Our Work: 2019

As part of CDC’s Ebola preparedness response, healthcare personnel at Bwera Hospital in Uganda participate in an infection prevention and control training.

In a personal protective equipment (PPE) supplement in Clinical Infectious Diseases, CDC scientists summarize recent data from CDC’s Prevention Epicenters Program and describe steps for improving the routine use of PPE as well as Ebola-specific PPE in healthcare settings. And in an October 4 MMWR article, scientists and colleagues from CDC, Makerere University (Uganda), and the Uganda Ministry of Health describe CDC’s rapid scale-up of infection prevention and control (IPC) assessments in four frontline healthcare facilities in Uganda shortly after the recognition of the Ebola outbreak in neighboring areas of Democratic Republic of Congo.

Dominic Rose (at left) collects mosquito larvae while Janet McAllister records data.

A busy mosquito season has prompted several CDC deployments for vector-borne disease outbreak responses. CDC visited Arizona to provide technical assistance to health officials in that state, which as of October 15 had reported more West Nile virus disease cases than any other state this year. A CDC team also traveled to the Marshall Islands to help local health authorities respond to a dengue outbreak (you can see them at work in the photo). In response to a technical assistance request from Honduras, experiencing its worst dengue outbreak in 50 years, CDC helped local health officials enhance the country’s dengue surveillance and evaluate patients who died of this disease. The team visited local hospitals and dengue units to evaluate and recommend improvements to patient care and met with public health organizations such as the Pan American Health Organization. CDC traveled to Guam in October to help local health officials with mosquito surveillance and control efforts as they respond to the country’s first dengue outbreak in over 70 years.

As of October 29, a total of 35 cases of eastern equine encephalitis in people, including 13 deaths, have been reported so far this year. This is the highest number of cases reported in any given year in the last 50 years. In response, CDC has provided technical assistance for mosquito control and diagnostic testing to Indiana, Massachusetts, Michigan, and Rhode Island. The Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) recently awarded special funding to the same four states to support surveillance and mosquito abatement efforts to address the outbreak. ELC and DVBD staff worked with the four states to determine the states’ areas of greatest need and finalize funding recommendations.

CDC, with federal and state partners, is investigating a multistate outbreak of Salmonella infections linked to pet turtles. Twenty-one ill people in 13 states have been reported. Sick people reported buying the turtles from pet stores or receiving them as a gift.

Senator Bob Casey addresses attendees during the briefing. Seated at the table (L-R) are Amanda Jezek (IDSA), Susan van Meter (AdvaMedDx), Michael Craig, Robin Patel (ASM/Mayo Clinic), and Calvin Yu (Becton Dickinson).

On October 24, the CDC participated in a Congressional briefing, Leading the Charge Against Antimicrobial Resistance: Partnering to Meet the Challenge. Sponsored by AdvaMedDx, the American Society for Microbiology, Becton Dickinson, and Research!America, the briefing highlighted the success of the AMR Challenge, one of the most ambitious and successful initiatives to catalyze action against antimicrobial resistance.

CDC has received broad support within HHS and Congress for utilizing the Challenge to build public-private partnerships across the One Health spectrum to combat antimicrobial resistance. A representative for the CDC’s Antibiotic Resistance Coordination and Strategy Unit briefed staffers from dozens of Congressional offices on how CDC is leading the public health charge against antimicrobial resistance by leveraging partnerships from across sectors, industries, and countries.

WIRED meets an outbreak expert: CDC ‘s Brian Amman sets Hollywood straight during an on-camera deconstruction of popular TV and movie outbreak scenes with WIRED. Brian gives a no-nonsense read from a scientist’s perspective on portrayals of diseases like Ebola and smallpox—as well as scenarios that include zombies and extraterrestrials.

Henry Walke (center), CDC's Ebola Response incident manager, talks to reporters during his recent visit to Dominican Republic of Congo and neighboring countries.

The outbreak of Ebola in eastern Democratic Republic of the Congo (DRC) has surpassed 3,000 cases and 2,000 deaths. As of October 1, a total of 3,197 cases and 2,136 deaths have been reported since the outbreak began in August 2018. There have been 991 survivors.

Texas is in the midst of its worst anthrax season since at least 2001, with one confirmed case in a person and confirmed animal cases on at least 20 ranches in five counties in southwest Texas. This compares with two to four confirmed animal cases in an average year in the whole state.

CDC has been consulting with federal and state health, agriculture, and environmental agencies to better assess the extent of the outbreak and help prevent human cases.

CDC continues to emphasize the importance of livestock vaccination against anthrax and getting an accurate count of affected animals. Local officials have theorized that there may be more cases in animals this year due to environmental conditions and increased numbers of biting flies. Outbreaks in west Texas have historically been associated with wet winters, followed by dry conditions, similar to the current conditions. Since anthrax spores can survive for years in the environment, the outbreak could have implications for disease for years to come.

Participants make notes during a One Health program exercise in Columbia in August

CDC’s One Health Office conducted a One Health Zoonotic Disease Prioritization Workshop in Bogota, Colombia, during August 26-30. This was the first workshop of its kind in Latin America.

The top zoonotic disease threats in Colombia include brucellosis, encephalitis viruses (eastern equine encephalitis, Venezuelan equine encephalitis, western equine encephalitis, and West Nile viruses), avian influenza, leptospirosis, rabies, and zoonotic tuberculosis. To date, CDC has helped to host 25 workshops around the world to help countries, regions, and other jurisdictions prioritize their top zoonotic diseases of concern and make plans to advance a One Health approach.

AMR Challenge guests viewed art and videos aimed at generating awareness about the topic.

As the UN General Assembly convened on September 23, Secretary Alex Azar celebrated the successful US-led AMR Challenge year by urging world leaders to keep antibiotic resistance a top priority.

The AMR Challenge was an unprecedented global initiative led by CDC and HHS to head off the threat posed by resistant germs. CDC collected nearly 350 commitments from 33 countries to escalate government, civil society, and private industry efforts to save lives by improving infection prevention and use of antibiotics, developing new vaccines and drugs, and sharing data to help scientists stay ahead of antibiotic-resistant germs.

Emerging Infectious Diseases is going green and transitioning to an online-only journal starting with the January 2020 issue. Visit the journal’s website to read any of EID’s 10,000-plus articles, along with a trove of supplementary material. You can search for articles by topic, country, or author, and explore 14 curated spotlight topics.

Take a few minutes to sign up for email notifications for the journal’s monthly table of contents, free CME articles, podcasts, and more than 20 infectious disease topics of interest.

DFWED, with federal and state partners, is investigating numerous multistate foodborne outbreaks, including the following:

• Salmonella infections linked to backyard poultry. Two deaths and over 1,000 illnesses have been reported from 49 states.
• Multidrug-resistant Salmonella infections linked to contact with pig ear dog treats. Over 140 illnesses have been reported from 35 states. CDC and FDA advise people not to buy or feed any pig ear dog treats at this time.
• Salmonella infections linked to Cavi brand whole, fresh papayas. Seventy-one illnesses have been reported from eight states.
• E. coli infections linked to ground bison produced by Northfork Bison Distributions, Inc. Twenty-one illnesses have been reported from seven states.

August marked one year since the current Ebola outbreak was declared in the Democratic Republic of the Congo. The number of cases has surpassed 3,000, including more than 2,000 deaths, making this the second-largest Ebola epidemic on record. CDC staff have conducted more than 360 deployments. CDC continues to work closely with our partners, at home and abroad, to end the outbreak.

CDC launched a series of 11 new infection control training courses as part of the new States Targeting Reduction in Infections via Engagement (STRIVE) curriculum for infection prevention teams, hospital leaders, clinical educators, nurse and physician managers, environmental services managers, all patient care staff, and patient/family advisors. The STRIVE curriculum will include over 40 individual training modules grouped into 11 courses that focus on foundational and targeted infection prevention strategies, and it will offer free Continuing Education. These training courses were developed by national infection prevention experts led by the Health Research & Educational Trust.

CDC and its public health partners in all 50 states are tracking and classifying foodborne illness in a new way, using whole genome sequencing (WGS) to detect and stop outbreaks and combat drug-resistant bacteria. PulseNet, the national network of laboratories that detects outbreaks of foodborne disease, moved to this new gold standard on July 15. By giving us more data about the foodborne bacteria that make people sick, WGS improves investigators’ ability to link cases of illness to outbreaks and identify common sources of infection.

Public Health Grand Rounds interviewed CDC’s Rickettsial Zoonoses Branch Chief Gil Kersh for a webcast, “Beyond the Data—Emerging Tickborne Diseases,” which was posted on July 16 following an encore presentation of the 2017 Grand Rounds session on “Emerging Tickborne Diseases.” Gil discussed changes since the 2017 presentation, including increased numbers of tickborne disease cases, new materials for healthcare providers, and hot topics such as alpha-gal allergy and the Asian longhorned tick.

“Rabies: A Forgotten Killer” was the theme for CDC’s June Vital Signs report released on June 13. Human deaths from rabies in the United States have declined dramatically over the past 80 years, from about 30-50 each year in the 1940s to an average of 1-3 per year today. This decrease is primarily due to routine pet vaccination and the availability of postexposure prophylaxis (PEP) using rabies vaccine and rabies immune globulin. Each year, about 55,000 people get PEP after a potential rabies exposure. Bats are responsible for around 70% of rabies deaths among people in recent years.

Measles is a highly contagious disease, and outbreaks are occurring worldwide. CDC’s Travelers’ Health Branch has posted a global measles outbreak travel notice. CDC has conducted over 75 contact investigations for measles involving more than 1,500 contacts in 2019 alone (compared with 81 contact investigations in 2018 and 15 in 2017). CDC is also working with partners to ensure that US-bound refugees are vaccinated or immune to measles before they travel.

On June 13, CDC activated its Emergency Operations Center to support the response to the current outbreak of Ebola in Democratic Republic of the Congo (DRC). This outbreak is the second-largest outbreak of Ebola ever and the largest in DRC’s history. As of July 7, a total of 2,418 cases and 1,625 deaths from the disease have been reported.

On June 24, CDC released an Ebola PSA recorded by Congolese native and retired professional basketball player Dikembe Mutombo. CDC is grateful to Mr. Mutombo for helping to reduce misinformation and encouraging communities to work together to combat Ebola. The PSA focuses on four key messages: getting treatment as quickly as possible, keeping away from fluids of people who are sick with Ebola or who have died from it, allowing safe and dignified burials for family members who have died, and accepting the vaccine.

CDC launched two new infection prevention and control (IPC) training tools for nurses and environmental services (EVS) personnel. The first, “Let’s Talk Patient Safety: Reducing HAI Transmission Risk,” is an online interactive infection control training that offers free continuing education and helps frontline healthcare professionals identify infection risks and prevent the spread of healthcare-associated infections (HAIs). The second, “EVS and the Battle against Infection,” is an interactive graphic novel that illustrates the important role of EVS personnel in preventing HAIs. The training features real-world IPC scenarios and allows participants to choose options that affect the story’s outcome.

CDC, with federal and state partners, is investigating various outbreaks, including the following:

• E. coli infections linked to flour. Eight states have reported 17 cases of Shiga toxin-producing E. coli O26 infections linked to flour. On May 23, 2019, ADM Milling Co. and ALDI recalled 5-lb. bags of Baker’s Corner All Purpose Flour because they may be contaminated with E. coli. CDC recommends that consumers not use any of the recalled flour. If you stored flour purchased from ALDI in another contaimer and don’t remember the brand or “better by” date, throw it away. Consumers should thoroughly wash the containers before using them again.
• Gastrointestinal illnesses linked to oysters imported from Mexico. Five states have reported 16 people with illnesses linked to multiple pathogens, including Vibrio parahaemolyticus, Vibrio albensis, Shigella flexneri, and Shiga toxin-producing coli non-O157. CDC advises consumers, restaurants, and retailers not to eat, serve, or sell oysters harvested from Estero El Cardon, an estuary in Baja California Sur, Mexico.
• Salmonella infections linked to contact with backyard poultry. Twenty-one states have reported 52 illnesses. CDC recommends that people always wash their hands thoroughly with soap and water right after handling chicken, ducks, other live poultry, or anything in the environment where they live and roam. Set aside a pair of shoes to wear while taking care of poultry and keep those shoes outside the house.
• Salmonella infections linked to Karawan and SoCo brands of tahini. Three states have reported four ill people, including one person who was hospitalized. CDC recommends that consumers, restaurants, and retailers not eat, serve, or sell recalled Karawan or SoCo brands of tahini. If you have Karawan or SoCo brands of tahini and do not know if they were recalled, do not eat them. Throw them away.

On April 24, CDC’s One Health Office released its report from the US One Health Zoonotic Disease Prioritization Workshop. The workshop, its report, and the list of priority zoonotic diseases from the workshop—the result of a joint effort between CDC, the US Department of Agriculture, and the US Department of the Interior—represent a critical step toward a coordinated, US-specific approach to One Health. The report covers the prioritization process, the eight priority diseases, and discussions and recommendations for addressing these zoonotic diseases using a One Health approach.

Given that three rabid dogs have been imported from Egypt since May 2015, CDC is temporarily suspending the importation of dogs from Egypt, including dogs originating in Egypt that are imported from third-party countries, if the dogs have lived in those countries for less than 6 months. CDC is taking this action to protect public health and prevent the reintroduction of dog rabies (canine rabies virus variant), which has been eliminated from the United States since 2007. CDC will maintain this suspension until appropriate veterinary safeguards have been established to prevent the importation of rabid dogs from Egypt.

On May 13, CDC debuted a new Rocky Mountain spotted fever (RMSF) training module to help clinicians recognize and diagnose RMSF, a bacterial disease spread through the bite of an infected tick. The signs and symptoms of RMSF can be difficult to differentiate from those of other diseases, but early recognition and treatment are key to preventing severe and fatal outcomes. The module includes knowledge checks, case-based scenarios, and a rash comparison tool. Free continuing education credit is available for physicians, nurse practitioners, physician assistants, veterinarians, nurses, epidemiologists, public health professionals, educators, and health communicators.

CDC, with federal and state partners, is investigating various multistate foodborne outbreaks, including the following:

• E. coli O103 infections linked to ground beef. Ten states have reported 177 illnesses. Two companies have recalled ground beef products that were sold to restaurants and institutions because they may be contaminated with E. coli O103. CDC advises consumers and restaurants to handle and cook ground beef safely.
• Salmonella Carrau illnesses linked to pre-cut melons produced by Caito Foods LLC. Ten states have reported 117 illnesses. CDC advises consumers, retailers, and restaurants not to eat, serve, or sell recalled pre-cut melons.
• Salmonella Newport illnesses linked to frozen, raw ground tuna produced by Jensen Tuna and distributed to restaurants and retailers. Seven states have reported 13 illnesses. CDC advises consumers not to order or buy prepared sushi or other foods containing recalled tuna. Restaurants and retailers should not sell or serve recalled tuna.
• Listeria infections linked to deli-sliced meats and cheeses. Four states have reported eight illnesses, including one death. CDC is not advising that consumers avoid eating products prepared at delis, or that retailers stop selling deli-sliced products.

One Health Office staff traveled to Fairbanks, Alaska, where they met with staff from DPEI’s Arctic Investigations Program (AIP) and participants from tribal, local, state, and federal partners to facilitate a One Health Zoonotic Disease Prioritization Workshop. While the One Health Office has assisted in conducting over 20 workshops to help countries and regions prioritize zoonotic diseases of greatest concern, this was the first time it had been done at the state level. AIP co-hosted the two days of meetings with the University of Alaska as part of its ongoing efforts to encourage a One Health approach to improving health in Alaska and the Arctic.

In other healthcare-associated infection news, CDC published the 2017 National and State Healthcare-Associated Infection (HAI) Progress Report and updated the Patient Safety Atlas to include 2017 HAI data. The report includes data across four healthcare settings: acute-care hospitals, critical access hospitals, inpatient rehabilitation facilities, and long-term acute care hospitals. This report shows that the United States has made significant reductions in several types of HAIs and highlights areas where more improvements are needed.

CDC staff recently led a rabies exercise in Beijing with experts from human and animal health sectors in China’s national government and 12 provinces. The exercise was part of the country’s efforts to work toward eliminating by 2030 human rabies cases spread by bites of rabid dogs. The participants used the Stepwise Approach towards Rabies Elimination (SARE) tool, which helps countries evaluate their current gaps and prioritize the short- and long-term activities needed to eliminate human rabies cases linked to dogs. The SARE tool is used throughout the world and provides a standard mechanism for countries to assess their rabies situation and measure progress.

CDC released a new Nursing Home Infection Preventionist Training Course, a comprehensive, free, online training for staff responsible for infection prevention and control programs. The course, developed in collaboration with the Centers for Medicare & Medicaid Services (CMS), provides an overview of the core activities of an infection prevention and control program and recommended practices to prevent healthcare-associated infections, control the spread of pathogens, and combat antibiotic resistance in nursing homes. This course is designed to help facilities provide staff with the required specialized infection prevention and control training as it relates to the phased implementation of CMS Requirements for Participation for Nursing Homes

The total number of people infected with Ebola virus in the Democratic Republic of Congo (DRC) has surpassed 1,000 (confirmed and probable). As of March 27, the total number of confirmed and probable cases was 1,044, including 642 deaths. CDC remains committed to working closely with the DRC Ministry of Health, the World Health Organization, and other partners to end this outbreak. CDC is deploying more staff to DRC to provide technical assistance and support for the response. For more details about the outbreak, see the latest media statement.

After reviewing current data on the spread of Zika, CDC updated its Zika travel guidance. Some areas of the world continue to experience outbreaks of Zika, while other areas have confirmed Zika in the past but may not have recent cases. CDC now recommends that pregnant women and couples trying to become pregnant within the next three months talk to their healthcare providers and carefully consider the risks and possible consequences of Zika infection before traveling to areas that have had active Zika transmission, even those where there is no current outbreak. CDC’s recommendation that pregnant women not travel to areas where a Zika outbreak is occurring has not changed. For more information, see the World Map of Areas with Zika.

The March 2019 Vital Signs report was about the national burden of infection and death caused by all Staphylococcus aureus (staph) in hospitals and the community. More than 119,000 people suffered from bloodstream staph infections in the United States in 2017—and nearly 20,000 died. The report underscores that both types of S. aureus (methicillin-resistant or MRSA, and methicillin-susceptible or MSSA) can be deadly.

The findings show that hospital infection control efforts successfully reduced rates of serious staph infections in the U.S. (about 17% each year 2005-2012). Recent data, however, show that this success is slowing and the rise in staph infections in the community may be linked to the opioid crisis.

A new JAMA article describes ongoing advances being made by CDC’s Advanced Molecular Detection (AMD) program in the field of next-generation sequencing. JAMA also posted a related clinical review podcast episode in which two of the article’s authors discussed the potential next-generation sequencing holds for improving clinical and public health microbiology.

Hantavirus disease is an uncommon illness in people, but it can cause severe or even fatal disease. While cases have occurred in most states across the country, incidence is highest in the west. CDC, in collaboration with Navajo Nation, Indian Health Service, and the Arizona and New Mexico departments of health, created a hantavirus training video for healthcare providers in the Four Corners region. This video focuses on the risk factors, clinical presentation, and methods for identifying hantavirus disease, as well as parameters for clinical management.

While viral hemorrhagic fevers (VHFs) like Lassa fever are very serious, they are not commonly seen in the United States. However, it is important for healthcare providers to understand high-consequence viruses such as Lassa so they can appropriately diagnose and care for their patients. CDC created two training videos for healthcare providers to learn about Lassa fever risk factors, incubation period, clinical presentation, diagnoses, treatment, and infection control measures for Lassa fever patients.

DPEI’s Arctic Investigations Program (AIP) works closely with Alaska Native partners to improve the health of Alaska and Arctic residents. They do this through research, surveillance, outbreak investigations—and flu shot clinics! For the past 10 years, AIP has set up shop at the health fair attached to the Alaska Federation of Natives Convention, the largest gathering of Native peoples in the United States. The Alaska Native Tribal Health Consortium and the Southcentral Foundation are organizations that provide health services to Alaska Natives. They provide the vaccine doses and AIP’s medical staff run the clinic. This year, staff administered 450 doses to anyone who requested it, including many repeat customers and US Senator Dan Sullivan.

On January 31, CDC’s Division of Global Migration and Quarantine published the Rabies-Free Dog Importation Guidance and updated the Importation Laws and Regulations webpage to add the Federal Register Notice. Since canine rabies virus variant (CRVV) was declared eliminated in the United States in 2007, federal importation regulations have successfully prevented reimportation of CRVV into this country, even though other rabies viruses still circulate among some wildlife species. The new policy focuses on the presence or absence of CRVV in the country the dog is coming from and the risk of reintroduction of CRVV into the United States. Requiring rabies vaccination of dogs from countries with high risk of CRVV transmission helps prevent CRVV from entering the United States, thereby lowering the risk of CRVV infection among humans.

• Salmonella Reading infections linked to raw turkey products. As of February 15, 2019, a total of 279 ill people had been reported from 41 states. Always handle raw turkey carefully and cook it thoroughly to prevent foodborne illness.
• Salmonella Typhimurium infections linked to contact with pet hedgehogs. As of January 25, 2019, eleven ill people have been reported from eight states. Don’t snuggle or kiss pet hedgehogs, because this can spread their germs to you.
• Salmonella Newport infections linked to ground beef. As of December 12, 2018, a total of 333 ill people had been reported from 28 states. Always handle and cook ground beef safely and cook it thoroughly to avoid foodborne illness.

The Ebola outbreak in DRC continues to be a significant area of effort for CDC staff. The outbreak has been ongoing for over five months and has grown to 733 cases and 459 deaths (as of January 27^th). Community resistance and security concerns continue to hamper response activities, and the recent general elections created even more tension in the area and throughout the country. CDC is working closely with partners to explore new approaches for strengthening the response and containing the outbreak.

A U.S. citizen was evacuated from DRC for observation at the University of Nebraska Medical Center following a high risk exposure. Luckily, the citizen completed their observation period without exhibiting any symptoms.

In addition, a new study out of China describes the characterization of a distinct filovirus (the virus family which includes Ebola and Marburg viruses) discovered in bats, named Měnglà virus (MLAV). It’s not yet known if MLAV could cause disease in either animals or people.

CDC posted a travel notice about recent cases of carbapenem-resistant Pseudomonas aeruginosa infections among US residents who had invasive surgery in Tijuana, Mexico. Most of the patients had undergone bariatric procedures, and approximately half had surgery at the Grand View Hospital in Tijuana. As a result of the investigation, the Mexican government closed the hospital until further notice. CDC recommends that travelers to Tijuana not have surgery at this hospital until the Mexican health authorities can confirm that the drug-resistant form of Pseudomonas aeruginosa is no longer present there.

CDC has released new data in its Antibiotic Resistance (AR) Investment Map, which showcases CDC’s funding in fiscal year 2018 to support efforts that protect people from antibiotic resistance in the United States and abroad. For the first time, the tool includes CDC’s extramural global AR activities and highlights successes that followed Congress’ unprecedented investment in CDC’s AR Solutions Initiative.

The AR Investment Map features

• Global and domestic extramural collaborations to identify and implement innovative solutions to protect people from the threat of antibiotic resistance.
• More than 170 state-reported successes (e.g., containing rare and concerning resistant germs to protect communities and stop dangerous germs from spreading).
• Printable global-, state-, and city-specific fact sheets that describe how CDC invests in activities in that area.

Python Cave in Uganda is not only home to snakes, but to thousands of Egyptian fruit bats. Several recent human cases of Marburg virus – a close cousin to Ebola – have surfaced with links to these bats, and nearby villages have experienced devastating outbreaks. To better understand how Marburg virus is spread, CDC worked with Ugandan experts to put GPS units on the backs of bats to track their movements. By learning where the bats travel at night, we hope to better predict which areas are most at risk for Marburg and stop the next outbreak before it ever starts. Watch the video about the journey and read a Washington Post article by Lena Sun, who followed along with the team.

CDC, with UK Science and Innovation Network and the Wellcome Trust, recently released a report summarizing existing scientific evidence on how antibiotics and antibiotic-resistant germs can be present in the environment from human and animal waste, pharmaceutical manufacturing waste, and use of antimicrobial pesticides for crops. The report shows that more research is needed and describes actions to address knowledge gaps. Find the report here under CDC Collaborations.