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Early Release

Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.

Volume 26, Number 9—September 2020

  • Seroepidemiologic Study Designs for Determining SARS-COV-2 Transmission and Immunity
    H. Clapham et al.

    Serologic studies are crucial for clarifying dynamics of the coronavirus disease pandemic. Past work on serologic studies (e.g., during influenza pandemics) has made relevant contributions, but specific conditions of the current situation require adaptation. Although detection of antibodies to measure exposure, immunity, or both seems straightforward conceptually, numerous challenges exist in terms of sample collection, what the presence of antibodies actually means, and appropriate analysis and interpretation to account for test accuracy and sampling biases. Successful deployment of serologic studies depends on type and performance of serologic tests, population studied, use of adequate study designs, and appropriate analysis and interpretation of data. We highlight key questions that serologic studies can help answer at different times, review strengths and limitations of different assay types and study designs, and discuss methods for rapid sharing and analysis of serologic data to determine global transmission of severe acute respiratory syndrome coronavirus 2.

  • Disparate Effects of Invasive Group A Streptococcus on Native Americans
    R. M. Close and J. B. McAuley

    Active surveillance of invasive group A Streptococcus (iGAS) disease indicates that its incidence in the US general population is low, but limited studies show rates for American Indians and Alaska Natives (AI/AN) are severalfold higher. Major disparities in rates of iGAS exist between Indigenous and non-Indigenous populations of Australia, New Zealand, and Canada, but much less is understood about iGAS among AI/AN in the United States. Although complex host–pathogen interactions influence the rates of iGAS, including strain variation and virulence, the number and type of concurrent conditions, and socioeconomic status, the relative contribution of each remains unclear. We highlight the poor correlation between the substantial effect of iGAS among Indigenous persons in industrialized countries and the current understanding of factors that influence iGAS disease in these populations. Prospective, large-scale, population-based studies of iGAS are needed that include AI/AN as a necessary first step to understanding the effects of iGAS.

  • Polyclonal Burkholderia cepacia Complex Outbreak in Peritoneal Dialysis Patients Caused by Contaminated Aqueous Chlorhexidine
    S. Wong et al.

    Whether Burkholderia cepacia complex should be an objectionable organism in antiseptic solutions with acceptable total bacterial counts is controversial. By using next-generation sequencing, we documented a polyclonal B. cepacia complex outbreak affecting peritoneal dialysis patients in Hong Kong that was caused by contaminated chlorhexidine solutions. Epidemiologic investigations at a manufacturing site identified a semiautomated packaging machine as the probable source of contamination in some of the brands. Use of whole-genome sequencing differentiated the isolates into 3 brand-specific clonal types. Changes in exit site care recommendations, rapid recall of affected products, and tightening of regulatory control for chlorhexidine-containing skin antiseptics could prevent future similar outbreaks. Environmental opportunistic pathogens, including B. cepacia complex, might be included in regular surveillance as indicator organisms for monitoring environmental contamination.

  • Pathology and Pathogenesis of SARS-CoV-2 Associated with Fatal Coronavirus Disease, United States
    R. B. Martines et al.

    An ongoing pandemic of coronavirus disease (COVID-19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Characterization of the histopathology and cellular localization of SARS-CoV-2 in the tissues of patients with fatal COVID-19 is critical to further understand its pathogenesis and transmission and for public health prevention measures. We report clinicopathologic, immunohistochemical, and electron microscopic findings in tissues from 8 fatal laboratory-confirmed cases of SARS-CoV-2 infection in the United States. All cases except 1 were in residents of long-term care facilities. In these patients, SARS-CoV-2 infected epithelium of the upper and lower airways with diffuse alveolar damage as the predominant pulmonary pathology. SARS-CoV-2 was detectable by immunohistochemistry and electron microscopy in conducting airways, pneumocytes, alveolar macrophages, and a hilar lymph node but was not identified in other extrapulmonary tissues. Respiratory viral co-infections were identified in 3 cases; 3 cases had evidence of bacterial co-infection.

  • Severe Acute Respiratory Syndrome Coronavirus 2 Prevalence, Seroprevalence, and Exposure Among Evacuees from Wuhan, China, 2020
    B. D. Hallowell et al.

    To determine prevalence of, seroprevalence of, and potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among a cohort of evacuees returning to the United States from Wuhan, China, in January 2020, we conducted a cross-sectional study of quarantined evacuees from 1 repatriation flight. Overall, 193 of 195 evacuees completed exposure surveys and submitted upper respiratory or serum specimens or both at arrival in the United States. Nearly all evacuees had taken preventive measures to limit potential exposure while in Wuhan, and none had detectable SARS-CoV-2 in upper respiratory tract specimens, suggesting the absence of asymptomatic respiratory shedding among this group at the time of testing. Evidence of antibodies to SARS-CoV-2 was detected in 1 evacuee, who reported experiencing no symptoms or high-risk exposures in the previous 2 months. These findings demonstrated that this group of evacuees posed a low risk of introducing SARS-CoV-2 to the United States.

  • Encephalopathy and Encephalitis Associated with Cerebrospinal Fluid Cytokine Alterations and Coronavirus Disease, Atlanta, Georgia, USA, 2020
    K. Benameur et al.

    Few detailed investigations of neurologic complications in severe acute respiratory syndrome coronavirus 2 infection have been conducted. We describe 3 patients with laboratory-confirmed coronavirus disease who showed development of encephalopathy and encephalitis. Neuroimaging showed nonenhancing unilateral, bilateral, and midline changes not readily attributable to vascular causes. All 3 patients had increased cerebrospinal fluid (CSF) levels of anti-S1 IgM. One patient who died also had increased levels of anti–envelope protein IgM. CSF analysis also showed markedly increased levels of interleukin (IL) 6, IL-8, and IL-10, but severe acute respiratory syndrome coronavirus 2 was not identified in any CSF sample. These changes provide evidence of CSF periinfectious/postinfectious inflammatory changes during coronavirus disease with neurologic complications.

  • Saprochaete clavata Outbreak Infecting Cancer Center through Dishwasher
    E. Menu et al.

    Saprochaete clavata is a pathogenic yeast responsible for rare outbreaks involving immunocompromised patients, especially those with hematologic malignancies. During February 2016–December 2017, we diagnosed S. clavata infections in 9 patients (8 with fungemia), including 3 within 1 month, at a cancer center in Marseille, France. The patients (median age 58 years), 4 of 9 of whom had acute myeloid leukemia, were hospitalized in 3 different wards. Ten environmental samples, including from 2 dishwashers and 4 pitchers, grew S. clavata, but no contaminated food was discovered. The outbreak ended after contaminated utensils and appliances were discarded. Whole-genome sequencing analysis demonstrated that all clinical and environmental isolates belonged to the same phylogenetic clade, which was unrelated to clades from previous S. clavata outbreaks in France. We identified a dishwasher with a deficient heating system as the vector of contamination.

  • Q-Fever Osteoarticular Infection in Children
    H. Dabaja-Younis et al.
  • Web-Based Interactive Tool to Identify Facilities at Risk of Receiving Patients with Multidrug-Resistant Organisms
    R. Octaria et al.

    To identify facilities at risk of receiving patients colonized or infected with multidrug-resistant organisms (MDROs), we developed an interactive web-based interface for visualization of patient-sharing networks among healthcare facilities in Tennessee, USA. Using hospital discharge data and the Centers for Medicare and Medicaid Services’ claims and Minimum Data Set, we constructed networks among hospitals and skilled nursing facilities. Networks included direct and indirect transfers, which accounted for <365 days in the community outside of facility admissions. Authorized users can visualize a facility of interest and tailor visualizations by year, network dataset, length of time in the community, and minimum number of transfers. The interface visualizes the facility of interest with its connected facilities that receive or send patients, the number of interfacility transfers, and facilities at risk of receiving transfers from the facility of interest. This tool will help other health departments enhance their MDRO outbreak responses.

  • Invasive Infections with Nannizziopsis obscura Species Complex in 9 Patients from West Africa, France, 2004–2020
    D. Garcia-Hermoso et al.
  • Association of Biosecurity and Hygiene Practices with Environmental Contamination with Influenza A Viruses in Live Bird Markets, Bangladesh
    S. Chowdhury et al.

    In Bangladesh, live bird market environments are frequently contaminated with avian influenza viruses. Shop-level biosecurity practices might increase risk for environmental contamination. We sought to determine which shop-level biosecurity practices were associated with environmental contamination. We surveyed 800 poultry shops to describe biosecurity practices and collect environmental samples. Samples from 205 (26%) shops were positive for influenza A viral RNA, 108 (14%) for H9, and 60 (8%) for H5. Shops that slaughtered poultry, kept poultry overnight, remained open without rest days, had uneven muddy floors, held poultry on the floor, and housed sick and healthy poultry together were more frequently positive for influenza A viruses. Reported monthly cleaning seemed protective, but disinfection practices were not otherwise associated with influenza A virus detection. Slaughtering, keeping poultry overnight, weekly rest days, infrastructure, and disinfection practices could be targets for interventions to reduce environmental contamination.

  • Risk-Based Estimate of Human Fungal Disease Burden, China
    L. Zhou et al.

    We conducted a systematic literature review to obtain risk population–based fungal disease incidence or prevalence data from China. Data were categorized by risk factors and extrapolated by using most recent demographic figures. A total of 71,316,101 cases (5.0% of the population) were attributed to 12 risk factors and 17 fungal diseases. Excluding recurrent Candida vaginitis (4,057/100,000 women) and onychomycosis (2,600/100,000 persons), aspergillosis (317/100,000 persons) was the most common problem; prevalence exceeded that in most other countries. Cryptococcal meningitis, an opportunistic infection, occurs in immunocompetent persons almost twice as often as AIDS. The pattern of fungal infections also varies geographically; Talaromyces marneffei is distributed mainly in the Pearl River Basin, and the Yangtze River bears the greatest histoplasmosis burden. New host populations, new endemic patterns, and high fungal burdens in China, which caused a huge impact on public health, underscore the urgent need for building diagnostic and therapeutic capacity.

  • Molecular Description of a Novel Orientia Species Causing Scrub Typhus in Chile
    K. Abarca et al.

    Scrub typhus is a potentially fatal rickettsiosis caused by Orientia species intracellular bacteria of the genus Orientia. Although considered to be restricted to the Asia Pacific region, scrub typhus has recently been discovered in southern Chile. We analyzed Orientia gene sequences of 16S rRNA (rrs) and 47-kDa (htrA) from 18 scrub typhus patients from Chile. Sequences were ≥99.7% identical among the samples for both amplified genes. Their diversity was 3.1%–3.5% for rrs and 11.2%–11.8% for htrA compared with O. tsusugamushi and 3.0% for rrs and 14.8% for htrA compared with Candidatus Orientia chuto. Phylogenetic analyses of both genes grouped the specimens from Chile in a different clade from other Orientia species. Our results indicate that Orientia isolates from Chile constitute a novel species, which, until they are cultivated and fully characterized, we propose to designate as Candidatus Orientia chiloensis, after the Chiloé Archipelago where the pathogen was identified.

  • Evaluation of World Health Organization–Recommended Hand Hygiene Formulations
    M. Suchomel et al.

    As a result of the coronavirus disease pandemic, commercial hand hygiene products have become scarce and World Health Organization (WHO) alcohol-based hand rub formulations containing ethanol or isopropanol are being produced for hospitals worldwide. Neither WHO formulation meets European Norm 12791, the basis for approval as a surgical hand preparation, nor satisfies European Norm 1500, the basis for approval as a hygienic hand rub. We evaluated the efficacy of modified formulations with alcohol concentrations in mass instead of volume percentage and glycerol concentrations of 0.5% instead of 1.45%. Both modified formulations met standard requirements for a 3-minute surgical hand preparation, the usual duration of surgical hand treatment in most hospitals in Europe. Contrary to the originally proposed WHO hand rub formulations, both modified formulations are appropriate for surgical hand preparation after 3 minutes when alcohol concentrations of 80% wt/wt ethanol or 75% wt/wt isopropanol along with reduced glycerol concentration (0.5%) are used.

  • Heterogeneity of Dengue Illness in Community-Based Prospective Study, Iquitos, Peru
    W. H. Elson et al.

    Measuring heterogeneity of dengue illness is necessary to define suitable endpoints in dengue vaccine and therapeutic trials and will help clarify behavioral responses to illness. To quantify heterogeneity in dengue illness, including milder cases, we developed the Dengue Illness Perceptions Response (IPR) survey, which captured detailed symptom data, including intensity, duration, and character, and change in routine activities caused by illness. During 2016–2019, we collected IPR data daily during the acute phase of illness for 79 persons with a positive reverse transcription PCR result for dengue virus RNA. Most participants had mild ambulatory disease. However, we measured substantial heterogeneity in illness experience, symptom duration, and maximum reported intensity of individual symptoms. Symptom intensity was a more valuable predicter of major activity change during dengue illness than symptom presence or absence alone. These data suggest that the IPR measures clinically useful heterogeneity in dengue illness experience and its relation to altered human behavior.

  • Isolation, Sequence, Infectivity, and Replication Kinetics of Severe Acute Respiratory Syndrome Coronavirus 2
    A. Banerjee et al.

    Since its emergence in Wuhan, China, in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected ≈6 million persons worldwide. As SARS-CoV-2 spreads across the planet, we explored the range of human cells that can be infected by this virus. We isolated SARS-CoV-2 from 2 infected patients in Toronto, Canada; determined the genomic sequences; and identified single-nucleotide changes in representative populations of our virus stocks. We also tested a wide range of human immune cells for productive infection with SARS-CoV-2. We confirm that human primary peripheral blood mononuclear cells are not permissive for SARS-CoV-2. As SARS-CoV-2 continues to spread globally, it is essential to monitor single-nucleotide polymorphisms in the virus and to continue to isolate circulating viruses to determine viral genotype and phenotype by using in vitro and in vivo infection models.

  • Incidence and Seroprevalence of Avian Influenza in a Cohort of Backyard Poultry Growers, Egypt, August 2015–March 2019
    M. R. Gomaa et al.

    Currently enzootic avian influenza H5N1, H9N2, and H5N8 viruses were introduced into poultry in Egypt in 2006, 2011, and 2016, respectively. Infections with H5N1 and H9N2 were reported among poultry-exposed humans. We followed 2,402 persons from households raising backyard poultry from 5 villages in Egypt during August 2015–March 2019. We collected demographic, exposure, and health condition data and annual serum samples from each participant and obtained swab samples from participants reporting influenza-like illness symptoms. We performed serologic and molecular analyses and detected 4 cases of infection with H5N1 and 3 cases with H9N2. We detected very low seroprevalence of H5N1 antibodies and no H5N8 antibodies among the cohort; up to 11% had H9 antibodies. None of the exposure, health status, or demographic variables were related to being seropositive. Our findings indicate that avian influenza remains a public health risk in Eqypt, but infections may go undetected because of their mild or asymptomatic nature.

  • Retrospective Description of Pregnant Women Infected with Severe Acute Respiratory Syndrome Coronavirus 2, France
    A. J. Vivanti et al.

    Little data are available on the management of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We conducted a retrospective study of 100 pregnant women with SARS-CoV-2 infection in 4 obstetric units in the Paris metropolitan area of France during March 12–April 13, 2020. Among patients, 52 (52%) were hospitalized, 10 (10%) in intensive care units (ICUs). Women with higher body mass indexes (BMIs; median 30.7 kg/m2) were more likely to be hospitalized in ICUs than other women (median BMI 26.2 kg/m2). Women hospitalized in ICUs had lower lymphocyte count at diagnosis (median 0.77 × 109 cells/L) than women not hospitalized in ICUs (median lymphocyte count 1.15 × 109 cells/L). All women requiring oxygen >5 L/min were intubated. Clinical and laboratory evaluation of SARS-CoV-2−positive pregnant women at the time of diagnosis can identify patients at risk for ICU hospitalization.

  • Detection of H1 Swine Influenza A Virus Antibodies in Human Serum Samples by Age Group
    E. Vandoorn et al.

    Most H1 influenza A viruses (IAVs) of swine are derived from past human viruses. As human population immunity against these IAVs gradually decreases, the risk of reintroduction to humans increases. We examined 549 serum samples from persons 0–97 years of age collected in Belgium during 2017–2018 for hemagglutination inhibiting and virus neutralizing antibodies against 7 major H1 swine IAV (swIAV) clades and 3 human progenitor IAVs. Seroprevalence (titers >40) rates were >50% for classical swine and European human-like swIAVs, >24% for North American human-like δ1a and Asian avian-like swIAVs, and <10% for North American human-like δ1b and European avian-like swIAVs, but rates were age-dependent. Antibody titers against human-like swIAVs and supposed human precursor IAVs correlated with correlation coefficients of 0.30–0.86. Our serologic findings suggest that European avian-like, clade 1C.2.1, and North American human-like δ1b, clade 1B.2.2.2, H1 swIAVs pose the highest pandemic risk.

  • Costs Associated with Nontuberculous Mycobacteria Infection, Ontario, Canada, 2001–2012
    L. C. Ramsay et al.

    To determine incidence-based healthcare costs attributable to nontuberculous mycobacterial (NTM) pulmonary disease (PD) and NTM pulmonary isolation (PI), from the healthcare payer perspective, we conducted a population-based matched cohort study in Ontario, Canada. We established cohorts of patients with incident NTM-PD and NTM-PI during 2001–2012 by using individually linked laboratory data and health administrative data, matched to unexposed persons from the general population. To estimate attributable costs for acute and long-term illness, we used a phase-of-care approach. Costs were stratified by age, sex, and healthcare resource, and reported in 2018 Canadian dollars (CAD) and US dollars (USD), standardized to 10 days. Costs were highest during the before-death phase (NTM-PD CAD $1,352 [USD $1,044]; NTM-PI CAD $731 [USD $565]). The cumulative mean attributable 1-year costs were CAD $14,953 (USD $11,541) for NTM-PD and CAD $8,729 (USD $6,737) for NTM-PI. Costs for patients with NTM-PD and NTM-PI were higher than those for unexposed persons.

  • No Change in Risk for Antibiotic-Resistant Salmonellosis from Beef, United States, 2002–2010
    S. Costard et al.

    Restricting antibiotic use in food production animals is a target for reducing antimicrobial drug–resistant infections in humans. To estimate the probability of antibiotic-resistant nontyphoidal salmonellosis per meal made with beef during 2002–2010, we used US surveillance data. Applying data for nontyphoidal Salmonella in raised-without-antibiotics cattle, we then tested the effect of removing antibiotic use from all beef cattle production. We found an average of 1.2 antibiotic-resistant nontyphoidal salmonellosis cases per 1 million meals made with beef initially contaminated with antibiotic-resistant nontyphoidal Salmonella at slaughter or retail and 0.031 cases per 1 million meals irrespective of beef contamination status. Neither outcome changed except for increases in 2003 and 2009 (>98% confidence) when larger or more outbreaks occurred. Switching all beef production to a raised-without-antibiotics system may not have a substantial effect on antibiotic-resistant nontyphoidal salmonellosis (94.3% confidence).

  • Hepatitis E Virus Genotype 7 RNA and Antibody Kinetics in Naturally Infected Dromedary Calves, United Arab Emirates
    V. M. Corman et al.

    Orthohepevirus A genotype 7 is a novel zoonotic variant of hepatitis E virus. To clarify infection in the animal reservoir, we virologically monitored 11 dromedary dam–calf pairs. All calves became infected during the first 6 months of life and cleared the virus after an average of 2 months. Dams did not become infected.

  • Detection of Severe Acute Respiratory Syndrome Coronavirus 2 RNA on Surfaces in Quarantine Rooms
    F. Jiang et al.

    We investigated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) environmental contamination in 2 rooms of a quarantine hotel after 2 presymptomatic persons who stayed there were laboratory-confirmed as having coronavirus disease. We detected SARS-CoV-2 RNA on 8 (36%) of 22 surfaces, as well as on the pillow cover, sheet, and duvet cover.

  • Clinicopathologic and Immunohistochemical Findings from Autopsy of Patient with COVID-19, Japan
    T. Adachi et al.

    An autopsy of a patient in Japan with coronavirus disease indicated pneumonia lung pathology, manifested as diffuse alveolar damage. We detected severe acute respiratory syndrome coronavirus 2 antigen in alveolar epithelial cells and macrophages. Coronavirus disease is essentially a lower respiratory tract disease characterized by direct viral injury of alveolar epithelial cells.

  • Lyme Borreliosis with Scalp Eschar Mimicking Rickettsial Infection, Austria
    M. Markowicz et al.

    We report on a patient in Austria with scalp eschar and neck lymphadenopathy. Rickettsial etiology was excluded by culture, PCR, and serologic tests. Borrelia afzelii was identified from the eschar swab by PCR. Lyme borreliosis can mimic rickettsiosis; appropriate tests should be included in the diagnostic workup of patients with eschars.

  • Large Outbreak of Coronavirus Disease among Wedding Attendees, Jordan
    D. Yusef et al.

    In March 2020, a wedding in Jordan led to a large outbreak of coronavirus disease (COVID-19). We collected data on 350 wedding attendees, 76 who of whom developed COVID-19. Our study shows high communicability of COVID-19 and the enormous risk for severe acute respiratory syndrome 2 virus transmission during mass gatherings.

  • Carbapenemase-Producing Gram-Negative Bacteria in Andalusia, Spain, 2014–2018
    I. López-Hernández et al.

    The emergence and spread of carbapenemase-producing gram-negative bacteria is a major public health concern. We used data collected from microbiology laboratories as part of the PIRASOA program during 2014–2018 to study the epidemiology of carbapenemase-producing bacteria in Andalusia, Spain. Our findings highlight the importance of ongoing surveillance and epidemiologic studies for these bacteria.

  • Enterovirus D68 Subclade B3 in Children with Acute Flaccid Paralysis in West Africa, 2016
    A. Fall et al.

    We tested for enterovirus D68 in fecal samples collected during June–September 2016 from 567 patients with acute flaccid paralysis in 7 West Africa nations. Children <5 years old comprised 64.3% of enterovirus D68 positive patients. Our findings emphasize the need for active surveillance for acute flaccid myelitis.

  • Role of Wildlife in Emergence of Ebola Virus in Kaigbono (Likati), Democratic Republic of the Congo, 2017
    S. Gryseels et al.

    After the 2017 Ebola virus (EBOV) outbreak in Likati, a district in northern Democratic Republic of the Congo, we sampled small mammals from the location where the primary case-patient presumably acquired infection. None tested positive for EBOV RNA or antibodies against EBOV, highlighting the ongoing challenge in detecting animal reservoirs for EBOV.

  • Emergence of pstS-Null Vancomycin-Resistant Enterococcus faecium Clone ST1478, Canada, 2013–2018
    M. McCracken et al.

    Rates of vancomycin-resistant enterococci bloodstream infections have remained relatively low in Canada. We recently observed an increase of 113% in these infections rates, which coincided with emergence of Enterococcus faecium pstS-null sequence type 1478. The proportion of this sequence type increased from 2.7% to 38.7% for all tested isolates from 2013–2018.

  • Clusters of Coronavirus Disease in Communities, Japan, January–April 2020
    Y. Furuse et al.

    We analyzed 3,184 cases of coronavirus disease in Japan and identified 61 case-clusters in healthcare and other care facilities, restaurants and bars, workplaces, and music events. We also identified 22 probable primary case-patients for the clusters; most were 20–39 years of age and presymptomatic or asymptomatic at virus transmission.

  • Sequence Type Changes Associated with Decreasing Macrolide-Resistant Mycoplasma pneumoniae, Japan
    M. Morozumi et al.

    We compared sequence types (STs) of Mycoplasma pneumoniae isolates from Japan during 2002–2019. ST3 and ST14 dominated during 2002–2016, and ST7 and ST33 dominated during 2018–2019. These STs were associated with a decrease in macrolide-resistant strains after an epidemic of infection with M. pneumoniae during 2011–2012.

  • Mycobacterial Testing Trends, United States, 2009–2015
    S. G. Dean et al.

    We studied 31 US healthcare facilities to characterize trends in mycobacterial testing. During 2009–2015, testing for acid-fast bacilli increased 3.2% annually, and prevalence of pathogenic nontuberculous mycobacteria increased 4.5% annually. These increases were highest for subpopulations at high risk of infection, including older women, Asians, and patients with concurrent conditions.

  • Persistence of Severe Acute Respiratory Syndrome Coronavirus 2 in Aerosol Suspensions
    A. C. Fears et al.

    We aerosolized severe acute respiratory syndrome coronavirus 2 and determined that its dynamic aerosol efficiency surpassed those of severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome. Although we performed experiment only once across several laboratories, our findings suggest retained infectivity and virion integrity for up to 16 hours in respirable-sized aerosols.

  • Updated Estimates of Chronic Conditions Affecting Risk for Complications from Coronavirus Disease, United States
    M. L. Adams et al.

    We updated estimates of adults at risk for coronavirus disease complications on the basis of data for China by using recent US hospitalization data. This update to our previous publication substitutes obesity for cancer as an underlying condition and increases adults reporting any of the conditions from 45.4% to 56.0%.

  • Oxacillinase-181 Carbapenemase-Producing Klebsiella pneumoniae in Neonatal Intensive Care Unit, Ghana, 2017–2019
    A. Labi et al.

    We sequenced 29 carbapenemase-producing Klebsiella pneumoniae isolates from a neonatal intensive care unit in Ghana. Twenty-eight isolates were sequence type 17 with blaOXA-181 and differed by 0–32 single-nucleotide polymorphisms. Improved surveillance and infection control are needed to characterize and curb the spread of multidrug-resistant organisms in sub-Saharan Africa.

  • Fatal Measles Inclusion-Body Encephalitis in Adult with Untreated AIDS, France
    C. Rodriguez et al.

    We report a fatal case of measles inclusion-body encephalitis occurring in a woman from Romania with AIDS. After an extensive but unsuccessful diagnostic evaluation, a pan-pathogen shotgun metagenomic approach revealed a measles virus infection. We identified no mutations previously associated with neurovirulence.

  • Chromobacterium haemolyticum Pneumonia Associated with Near-Drowning and River Water, Japan
    H. Kanamori et al.

    We report a severe case of Chromobacterium haemolyticum pneumonia associated with near-drowning and detail the investigation of the pathogen and river water. Our genomic and environmental investigation demonstrated that river water in a temperate region can be a source of C. haemolyticum causing human infections.

  • Identification of Streptococcus suis Meningitis by Direct Triplex Real-Time PCR, Burkina Faso
    M. Ouattara et al.

    Meningitis confirmation in Burkina Faso uses PCR for detecting Streptococcus pneumoniae, Neisseria meningitidis, or Hemophilus influenzae. We identified 38 cases of meningitis among 590 that were PCR-positive for 3 nonpneumococcal streptococcal pathogens, including 21 cases of Streptococcus suis. Among the country’s 13 regions, 10 had S. suis–positive cases.

  • Duration of Carbapenemase-Producing Enterobacteriaceae Carriage in Hospital Patients
    Y. Mo et al.

    To determine the duration of carbapenemase-producing Enterobacteriaceae (CPE) carriage, we studied 21 CPE carriers for »1 year. Mean carriage duration was 86 days; probability of decolonization in 1 year was 98.5%, suggesting that CPE-carriers’ status can be reviewed yearly. Prolonged carriage was associated with use of antimicrobial drugs.

  • Anicteric Leptospirosis-Associated Meningitis in a Tropical Urban Environment, Brazil
    S. A. Nabity et al.

    While studying aseptic meningitis in Salvador, Brazil, we diagnosed anicteric leptospirosis in 1.7% (5/295) of patients hospitalized for aseptic meningitis. Leptospirosis-associated meningitis patients had lower mean cerebrospinal fluid cell counts and protein than other-cause aseptic meningitis (p<0.05). Clinicians must consider leptospirosis-associated meningitis in appropriate clinical-epidemiologic contexts.

  • Assessing 3 Outbreak Detection Algorithms in an Electronic Syndromic Surveillance System in a Resource-Limited Setting
    E. Alsentzer et al.

    We evaluated the performance of X-bar chart, exponentially weighted moving average, and C3 cumulative sums aberration detection algorithms for acute diarrheal disease syndromic surveillance at naval sites in Peru during 2007–2011. The 3 algorithms’ detection sensitivity was 100%, specificity was 97%–99%, and positive predictive value was 27%–46%.

  • Toxigenic Corynebacterium diphtheriae–Associated Genital Ulceration
    F. Fuchs et al.

    In October 2016, an adolescent boy sought care for acute genital ulceration in Cologne, Germany. We presumed a sexually transmitted infection, but initial diagnostic procedures yielded negative results. He was hospitalized because swab samples from the lesion grew toxigenic Corynebacterium diphtheriae, leading to the diagnosis of possibly sexually transmitted cutaneous diphtheria.

  • Human Borrelia miyamotoi Infection, Austria
    S. Tobudic et al.

    We report a human case of Borrelia miyamotoi infection diagnosed in Austria. Spirochetes were detected in Giemsa-stained blood smears. The presence of B. miyamotoi in the patient’s blood was confirmed by PCR, and phylogenetic analysis identified an infection with a strain from Europe.

  • Japanese Encephalitis Virus as Cause of Acute Encephalitis, Bhutan
    S. Wangchuk et al.

    In 2011, Bhutan’s Royal Centre for Disease Control began Japanese encephalitis (JE) surveillance at 5 sentinel hospitals in throughout Bhutan. During 2011–2018, a total of 20 JE cases were detected, indicating JE virus causes encephalitis in Bhutan. Maintaining JE surveillance will help improve understanding of JE epidemiology in this country.

Research Letters
  • Latent Tuberculosis Screening Using Electronic Health Record Data
    J. D. Jenks et al.

    Screening for latent tuberculosis infection is recommended for foreign-born persons in the United States. We used proxy data from electronic health records to determine that 17.5% of foreign-born outpatients attending the UC San Diego Health clinic (San Diego, CA, USA) underwent screening. Ending the global tuberculosis epidemic requires improved screening.

  • Typhus Group Rickettsiosis, Brazilian Amazon
    A. Minervino et al.

    Rickettsia rickettsii infection is the only rickettsiosis included in the list of reportable diseases in Brazil, where typhus group rickettsioses, mainly murine typhus, have been underreported. We report a case of typhus group rickettsiosis with unique ecologic particularities in a patient from the Brazilian Amazon, where, to our knowledge, rickettsioses have not been reported.

  • Information-Accessing Behavior during Zika Virus Outbreak, United States, 2016
    R. Piltch-Loeb and D. Abramson

    We used latent class analysis to examine Zika virus–related information-accessing behavior of US residents during the 2016 international outbreak. We characterized 3 classes of information-accessing behavior patterns: universalists, media seekers, and passive recipients. Understanding these patterns is crucial to planning risk communication during an emerging health threat.

  • Clostridioides difficile in COVID-19 Patients, Detroit, Michigan, USA, March–April 2020
    A. Sandhu et al.

    We describe 9 patients at a medical center in Detroit, Michigan, USA, with severe acute respiratory syndrome coronavirus 2 and Clostridioides difficile. Both infections can manifest as digestive symptoms and merit screening when assessing patients with diarrhea during the coronavirus disease pandemic. These co-infections also highlight the continued importance of antimicrobial stewardship.

  • Acute Cerebral Stroke with Multiple Infarctions and COVID-19, France, 2020
    S. Zayet et al.

    We describe 2 cases in coronavirus disease patients in France involving presumed thrombotic stroke that occurred during ongoing anticoagulation treatment for atrial fibrillation stroke prophylaxis; 1 patient had positive antiphospholipid antibodies. These cases highlight the severe and unique consequences of coronavirus disease–associated stroke.

  • SARS-CoV-2 RNA Detection on Disposable Wooden Chopsticks, Hong Kong
    G. Lui et al.

    We detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA on disposable wooden chopsticks used by 5 consecutive asymptomatic and postsymptomatic patients admitted for isolation and care at our hospital. Although we did not assess virus viability, our findings may suggest potential for transmission through shared eating utensils.

  • Parotitis-Like Symptoms Associated with COVID-19, France, March–April 2020
    J. R. Lechien et al.

    We report the clinical features of 3 patients in France who had parotitis (inflammation of the parotid salivary glands) as a clinical manifestation of confirmed coronavirus disease. Results from magnetic resonance imaging support the occurrence of intraparotid lymphadenitis, leading to a parotitis-like clinical picture.

  • Effectiveness of N95 Respirator Decontamination and Reuse against SARS-CoV-2 Virus
    R. J. Fischer et al.

    The coronavirus pandemic has created worldwide shortages of N95 respirators. We analyzed 4 decontamination methods for effectiveness in deactivating severe acute respiratory syndrome coronavirus 2 virus and effect on respirator function. Our results indicate that N95 respirators can be decontaminated and reused, but the integrity of respirator fit and seal must be maintained.

  • Effects of Proactive Social Distancing on COVID-19 Outbreaks in 58 Cities, China
    Z. Du et al.

    Cities across China implemented stringent social distancing measures in early 2020 to curb coronavirus disease outbreaks. We estimated the speed with which these measures contained transmission in cities. A 1-day delay in implementing social distancing resulted in a containment delay of 2.41 (95% CI 0.97–3.86) days.

  • Effect of Environmental Conditions on SARS-CoV-2 Stability in Human Nasal Mucus and Sputum
    M. Matson et al.

    We found that environmental conditions affect the stability of severe acute respiratory syndrome coronavirus 2 in nasal mucus and sputum. The virus is more stable at low-temperature and low-humidity conditions, whereas warmer temperature and higher humidity shortened half-life. Although infectious virus was undetectable after 48 hours, viral RNA remained detectable for 7 days.

  • Severe Acute Respiratory Syndrome Coronavirus 2 among Asymptomatic Workers Screened for Work Resumption, China
    X. Han et al.

    After the outbreak in Wuhan, China, we assessed 29,299 workers screened for severe acute respiratory syndrome coronavirus 2 by reverse transcription PCR. We noted 18 (0.061%) cases of asymptomatic infection; 13 turned negative within 8.0 days, and 41 close contacts tested negative. Among 6 contacts who had serologic tests, none were positive.

  • Putative Conjugative Plasmids with tcdB and cdtAB Genes in Clostridioides difficile
    G. Ramírez-Vargas and C. Rodríguez

    The major toxins of Clostridioides difficile (TcdA, TcdB, CDT) are chromosomally encoded in nearly all known strains. Following up on previous findings, we identified 5 examples of a family of putative conjugative plasmids with tcdB and cdtAB in clinical C. difficile isolates from multilocus sequence typing clades C-I, 2, and 4.

  • Methemoglobinemia in Patient with G6PD Deficiency and SARS-CoV-2 Infection
    K. Palmer et al.

    We report a case of intravascular hemolysis and methemoglobinemia, precipitated by severe acute respiratory syndrome coronavirus 2 infection, in a patient with undiagnosed glucose-6-phosphate dehydrogenase deficiency. Clinicians should be aware of this complication of coronavirus disease as a cause of error in pulse oximetry and a potential risk for drug-induced hemolysis.

  • Prolonged Infectivity of SARS-CoV-2 in Fomites
    B. Pastorino et al.

    We spotted severe acute respiratory syndrome coronavirus 2 on polystyrene plastic, aluminum, and glass for 96 hours with and without bovine serum albumin (3 g/L). We observed a steady infectivity (<1 log10 drop) on plastic, a 3.5 log10 decrease on glass, and a 6 log10 drop on aluminum. The presence of proteins noticeably prolonged infectivity.

  • Asymptomatic SARS-CoV-2 Infection in Nursing Homes, Barcelona, Spain, April 2020
    B. Borras-Bermejo et al.

    During the coronavirus disease pandemic in Spain, from April 10–24, 2020, a total of 5,869 persons were screened for severe acute respiratory syndrome coronavirus 2 at nursing homes. Among residents, 768 (23.9%) tested positive; among staff, 403 (15.2%). Of those testing positive, 69.7% of residents and 55.8% of staff were asymptomatic.

  • Large SARS-CoV-2 Outbreak Caused by Asymptomatic Traveler, China
    J. Liu et al.

    An asymptomatic person infected with severe acute respiratory syndrome coronavirus 2 returned to Heilongjiang Province, China, after international travel. The traveler’s neighbor became infected and generated a cluster of >71 cases, including cases in 2 hospitals. Genome sequences of the virus were distinct from viral genomes previously circulating in China.

  • Antibody Responses after Classroom Exposure to Teacher with Coronavirus Disease, March 2020
    N. E. Brown et al.

    After returning from Europe to the United States, on March 1, 2020, a symptomatic teacher received positive test results for severe acute respiratory syndrome coronavirus 2. Of the 21 students exposed to the teacher in the classroom, serologic results suggested past infection for 2. Classroom contact may result in virus transmission.

  • Buying Time with COVID-19 Outbreak Response, Israel
    E. Leshem et al.

    Israel's response during the containment phase of the COVID-19 outbreak in early 2020 led to a delay in sustained community transmission and effective mitigation. During February–April 2020, a total of 15,981 confirmed cases resulted in 223 deaths. A total of 179,003 persons reported electronically to self-quarantine and were entitled to paid sick leave.

  • Severe Fever with Thrombocytopenia Syndrome Virus in Ticks and SFTS Incidence in Humans, South Korea
    J. Yoo et al.

    During 2016–2018, we collected 3,193 ticks from rural areas in South Korea to investigate the prevalence of severe fever with thrombocytopenia syndrome virus (SFTSV). We detected SFTSV in ticks at an infection rate (IR) of 11.1%. We noted increases in the human IR associated with the monthly SFTSV IR in ticks.

  • Leuconostoc lactis and Staphylococcus nepalensis Bacteremia, Japan
    S. Hosoya et al.

    Leuconostoc lactis is a glycopeptide-resistant, gram-positive, facultative anaerobic coccus isolated from dairy products, whereas Staphylococcus nepalensis is coagulase-negative coccus that has not been identified as human pathogen. We report an instructive case of L. lactis and S. nepalensis bacteremia in a 71-year-old man who experienced Boerhaave syndrome after a meal.

About the Cover


Volume 26, Number 10—October 2020

  • Operating Protocols of a Community Treatment Center for Isolation of Patients with Coronavirus Disease, South Korea
    E. Kang et al.

    Most persons with confirmed coronavirus disease (COVID-19) have no or mild symptoms. During the COVID-19 pandemic, communities need efficient methods to monitor asymptomatic patients to reduce transmission. We describe the structure and operating protocols of a community treatment center (CTC) run by Seoul National University Hospital (SNUH) in South Korea. SNUH converted an existing facility into a CTC to isolate patients who had confirmed COVID-19 but mild or no symptoms. Patients reported self-measured vital signs and symptoms twice a day by using a smartphone application. Medical staff in a remote monitoring center at SNUH reviewed patient vital signs and provided video consultation to patients twice daily. The CTC required few medical staff to perform medical tests, monitor patients, and respond to emergencies. During March 5–26, 2020, we admitted and treated 113 patients at this center. CTCs could be an alternative to hospital admission for isolating patients and preventing community transmission.

  • Community Treatment Centers for Isolation of Asymptomatic and Mildly Symptomatic Patients with Coronavirus Disease, South Korea
    W. Choi et al.

    As a part of measures to decrease spikes in coronavirus disease (COVID-19) cases and deaths outside of hospitals, the government of South Korea introduced a plan for community treatment centers (CTCs) to isolate and monitor patients with mild COVID-19 symptoms. We assessed outcomes of 568 patients admitted to 3 CTCs near Daegu. More (64.6%) women than men (35.4%) were admitted, and the mean age of patients was 36.0 years (SD +15.0 years). Among all patients, 75.7% remained asymptomatic while at the CTCs. The mean time patients remained at CTCs was 19.6 days (SD +5.8 days) from the day of diagnosis until our study ended on March 23, 2020. Because they offer appropriate clinical triaging and daily monitoring for patients, CTCs are a safe alternative to medical institutions for asymptomatic or mildly symptomatic patients with COVID-19.

  • Clinical Course of Asymptomatic and Mildly Symptomatic Patients with Coronavirus Disease Admitted to Community Treatment Centers, South Korea
    Y. Lee et al.

    We evaluated the clinical course of asymptomatic and mildly symptomatic patients with laboratory-confirmed coronavirus disease (COVID-19) admitted to community treatment centers (CTCs) for isolation in South Korea. Of 632 patients, 75 (11.9%) had symptoms at admission, 186 (29.4%) were asymptomatic at admission but developed symptoms during their stay, and 371 (58.7%) remained asymptomatic during their entire clinical course. Nineteen (3.0%) patients were transferred to hospitals, but 94.3% (573/613) of the remaining patients were discharged from CTCs upon virologic remission. The mean virologic remission period was 20.1 days (SD + 7.7 days). Nearly 20% of patients remained in the CTCs for 4 weeks after diagnosis. The virologic remission period was longer in symptomatic patients than in asymptomatic patients. In mildly symptomatic patients, the mean duration from symptom onset to virologic remission was 11.7 days (SD + 8.2 days). These data could help in planning for isolation centers and formulating self-isolation guidelines.

  • Investigations of Shiga Toxin-Producing Escherichia coli Outbreaks Linked to Leafy Greens, United States and Canada, 2009–2018
    K. E. Marshall et al.
  • Healthcare-associated Legionnaires’ Disease, Europe, 2008−2017
    J. Beauté et al.
  • Nationwide External Quality Assessment of SARS-CoV-2 Molecular Testing, South Korea
    H. Sung et al.

    External quality assessment (EQA) is essential for ensuring reliable test results, especially when laboratories are using assays authorized for emergency use for newly emerging pathogens. We developed an EQA panel to assess the quality of real-time reverse transcription PCR assays being used in South Korea to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With the participation of 23 public health organization laboratories and 95 nongovernmental laboratories involved in SARS-CoV-2 testing, we conducted qualitative and semiquantitative performance assessments by using pooled respiratory samples containing different viral loads of SARS-CoV-2 or human coronavirus OC43. A total of 110 (93.2%) laboratories reported correct results for all qualitative tests; 29 (24.6%) laboratories had >1 outliers according to cycle threshold values. Our EQA panel identified the potential weaknesses of currently available commercial reagent kits. The methodology we used can provide practical experience for those planning to conduct evaluations for testing of SARS-CoV-2 and other emerging pathogens in the future.

  • Sequential Acquisition of Human Papillomavirus Infection at Genital and Anal Sites, Liuzhou, China
    F. Wei et al.
  • Impact of Social Distancing Measures on Coronavirus Disease Healthcare Demand, Central Texas, USA
    X. Wang et al.

    Social distancing orders have been enacted worldwide to slow the coronavirus disease (COVID-19) pandemic, reduce strain on healthcare systems, and prevent deaths. To estimate the impact of the timing and intensity of such measures, we built a mathematical model of COVID-19 transmission that incorporates age-stratified risks and contact patterns and projects numbers of hospitalizations, patients in intensive care units, ventilator needs, and deaths within US cities. Focusing on the Austin metropolitan area of Texas, we found that immediate and extensive social distancing measures were required to ensure that COVID-19 cases did not exceed local hospital capacity by early May 2020. School closures alone hardly change the epidemic curve. A 2-week delay in implementation was projected to accelerate the timing of peak healthcare needs by 4 weeks and cause a bed shortage in intensive care units. This analysis informed the Stay Home-Work Safe order enacted by Austin on March 24, 2020.

  • Multicenter Prevelance Study Comparing Molecular and Toxin Assays for Clostridioides difficile Surveillance, Swtizerland
    A. F. Widmer et al.
  • Association between Shiga Toxin–Producing Escherichia coli O157:H7 stx Subtype and Disease Severity, England, 2009–2019
    L. Byrne et al.
  • Effectiveness of 23-valent Pneumococcal Polysaccharide Vaccine against Invasive Pneumococcal Disease in Adults ≥20 Years of Age, Japan
    R. Shimbashi et al.
  • Effect of Nonpharmaceutical Interventions on Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, South Korea, 2020
    S. Ryu et al.

    We analyzed transmission of coronavirus disease outside of the Daegu-Gyeongsangbuk provincial region in South Korea. We estimated that nonpharmaceutical measures reduced transmissibility by a maximum of 33% without resorting to a strict lockdown strategy. To optimize epidemic control, continuous efforts to monitor the transmissibility are needed.

  • Rapid, Sensitive, Full-Genome Sequencing of Severe Acute Respiratory Syndrome Coronavirus 2
    C. R. Paden et al.

    We describe validated protocols for generating high-quality, full-length severe acute respiratory syndrome coronavirus 2 genomes from primary samples. One protocol uses multiplex reverse transcription PCR, followed by MinION or MiSeq sequencing; the other uses singleplex, nested reverse transcription PCR and Sanger sequencing. These protocols enable sensitive virus sequencing in different laboratory environments.

  • Seoul Orthohantavirus in Wild Black Rats, Senegal, 2012–2013
    M. M. Diagne et al.
  • Emerging Sandfly-borne Phlebovirus in China
    J. Wang et al.
  • Silent Circulation of Rift Valley Fever in Humans in Botswana
    C. E. Sanderson et al.
  • Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020
    Y. Park et al.

    We analyzed reports for 59,073 contacts of 5,706 coronavirus disease (COVID-19) index patients reported in South Korea during January 20–March 27, 2020. Of 10,592 household contacts, 11.8% had COVID-19. Of 48,481 nonhousehold contacts, 1.9% had COVID-19. Use of personal protective measures and social distancing reduces the likelihood of transmission.

  • Main Routes of Entry and Genomic Diversity of SARS-CoV-2, Uganda
    D. Bugembe et al.

    We established rapid local viral sequencing to document the genomic diversity of severe acute respiratory syndrome coronavirus 2 entering Uganda. Virus lineages closely followed the travel origins of infected persons. Our sequence data provide an important baseline for tracking any further transmission of the virus throughout the country and region.

  • High Proportion of Asymptomatic SARS-CoV-2 Infections in 9 Long-Term Care Facilities, Pasadena, California, USA, April 2020
    M. Feaster and Y. Goh

    Our analysis of coronavirus disease prevalence in 9 long-term care facilities demonstrated a high proportion (40.7%) of asymptomatic infections among residents and staff members. Infection control measures in congregate settings should include mass testing-based strategies in concert with symptom screening for greater effectiveness in preventing the spread of severe acute respiratory syndrome coronavirus 2.

  • Coronavirus Disease among Persons with Sickle Cell Disease, United States, March 20–May 21, 2020
    J. A. Panepinto et al.

    Sickle cell disease (SCD) disproportionately affects Black or African American persons in the United States and can cause multisystem organ damage and reduced lifespan. Among 178 persons with SCD in the United States who were reported to an SCD–coronavirus disease case registry, 122 (69%) were hospitalized and 13 (7%) died.

  • Highly Pathogenic Francisella hispaniensis Infections Causing Multiple Organ Failure Related to Seawater Exposure
    H. Zhou et al.
  • Basic Reproduction Number of Chikungunya Virus Transmitted by Aedes Mosquitoes
    N. Haider et al.
  • Limitations of Ribotyping as Genotyping Method for Corynebacterium ulcerans
    T. Sekizuka et al.
  • Polyester Vascular Graft Material and Risk for Intracavitary Thoracic Vascular Graft Infection
    T. A. Schweizer et al.
  • Deaths Associated with Pneumonic Plague, 1946–2017
    A. P. Salam et al.
Research Letters
  • COVID-19 in Patient with Sarcoidosis Receiving Long-Term Hydroxychloroquine Treatment, France, 2020
    F. Bénézit et al.

    Because of in vitro studies, hydroxychloroquine is under evaluation as a preexposure or postexposure prophylaxis for coronavirus disease (COVID-19) and as a possible COVID-19 curative treatment. We report a case of COVID-19 in a patient with sarcoidosis who was receiving long-term hydroxychloroquine treatment, despite adequate plasma concentrations.

  • Undetected Circulation of African Swine Fever in Wild Boar, Asia
    T. Vergne et al.

    African swine fever is a growing threat to the livestock industry. We examined data indicating that in most countries in Asia, most notified events were related to farm outbreaks; meanwhile, only a few wild boar cases were reported. We hypothesize the virus circulates unnoticed in wild boar populations in Asia.

  • Review of Mental Health Response to COVID-19, China
    A. Miu et al.

    Public mental health response to coronavirus disease is essential. After reviewing systemic and local efforts in China, we found efficient coordination and human resources. We recommend better symptom assessment, monitoring of organizations, and basic needs protection. This recommendation can inform how other countries can overcome mental health challenges during this pandemic.

  • Viral RNA Load in Mildly Symptomatic and Asymptomatic Children with COVID-19, Seoul
    M. Han et al.

    Along with positive SARS-CoV-2 RNA in nasopharyngeal swabs, viral RNA was detectable at high concentration for >3 weeks in fecal samples from 12 mildly symptomatic and asymptomatic children with COVID-19. Saliva also tested positive during the early phase of infection. If proven infectious, feces and saliva could serve as transmission sources.

  • Q Fever Endocarditis and a New Genotype of Coxiella burnetii, Greece
    I. Karageorgou et al.
  • Antibody Responses to SARS-CoV-2 at 8 Weeks Postinfection in Asymptomatic Patients
    P. Choe et al.

    We compared levels of severe acute respiratory syndrome coronavirus 2 neutralizing antibodies in recovery plasma from 7 completely asymptomatic coronavirus disease patients with those in symptomatic patients in South Korea. We found that serologic diagnostic testing was positive for 71% (5/7) of completely asymptomatic patients, but neutralizing antibody response occurred in all 7 patients.

  • Disappearance of SARS-CoV-2 Antibodies in Infants Born to Women with COVID-19, Wuhan, China
    J. Gao et al.

    We report the detection and decline over time of severe acute respiratory syndrome coronavirus 2 antibodies in infants born to women with coronavirus disease. Among 11 infants tested at birth, all had detectable IgG and 5 had detectable IgM. IgG titers with positive IgM declined more slowly than those without.

  • Relative Bradycardia in Patients with Mild-to-Moderate Coronavirus Disease, Japan
    K. Ikeuchi et al.

    Coronavirus disease is reported to affect the cardiovascular system. We showed that relative bradycardia was a common characteristic for 54 patients with PCR-confirmed mild-to-moderate coronavirus disease in Japan. This clinical sign could help clinicians to diagnose this disease.

  • Culture-Competent SARS-CoV-2 in Nasopharynx of Symptomatic Neonates, Children, and Adolescents
    A. G. L’Huillier et al.

    Children do not seem to drive transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We isolated culture-competent virus in vitro from 12 (52%) of 23 SARS-CoV-2–infected children; the youngest was 7 days old. Our findings show that symptomatic neonates, children, and teenagers shed infectious SARS-CoV-2, suggesting that transmission from them is plausible.

  • Retrospective Screening for SARS-CoV-2 RNA in California, USA, Late 2019
    C. A. Hogan et al.

    To investigate the possibility of earlier cases of severe acute respiratory syndrome coronavirus 2 infection than previously recognized, we retrospectively tested pooled samples from 1,700 persons with respiratory signs/symptoms seen at Stanford Health Care, Palo Alto, California, USA, during the last 2 months of 2019. We found no evidence of earlier infection.

  • Coronavirus Disease Exposure and Spread from Nightclubs, South Korea
    C. Kang et al.

    At least 246 cases of coronavirus disease (COVID-19) have been linked to nightclubs in Seoul, South Korea. During the April 30–May 5 holiday, young adults from across the country who visited nightclubs in Seoul contracted COVID-19 and spread it nationally. Nightclubs were temporarily closed to limit COVID-19 spread.

  • Streptococcus equi subsp. zooepidemicus–Associated Sudden Deaths in Swine, Canada
    M. O. Costa and B. Lage
  • Rapid Screening Evaluation of SARS-CoV-2 IgG Assays Using Z-Scores to Standardize Results
    M. K. Das et al.

    Many serologic tests are now available for measuring severe acute respiratory syndrome coronavirus 2 antibodies to evaluate potential protective immunity and for seroprevalence studies. We describe an approach to standardizing positivity thresholds and quantitative values for different assays that uses z-scores to enable rapid and efficient comparison of serologic test performance.

  • Effect of COVID-19 on Tuberculosis Notification, South Korea
    N. Kwak et al.

    After South Korea raised its infectious disease alert to the highest level in response to coronavirus disease emergence, tuberculosis notification during the first 18 weeks of 2020 decreased significantly from the same period for each year during 2015–2019. Adequate measures to diagnose, control, and prevent tuberculosis need to be maintained.

  • Fatal Chlamydia avium Infection in Captive Picazuro Pigeons, the Netherlands
    M. Kik et al.
  • Eliminating Spiked Bovine Spongiform Encephalopathy Agent Activity from Heparin
    C. Bett et al.

    US manufacturers, concerned about bovine spongiform encephalopathy (BSE), ceased marketing bovine heparin in the 1990s. Recent short supplies of safe porcine heparin suggest that reintroducing bovine heparin might benefit public health. We purified heparin from crude bovine extract spiked with BSE agent, removing substantial infectivity and abnormal prion proteins (PrPTSE).

  • Effects of COVID-19 Prevention Measures on Other Common Infections, Taiwan
    H. Lee and S. Lin

    To determine whether policies to limit transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) hinder spread of other infectious diseases, we analyzed the National Health Insurance database in Taiwan. Rates of other infections were significantly lower after SARS-CoV-2 prevention measures were announced. This finding can be applied to cost-effectiveness of SARS-CoV-2 prevention.

  • Inappropriate Administration of Rabies Postexposure Prophylaxis, Cook County, Illinois, USA
    H. D. Steinberg et al.
  • Using Virus Sequencing to Determine Source of SARS-CoV-2 Transmission for Healthcare Worker
    N. Safdar et al.

    Whether a healthcare worker’s severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is community or hospital acquired affects prevention practices. We used virus sequencing to determine that infection of a healthcare worker who cared for 2 SARS-CoV-2–infected patients was probably community acquired. Appropriate personal protective equipment may have protected against hospital-acquired infection.

Another Dimension
  • The Last Plague or Before the Graying
    R. O. Valdiserri
Books and Media
  • The Mosquito: Human History of Our Deadliest Predator
    T. Snyder
Online Reports
  • Effectiveness of Cloth Masks for Protection Against Severe Acute Respiratory Syndrome Coronavirus 2
    A. A. Chughtai et al.

    Cloth masks have been used in healthcare and community settings to protect the wearer from respiratory infections. The use of cloth masks during the coronavirus disease (COVID-19) pandemic is under debate. The filtration effectiveness of cloth masks is generally lower than that of medical masks and respirators; however, cloth masks may provide some protection if well designed and used correctly. Multilayer cloth masks, designed to fit around the face and made of water-resistant fabric with a high number of threads and finer weave, may provide reasonable protection. Until a cloth mask design is proven to be equally effective as a medical or N95 mask, wearing cloth masks should not be mandated for healthcare workers. In community settings, however, cloth masks may be used to prevent community spread of infections by sick or asymptomatically infected persons, and the public should be educated about their correct use.

  • Enterovirus-D68–Associated Acute Flaccid Myelitis, United States, 2020
    S. Kidd et al.


Volume 26, Number 11—November 2020

  • The Problem of Dark Matter in Neonatal Sepsis
    S. A. Sinnar and S. J. Schiff
  • Measuring Timeliness of Outbreak Detection, Notification, and Control in the WHO African Region, 2017–2019
    B. Impouma et al.
  • Three Patients with COVID-19 and Pulmonary Tuberculosis, Wuhan, China, January–February 2020
    Z. Yao et al.

    During January–February 2020, coronavirus disease (COVID-19) and tuberculosis were diagnosed for 3 patients in Wuhan, China. All 3 patients had COVID-19 pneumonia. One severely ill patient died after acute respiratory distress syndrome developed. Clinicians and public health officials should be aware of underlying chronic infections such as tuberculosis in COVID-19 patients.

  • Validated Methods for Removing Select Agent Samples from Biosafety Level 3 Laboratories
    A. E. Kesterson et al.
  • Epidemiology of COVID-19 Outbreak on Cruise Ship Quarantined at Yokohama, Japan, February 2020
    E. Taskforce
  • High Dengue Burden and Circulation of 4 Virus Serotypes among Children with Undifferentiated Fever, Kenya, 2014–2017
    M. M. Shah et al.
  • Two New Cases of Pulmonary Infection by Mycobacterium shigaense
    S. Yoshida et al.
  • Multiple Introductions of Salmonella Typhi H58 with Reduced Fluoroquinolone Susceptibility, Chile
    M. Maes et al.
  • SARS-CoV-2 Virus Culture and Subgenomic RNA for Respiratory Specimens from Patients with Mild Coronavirus Disease
    R. Perera et al.

    We investigated 68 respiratory specimens from 35 coronavirus disease patients in Hong Kong, of whom 32 had mild disease. We found that severe acute respiratory syndrome coronavirus 2 and subgenomic RNA were rarely detectable beyond 8 days after onset of illness. However, virus RNA was detectable for many weeks by reverse transcription PCR.

  • Chikungunya Virus Infection in Blood Donors and Patients with Acute Febrile Illness, Mandalay, Myanmar, 2019
    A. Kyaw et al.
  • Asymptomatic Transmission of COVID-19 on Aircraft
    S. Bae et al.
  • Potential Role of Social Distancing in Mitigating Spread of Coronavirus Disease, South Korea
    S. Park et al.
  • Identification of a Novel α-herpesvirus Associated with Ulcerative Stomatitis in Donkeys
    V. Martella et al.
  • Multidrug-Resistant Hypervirulent Group B Streptococcus in Neonatal Invasive Infections, France, 2007–2019
    C. Plainvert et al.
Research Letters
  • Four Patients with COVID-19 and Tuberculosis, Singapore, April–May 2020
    S. Tham et al.

    Coronavirus disease (COVID-19) and tuberculosis (TB) developed in 4 foreign workers living in dormitories in Singapore during April–May 2020. Clinical manifestations and atypical radiographic features of COVID-19 led to the diagnosis of TB through positive interferon-gamma release assay and culture results. During the COVID-19 pandemic, TB should not be overlooked.

  • Seroprevalence of SARS-CoV-2–Specific Antibodies, Faroe Islands
    M. Petersen et al.

    We conducted a nationwide study of the prevalence of severe acute respiratory syndrome coronavirus 2 infection in the Faroe Islands. Of 1,075 randomly selected participants, 6 (0.6%) tested seropositive for antibodies to the virus. Adjustment for test sensitivity and specificity yielded a 0.7% prevalence. Our findings will help us evaluate our public health response.

  • Detection of SARS-CoV-2 in Hemodialysis Effluent of Patient with COVID-19 Pneumonia, Japan
    A. Okuhama et al.
  • Seroprevalence of SARS-CoV-2 and Infection Fatality Ratio, Orleans and Jefferson Parishes, Louisiana, USA, May 2020
    A. K. Feehan et al.

    Using a novel recruitment method and paired molecular and antibody testing for severe acute respiratory syndrome coronavirus 2 infection, we determined seroprevalence in a racially diverse municipality in Louisiana, USA. Infections were highly variable by ZIP code and differed by race/ethnicity. Overall census-weighted seroprevalence was 6.9%, and the calculated infection fatality ratio was 1.63%.

  • Detection of SARS-CoV-2 in Hemodialysis Effluent of Patient with COVID-19 Pneumonia, Japan
    A. Okuhama et al.

    We report detection of severe acute respiratory syndrome coronavirus 2 RNA in hemodialysis effluent from a patient in Japan with coronavirus disease and prolonged inflammation. Healthcare workers should observe strict standard and contact precautions and use appropriate personal protective equipment when handling hemodialysis circuitry from patients with diagnosed coronavirus disease.

  • Sporotrichosis Cases in Commercial Insurance Data, United States, 2012–2018
    K. Benedict and B. R. Jackson
  • Burkholderia pseudomallei in Soil, US Virgin Islands, 2019
    N. E. Stone et al.
  • Saliva Alternative to Upper Respiratory Swabs for SARS-CoV-2 Diagnosis
    R. L. Byrne et al.
  • Abrupt Subsidence of Seasonal Influenza after COVID-19 Outbreak, Hong Kong, China
    N. Wong et al.
Another Dimension
  • Isolation Cocoon, May 2020
    R. Louie


Volume 26, Number 12—December 2020

  • Small Particle Aerosol Exposure of African Green Monkeys to MERS-CoV as a Model for Highly Pathogenic Coronavirus Infection
    A. Totura et al.

    Emerging coronaviruses are a global public health threat because of the potential for person-to-person transmission and high mortality rates. Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012, causing lethal respiratory disease in »35% of cases. Primate models of coronavirus disease are needed to support development of therapeutics, but few models exist that recapitulate severe disease. For initial development of a MERS-CoV primate model, 12 African green monkeys were exposed to 103, 104, or 105 PFU target doses of aerosolized MERS-CoV. We observed a dose-dependent increase of respiratory disease signs, although all 12 monkeys survived for the 28-day duration of the study. This study describes dose-dependent effects of MERS-CoV infection of primates and uses a route of infection with potential relevance to MERS-CoV transmission. Aerosol exposure of African green monkeys might provide a platform approach for the development of primate models of novel coronavirus diseases.

  • Equine-Like H3 Avian Influenza Viruses in Wild Birds, Chile
    N. Bravo-Vasquez et al.
  • Trends in Population Dynamics of Escherichia coli Sequence Type 131, 2006–2016
    G. Peirano et al.
  • Coyotes as Reservoirs for Onchocerca lupi, United States, 2015–2018
    C. C. Roe et al.
  • Direct Transmission of Severe Fever with Thrombocytopenia Syndrome Virus from Domestic Cat to Veterinary Personnel
    A. Yamanaka et al.
  • Differential Tropism of SARS-CoV and SARS-CoV-2 in Bat Cells
    S. Lau et al.

    Severe acute respiratory syndrome coronavirus 2 did not replicate efficiently in 13 bat cell lines, whereas severe acute respiratory syndrome coronavirus replicated efficiently in kidney cells of its ancestral host, the Rhinolophus sinicus bat, suggesting different evolutionary origins. Structural modeling showed that RBD/RsACE2 binding may contribute to the differential cellular tropism.

  • Novel Rickettsia Species Infecting Dogs, United States
    J. M. Wilson et al.
  • Zoonotic Pathogens in Ticks from Migratory Birds, Italy
    E. Battisti et al.
  • Lymphocytic Choriomeningitis Virus Infections and Seroprevalence, Southern Iraq
    H. Alburkat et al.
  • Characterization and Source Investigation of Multidrug-Resistant Salmonella Anatum from a Sustained Outbreak, Taiwan
    Y. Feng et al.
  • Shedding of Marburg Virus in Naturally Infected Egyptian Rousette Bats, South Africa, 2017
    J. T. Pawęska et al.
Research Letters
  • Pathogenic New World relapsing fever Borrelia in a Myotis bat, Eastern China, 2015
    H. Han et al.
  • One-Year Retrospective Review of Psychiatric Consultations in Lassa Fever, Southern Nigeria
    E. O. Okogbenin et al.


The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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