China from Prequinolone to Quinolone Era, 1972–2013
    Q. Guo et al.
        View Abstract

    The expansion of hypervirulent sequence type 4821 clonal complex (CC4821) lineage Neisseria meningitidis bacteria has led to a shift in meningococcal disease epidemiology in China, from serogroup A (MenA) to MenC. Knowledge regarding the evolution and genetic origin of the emergent MenC strains is limited. In this study, we subjected 76 CC4821 isolates collected across China during 1972–1977 and 2005–2013 to phylogenetic analysis, traditional genotyping, or both. We show that successive recombination events within genes encoding surface antigens and acquisition of quinolone resistance mutations possibly played a role in the emergence of CC4821 as an epidemic clone in China. MenC and MenB CC4821 strains have spread across China and have been detected in several countries in different continents. Capsular switches involving serogroups B and C occurred among epidemic strains, raising concerns regarding possible increases in MenB disease, given that vaccines in use in China do not protect against MenB.

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  • Emerging Coxsackievirus A6 Causing Hand, Foot and Mouth Disease, Vietnam
    N. Anh et al.
        View Abstract

    Hand, foot and mouth disease (HFMD) is a major public health issue in Asia and has global pandemic potential. Coxsackievirus A6 (CV-A6) was detected in 514/2,230 (23%) of HFMD patients admitted to 3 major hospitals in southern Vietnam during 2011–2015. Of these patients, 93 (18%) had severe HFMD. Phylogenetic analysis of 98 genome sequences revealed they belonged to cluster A and had been circulating in Vietnam for 2 years before emergence. CV-A6 movement between localities within Vietnam occurred frequently, whereas viral movement across international borders appeared rare. Skyline plots identified fluctuations in the relative genetic diversity of CV-A6 corresponding to large CV-A6–associated HFMD outbreaks worldwide. These data show that CV-A6 is an emerging pathogen and emphasize the necessity of active surveillance and understanding the mechanisms that shape the pathogen evolution and emergence, which is essential for development and implementation of intervention strategies.

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Research Letters

About the Cover


Volume 24, Number 5—May 2018


  • History of Mosquitoborne Diseases in the United States and Implications for New Pathogens
    M. J. Moreno-Madriñán and M. Turell


  • Two Cases of Israeli Spotted Fever with Purpura Fulminans, Sharon District, Israel
    R. Cohen et al.
    View Summary

    Genetic sequencing should be used to confirm cases because purpura fulminans is a rare finding.

  • Antimicrobial-Resistant Bacteria in Hospitalized Children, Cambodia, 2007–2016


  • Dynamics of Spirochetemia and PCR Detection of Borrelia miyamotoi Disease
    L. Karan et al.


  • Human Usutu Virus Infection with Atypical Neurologic Presentation, Montpellier, France, 2016
    Y. Simonin et al.
  • Epizootic Hemorrhagic Disease Virus Serotype 6 Infection in Cattle, Japan, 2015
    Y. Kamomae et al.
  • External Quality Assessment for Zika Virus Molecular Diagnostic Testing, Brazil
    C. Fischer et al.
        View Abstract

    We conducted an external quality assessment of Zika virus molecular diagnostic tests in Brazil using a new Zika virus standard. Of 15 laboratories, 73% showed limited sensitivity and specificity. Viral load estimates varied significantly. Continuous quality assurance is needed to adequately estimate risk for Zika virus–associated disease and determine patient care.

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  • Seroprevalence of Severe Fever with Thrombocytopenia Syndrome Virus in Rural Areas, South Korea
    M. Han et al.
  • Equine Encephalosis Virus in India, 2008
    P. D. Yadav et al.
  • Foodborne Outbreaks Caused by Human Norovirus GII.P17-GII.17–Contaminated Dried Shredded Seaweed (Nori), Japan, 2017
    N. Sakon et al.
  • Fatal Visceral Leishmaniasis Caused by Leishmania infantum, Lebanon
    R. El Hajj et al.
  • Second Human Pegivirus in Hepatitis C Virus–Infected and Hepatitis C Virus/HIV-1–Coinfected Persons Who Inject Drugs, China
    H. Wang et al.
  • Heartland Virus and Hemophagocytic Lymphohistiocytosis in an Immunocompromised Patient, Missouri
    A. L. Carlson et al.
  • Alkhurma Hemorrhagic Fever Virus RNA in Hyalomma rufipes Ticks Infesting Migratory Birds, Europe and Asia Minor
    T. Hoffman et al.
  • Antimicrobial Resistance in Wound Infections, Ghana, 2014
    H. Janssen et al.

Research Letters

  • Borrelia miyamotoi sensu lato in Highly Endangered Père David Deer and Haemaphysalis longicornis
    Y. Yang et al.
  • Multiple Introductions of Influenza A(H5N8) Virus into Poultry, Egypt, 2017
    A. H. Salaheldin et al.
        View Abstract

    After high mortality rates among commercial poultry were reported in Egypt in 2017, we genetically characterized 4 distinct influenza A(H5N8) viruses isolated from poultry. Full-genome analysis indicated separate introductions of H5N8 clade reassortants from Europe and Asia into Egypt, which poses a serious threat for poultry and humans.

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  • Fatal Tickborne Encephalitis Virus Infections Caused by Siberian and European Subtypes, Finland, 2015
    S. Kuivanen et al.
  • Middle East Respiratory Syndrome Coronavirus Antibodies in Dromedary Camels, Bangladesh, 2015
    A. Islam et al.
  • A Mental Models Approach to Assessing Public Understanding of Zika Virus, Guatemala
    B. G. Southwell et al.
  • Zika Virus or TORCH Pathogens in Infants with Microcephaly, Guinea-Bissau, 2016
    M. Rosenstierne et al.


  • Potentially Same Novel Ehrlichia Species in Horses in Nicaragua and Brazil
    T. Vieira et al.

Books and Media

  • Catching Breath: The Making and Unmaking of Tuberculosis
    M. J. Oxtoby and E. M. Dufort
  • The Power of Plagues, Second Edition
    T. J. Marrie

Volume 24, Number 6—June 2018


  • Human Infections with Multistress-Tolerant Campylobacter jejuni
    E. Oh et al.


  • Foot-and-Mouth Disease Caused by an A/ASIA/G-VII Virus Lineage, Middle East, 2015–2016
    K. Bachanek-Bankowska et al.
  • Novel Poxvirus in Proliferative Lesions of Wild Rodents in East-Central Texas
    C. L. Hodo et al.
  • Importation of Human Seoul Virus Infection to Germany from Indonesia
    J. Hofmann et al.
  • Mixed Leptospira Infections in Diverse Reservoir Host Community in Madagascar
    M. Moseley et al.

Volume 24, Number 7—July 2018


  • Progress in Vaccine-Preventable and Respiratory Infectious Diseases—First 10 Years of the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 2006–2015
    A. J. Anderson et al.