Describe Angiostrongylus cantonensis is an important cause of eosinophilic meningitis in southern Vietnam.

1 )Rabies articlehttps://wwwnc.cdc.gov/eid/article/23/12/pdfs/17-1148.pdfSEARCH LETTERS 9. McBride A, Chau TTH, Hong NTT, Mai NTH, Anh NT, Thanh TT, et al. Angiostrongylus cantonensis is an important cause of eosinophilic meningitis in southern Vietnam. Clin Infect Dis. 2017;64:1784–7. http://dx.doi.org/10.1093/cid/cix118 Address for correspondence: Damien K.Y. Ming, Imperial College London, The Section of Infectious Diseases and Immunity, Commonwealth Building, Hammersmith Campus, London SW7 2AZ, UK; email: damien.ming@doctors.org.uk Tool for Eliminating Dog-Mediated Human Rabies through Mass Dog Vaccination Campaigns Eduardo A. Undurraga,1 Jesse D. Blanton, S.M. Thumbi, Athman Mwatondo, Mathew Muturi, Ryan M. Wallace Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.A. Undurraga, J.D. Blanton, R.M. Wallace); Kenya Medical Research Institute, Nairobi, Kenya (S.M. Thumbi); Washington State University, Pullman, Washington, USA (S.M. Thumbi); Kenya Ministry of Health, Nairobi (A. Mwatondo, M. Muturi) DOI: https://doi.org/10.3201/eid2312.171148 The World Health Organization and collaborating agencies have set the goal of eliminating dog-mediated human rabies by 2030. Building on experience with rabies endemic countries, we constructed a user-friendly tool to help public health officials plan the resources needed to achieve this goal through mass vaccination of dogs. Globally, rabies kills ≈60,000 persons annually; most (≈99%) cases are transmitted by domestic dogs (1–3). Controlling dog rabies through periodic mass vaccination campaigns substantially reduces human exposures (4). The elimination of dog rabies in most of the Western Hemisphere and countries in Asia has demonstrated the effectiveness and sustainability of vaccinating dogs (5,6) by combining massive dog rabies vaccination with coordinated efforts of the medical and veterinary sectors (One Health approach), including education about responsible pet ownership, rabies awareness campaigns, and access to postexposure prophylaxis (5,6). The World Health Organization recommends that at least 70% of the dog population be vaccinated to control and potentially eliminate dog rabies (3). In 2016, WHO and partner organizations set the goal of eliminating dog-mediated human rabies by 2030 (7). This goal could be achieved by massive, costly administration of preexposure and postexposure prophylaxis, mass vaccination of dogs, or both. Countries to which rabies is endemic in dogs are at different stages in their rabies control efforts (5,8). Countries at early stages face barriers related to a limited understanding of the local epidemiology, logistic and operational challenges, competing priorities from other diseases, and lack of planning tools to reasonably project the resources needed. During 2016, we estimated the resources potentially required to eliminate dog rabies globally by 2030 (7). We combined multiple data sources to estimate 4 key factors that affect this goal: country development, cost of dog vaccination programs, potential demand for dog rabies vaccine, and estimated number of vaccinators. We aimed to realistically assess the global situation by highlighting the main challenges that might hamper elimination efforts. However, although these global estimates can inform an important discussion about global and regional strategic planning and resource mobilization, they are not necessarily useful to inform country-level decision-making. We addressed this limitation by providing a user-friendly tool that requires only limited country-specific data to help countries plan toward the goal of eliminating dog rabies through mass dog vaccination. We designed the tool to plan for dog rabies elimination by 2030 (a 13-year framework). We assumed 13 years would be enough time for even the least developed rabies control programs to achieve elimination, provided the country was fully committed. The country’s starting point within this time frame would depend on its current dog vaccination rate, and the given country would demonstrate incremental improvements in preparation for the vaccination campaign (e.g., training of workforce involved, dog population surveys) or in the proportion of the dog population vaccinated. The tool requires input of demographic data (human population, percentage urban, human-to-dog ratio); current dog vaccination coverage; logistic data for the campaigns (available vaccinators, dog vaccination rates, campaign duration); and an estimated cost per vaccinated dog. We constructed a worksheet to help users estimate the cost per vaccinated dog based on a pilot campaign. The tool (including assumptions, instructions, and data requirements) is available for public use (online Technical Appendix, https://wwwnc.cdc.gov/ EID/article/23/12/17-1148-Techapp1.xlsm) and already has been used in Haiti and Guatemala as part of a rabies elimination workshop held at the Centers for Disease Control and 1 Current affiliation: Pontificia Universidad Católica de Chile, Santiago, Chile. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 23, No. 12, December 2017 2115 RESEARCH LETTERS 1Prevention (Atlanta, GA, USA). Users can account for uncertainty in point estimates by varying model parameters. To show the utility of the planning tool, we input known information from 2 recent mass dog vaccination campaigns in western Kenya to project expected longterm costs and a timeline for rabies elimination. With a conservative estimate of 523 (95% CI 138–1,100) annual human rabies-associated deaths and substantial medical costs (1), Kenya is actively trying to eliminate human rabies by 2030 (9). We used the following values: 46,050,302 persons, of whom 26% live in urban areas; 7.4 and 21.2 humans per dog in rural and urban areas, respectively; 5% of the dog population vaccinated; 4,300 available vaccinators; 100 dogs vaccinated daily per vaccinator; a 21-day campaign in each region; an estimated cost per dog vaccinated of US $1.81 (range US $1.48–$2.12); and 0% discount rate (Figure). Conditional on the availability of resources, the results suggest that Kenya can eliminate dog rabies during the next 13 years, in line with the 2030 global goal; vaccination campaigns would cost ≈US $62.0 million (range US $50.6 million–$72.8 million), equivalent to ≈$56.0 million additional aggregate spending over 13 years (not discounted). If the average vaccination rate was 100 dogs per vaccinator per day, Kenya would have enough capacity to conduct 21-day campaigns and reach the 70% dog vaccination goal. The tool enables users to estimate the resources required to eliminate rabies using country-specific input values. We hope this tool will help stimulate and inform a necessary discussion on strategic planning, resource mobilization, and continuous execution of rabies elimination. This work was funded by the Centers for Disease Control and Prevention. Dr. Undurraga was a Steven M. Teutsch Prevention Effectiveness Fellow in the Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, when this work was done. He is currently an assistant professor at the School of Government, Pontificia Universidad Católica de Chile, Santiago. His primary research interests include population health, health economics, and social policy. References 1. Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, et al.; Global Alliance for Rabies Control Partners for Rabies Prevention. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9:e0003709. Erratum in: PLoS Negl Trop Dis. 2015;9:e0003786. http://dx.doi.org/10.1371/ journal.pntd.0003709 2. Knobel DL, Cleaveland S, Coleman PG, Fèvre EM, Meltzer MI, Miranda MEG, et al. Re-evaluating the burden of rabies in Africa and Asia. Bull World Health Organ. 2005;83:360–8. Figure. Illustrative results from the planning aid tool for controlling dog rabies through dog vaccination using input data, Kenya, 2016. A) Number of annual dog vaccinations required in accordance with World Health Organization recommendations. The tool assumes a threshold of 70% of dog vaccination during 7 years as a conservative estimate to eliminate dog-mediated rabies. The actual proportion of the dog population that needs to be vaccinated depends on local conditions of rabies transmission (10). Based on field data, Kenya estimates that 3 consecutive years of 70% coverage of dog vaccination would end dog–dog rabies transmission. The estimate by Hampson et al. (1) estimate of 523 annual deaths was based on active surveillance in eastern Kenya; current passive surveillance reports higher bite rates, so the estimate probably represents a lower bound of the number of deaths that could be avoided through mass dog vaccination. B) Total annual cost (US $) of dog vaccination. Error bars indicate 95% CIs. Horizontal dotted line indicates current spending for dog vaccination. C) Net dog vaccination capacity (i.e., total number of dogs per year minus the number of dogs Kenya needs to vaccinate to achieve the dog vaccination coverage goal). If the number is positive, the country has enough capacity to vaccinate; if negative, the country needs more vaccinators, increased vaccination efficiency, or more campaign days. The estimated annual costs are based on the cost per dog vaccinated; excess vaccinator capacity is not included in the aggregate costs. 2116 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 23, No. 12, December 2017 RESEARCH LETTERS 3. World Health Organization. WHO Expert Consultation on Rabies. Second report [cited 2016 Mar 30]. http://apps.who.int/iris/ bitstream/10665/85346/1/9789240690943_eng.pdf 4. World Health Organization. Rabies vaccines: WHO position paper. Wkly Epidemiol Rec. 2010;85:309–20 [cited 2017 Oct 5]. http://www.who.int/wer/2010/wer8532/en/ 5. Rupprecht CE, Hanlon CA, Hemachudha T. Rabies re-examined. Lancet Infect Dis. 2002;2:327–43. http://dx.doi.org/10.1016/ S1473-3099(02)00287-6 6. Vigilato MAN, Clavijo A, Knobl T, Silva HMT, Cosivi O, Schneider MC, et al. Progress towards eliminating canine rabies: policies and perspectives from Latin America and the Caribbean. Philos Trans R Soc Lond B Biol Sci. 2013;368:20120143. http://dx.doi.org/10.1098/rstb.2012.0143 7. Wallace RM, Undurraga EA, Blanton JD, Cleaton J, Franka R. Elimination of dog-mediated human rabies deaths by 2030: needs assessment and alternatives for progress based on dog vaccination. Front Vet Sci. 2017;4:9. http://dx.doi.org/10.3389/fvets.2017.00009 8. Lembo T, Hampson K, Kaare MT, Ernest E, Knobel D, Kazwala RR, et al. The feasibility of canine rabies elimination in Africa: dispelling doubts with data. PLoS Negl Trop Dis. 2010;4:e626. http://dx.doi.org/10.1371/journal.pntd.0000626 9. Republic of Kenya Ministry of Health and Ministry of Agriculture. Strategic plan for the elimination of human rabies in Kenya 2014–2030 [cited 2017 Jun 1]. http://zdukenya.org/wp-content/ uploads/2012/09/National-Rabies-Elimination-Strategy.pdf 10. Zinsstag J, Dürr S, Penny MA, Mindekem R, Roth F, Menendez Gonzalez S, et al. Transmission dynamics and economics of rabies control in dogs and humans in an African city. Proc Natl Acad Sci U S A. 2009;106:14996–5001. http://dx.doi.org/ 10.1073/pnas.0904740106 Address for correspondence: Eduardo A. Undurraga, School of Government, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul CP 7820436, Región Metropolitana, Chile; email: eundurra@uc.cl Unexpected Infection with Armillifer Parasites Idzi Potters, Claude Desaive, Steven Van Den Broucke, Marjan Van Esbroeck, Lutgarde Lynen Author affiliations: Institute of Tropical Medicine Antwerp, Antwerp, Belgium (I. Potters, S. Van Den Broucke, M. Van Esbroeck, L. Lynen); Central University Hospital of Liège, Liège, Belgium (C. Desaive) DOI: https://doi.org/10.3201/eid2312.171189 Visceral pentastomiasis is usually found incidentally during surgery. We describe a case of visceral pentastomiasis discovered during inguinoscrotal hernia surgery for a man from Benin, Africa. Because surgical removal of nymphs is needed for symptomatic patients only, this patient’s asymptomatic pentastomiasis was not treated and he recovered from surgery uneventfully. I n November 2015, a surgeon from Belgium, working for Medics without Vacation in Bassila, Benin, Africa, incidentally discovered pentastomiasis in an adult man during surgery for a massive inguinoscrotal hernia (half a liter content). Other than the hernia, the patient had no health problems. During the procedure, the surgeon observed at least 10 coiled, larva-like structures on the patient’s peritoneal tissue. He removed the hernial sac and sent a tissue specimen to the national reference laboratory for parasitology at the Institute of Tropical Medicine (Antwerp, Belgium) for identification of the parasite. Apart from the hernia symptoms, the patient was asymptomatic, so the parasites were not removed; the patient’s surgical recovery was uneventful. Macroscopic examination of the peritoneal tissue detected 8 distinct, typical larva-like structures with an average length of 1–2 cm (Figure, panel A). Because the structures were suspected to be pentastomes, they were compared with reference material from the Institute of Tropical Medicine Educational Department (Figure, panel B) and confirmed as Armillifer spp. nymphs. On the basis of the patient’s residence in Benin, and the fact that the recovered nymphs consistently exhibited 2 )Outbreak of typhoid infection//www.cdc.gov https:/salmonella/2010/frozen-fruit-pulp-8-25-10.htmlultistate Outbreak of Human Typhoid Fever Infections Associated with Frozen Mamey Fruit Pulp (Final Update)NOTICE: This outbreak is over. The information on this page has been archived for historical purposes only and will not be updated.Posted August 25, 2010Outbreak SummaryCDC is collaborating with public health officials in two states and the U.S. Food and Drug Administration (FDA) to investigate an outbreak of Salmonella infections, serotype Typhi. Salmonella Typhi is the bacterium that causes typhoid fever. Typhoid fever is a very rare illness in the United States among non-international travelers and can cause serious symptoms, often times requiring hospitalization. Typhoid fever is contracted when food and water are contaminated by an infected individual and are then consumed by other people. Investigators are using DNA analysis of Salmonella bacteria obtained through diagnostic testing to identify cases of illness that may be part of this outbreak.As of 9:00am EDT on August 20, 2010, a total of 9 individuals infected with a matching strain of Salmonella serotype Typhi have been reported from 2 states since May 25, 2010. The number of ill persons identified in each state with this strain is as follows: CA (5) and NV (4).Among persons with reported illness onset dates available, illnesses began between April 10, 2010, and July 25, 2010. Infected individuals range in age from 4 to 31 years old and the median age is 21 years. Sixty-seven percent (67%) of cases are female and 100 percent report Hispanic ethnicity. Among 9 patients with available clinical information, 7 (78%) were hospitalized. Eight (89%) of 9 patients reported no international travel in the 60 days prior to illness onset. As of August 20, 2010, no deaths attributed to this infection have been reported.The outbreak can be visually described with a chart showing the number of persons who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after June 10, 2010, might not yet be reported due to the time it takes between when a person becomes ill, when laboratory testing is completed, when the diagnosis is confirmed, and when the illness is reported. For typhoid fever outbreaks, this takes an average of 8-10 weeks. This delay is denoted by the gray box on the epi curve.Outbreak InvestigationCDC and public health officials in two states conducted an epidemiologic study comparing foods eaten by ill and well persons. Among interviewed ill persons, 7 (78%) of 9 reported consuming frozen mamey fruit pulp in a milkshake or smoothie, also called a “batido” or “licuado”. Upon further investigation, it was found that 5 (71%) of 7 ill persons consumed Goya brand frozen mamey fruit pulp. One person consumed La Nuestra brand frozen mamey fruit pulp. Among well persons, 0 (0%) of 33 reported exposure to frozen mamey fruit pulp. No other food was found to be associated with illness. These results suggest that eating frozen mamey fruit pulp is a likely source of these illnesses. CDC and its public health partners will update the public on the progress of this investigation as information becomes available.Mamey, also called “zapote” or “sapote”, is a tropical fruit grown primarily in Central and South America. It is prepared by removing the inner seed and consuming the flesh raw, or adding it to milkshakes, jellies, or other foods or beverages. When preparing frozen mamey fruit pulp, it is peeled and mashed, and then consumed as a shake or smoothie. Frozen mamey fruit pulp can be purchased in grocery stores throughout the U.S., and packages have a 2-3 year shelf life.Recall Information•On August 13, 2010External, Goya Foods, Inc. announced voluntary recalls of frozen mamey pulp.•On August 20, 2010External, Montalvan’s Sales, Inc. announced a voluntary recall of “La Nuestra” brand of frozen mamey fruit pulp.Clinical Features/Signs and SymptomsMost persons infected with Salmonella Typhi develop high and sustained fever, headache, constipation, malaise, chills, and myalgia 2 to 5 weeks after infection. Infection is usually diagnosed by a blood culture. The illness can last from 3 to 4 weeks and infections may be severe or fatal if untreated. Typhoid fever should be treated with appropriate antimicrobial medications. More general information about Salmonella Typhi can be found here.Advice to Consumers•Until further notice, do not eat or drink Goya or La Nuestra brands of frozen mamey fruit pulp.•Individuals who think they might have become ill from eating frozen mamey fruit pulp should consult their health care providers.General Information•Typhoid Fever•Multistate and Nationwide Foodborne Outbreak Investigations: A Step-by-Step Guide•CDC’s Role in Outbreak InvestigationsAdditional Resources•Urgent Nationwide Frozen Mamey Fruit Products Recall (August 20, 2010)ExternalCDC’s Role in Food SafetyAs an agency within the U.S. Department of Health and Human Services (HHS), CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular with HHS’s U.S. Food and Drug Administration (FDA) and the Food Safety and Inspection Service within the United States Department of Agriculture (USDA). CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.3 article MRSAhttps://wwwnc.cdc.gov/eid/article/26/3/19-1408Methicillin-Resistant Staphylococcus aureus Bloodstream Infections and Injection Drug Use, Tennessee, USA, 2015–2017On This PageCME Introduction________________________________________Methods________________________________________Results________________________________________Discussion________________________________________CME Follow Up________________________________________Cite This ArticleFiguresFigureTablesTable 1________________________________________Table 2________________________________________Table 3DownloadsArticle ________________________________________Appendix ________________________________________Article & Appendix ________________________________________RIS [TXT – 2 KB] AltmetricMetric DetailsRelated ArticlesCommunity Outbreak of Hepatitis A, California________________________________________Hepatitis A Hospitalization Costs________________________________________Human Pegivirus 2 without Hepatitis C Co-infection________________________________________More articles on HepatitisMeghana P. Parikh , Rany Octaria, and Marion A. KainerAuthor affiliations: Tennessee Department of Health, Nashville, Tennessee, USA (M.P. Parikh, R. Octaria, M.A. Kainer); Vanderbilt University, Nashville (R. Octaria)Cite This ArticleIntroductionMedscape CME ACTIVITYIn support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 75% minimum passing score and complete the evaluation at http://www.medscape.org/journal/eidExternal Link; and (4) view/print certificate.Release date: February 12, 2020; Expiration date: February 12, 2021Learning ObjectivesUpon completion of this activity, participants will be able to:• Describe the prevalence of life-threatening IDU-related MRSA BSI in Tennessee in 2015–2017, according to an analysis of data from the NHSN and the Tennessee Hospital Discharge Data System• Determine the demographics and clinical characteristics of IDU-related MRSA BSI in Tennessee in 2015–2017, according to an analysis of data from the NHSN and the Tennessee Hospital Discharge Data System• Identify clinical and public health implications of the association of IDU practices with life-threatening MRSA BSI in Tennessee, according to an analysis of data from the NHSN and the Tennessee Hospital Discharge Data SystemCME EditorDeborah Wenger, MBA, Copyeditor, Emerging Infectious Diseases. Disclosure: Deborah Wenger, MBA, has disclosed no relevant financial relationships.CME AuthorLaurie Barclay, MD, freelance writer and reviewer, Medscape, LLC. Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.AuthorsDisclosures: Meghana Pendurthi Parikh, VMD, MPH; and Rany Octaria, MD, MPH, have disclosed no relevant financial relationships. Marion Kainer, MBBS, MPH, has disclosed the following relevant financial relationships: served as an advisor or consultant for Infectious Disease Consulting Corporation; Pfizer Inc.TopAbstractRecently, Tennessee, USA, has seen an increase in the use of commonly injected drugs, such as heroin and fentanyl. Injection drug use (IDU) practices can lead to life-threatening methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs) and other serious diseases. We matched MRSA BSIs identified through the National Healthcare Safety Network to the Tennessee Hospital Discharge Data System to characterize the prevalence, demographics, and clinical characteristics associated with IDU in this disease population. Of the 7,646 MRSA BSIs identified during 2015–2017, we found that 1,839 (24.1%) were IDU-related. IDU-related BSIs increased by 118.9%; the greatest rise occurred among emergency department–onset infections (197.4%). IDU was more often associated with white, female, 18–49-year-old, and uninsured persons (p<0.001). We found >1 additional IDU-related diagnoses in 84.2% of IDU-related BSIs. Targeted harm reduction strategies for persons at high risk of IDU are necessary to reduce MRSA BSIs in acute care settings.Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a prominent healthcare-associated pathogen causing illness and death (1,2). As a result of the widespread implementation of infection control practices in acute-care hospitals, nationwide decreases in hospital-onset MRSA (HO MRSA) bloodstream infections (BSIs) were seen during 2005–2012. However, recent data show that since then there has been no change in the incidence of HO MRSA BSIs (3). Surveillance data on MRSA BSIs from acute care hospitals in Tennessee show similar patterns in decline and stabilization of HO BSIs; however, state trends in community-onset (CO) BSIs vary greatly from reported national patterns. Nationwide estimates suggest that incidence of CO MRSA BSIs has remained stable during 2005–2016 (3), whereas Tennessee’s statewide surveillance showed a 37.2% increase in CO MRSA BSI events during 2011–2016 (4).CO MRSA BSIs, classified as having a positive blood sample collected on or before day 3 of hospitalization or during an emergency department (ED) visit (5), are often associated with previous healthcare procedures and hospitalizations (6,7). Additional risk factors for CO MRSA among previously healthy persons include, but are not limited to, close contact with colonized or infected persons (8), shared equipment that is not cleaned between users (9), and skin trauma (10,11). We postulate that Tennessee’s unique epidemiology of CO MRSA BSIs might be reflective of geographic differences in injection drug use (IDU) practices associated with the opioid epidemic. These patients might have clinical manifestations and risk factors that vary from those identified in previous literature. In the 2000s, opioid use was largely associated with abuse of prescription opioids, but during the past decade, the rise in opioid use and overdose deaths has been attributed to an increase in commonly injected drugs such as heroin and fentanyl (12–14). In Tennessee, although prescription opioids are still responsible for the greatest number of opioid deaths, overdose deaths associated with synthetic opioids increased by 666% and overdose deaths associated with heroin increased by 522% during 2012–2017 (15).IDU has long been identified as a risk factor for invasive MRSA infections, including skin and soft tissue infections (16–18), osteomyelitis and septic arthritis (19–21), bacteremia (17,22), and endocarditis (18,23,24). Data from 6 sites of the Centers for Disease Control and Prevention’s Emerging Infections Program (Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases) have shown that persons who inject drugs are >16 times more likely to develop invasive MRSA infections than persons who do not inject drugs and that the proportion of invasive MRSA associated with IDU has risen from 4.1% in 2012 to 9.2% in 2016 (10).We sought to describe the prevalence of IDU-related MRSA BSI cases in acute-care hospitals across Tennessee. In addition, we examined the demographic and clinical characteristics of IDU-related and non–IDU-related cases. With these data, we aim to inform targeted efforts to improve clinical response to high-risk MRSA BSI patients in both outpatient and inpatient settings. Furthermore, increased knowledge of the indirect impacts of the opioid epidemic is imperative for the development of policy-based prevention initiatives.MethodsData SourcesWe identified MRSA BSIs using the National Healthcare Safety Network (NHSN), a nationwide reporting system through which acute care hospitals in Tennessee track laboratory-identified MRSA BSIs from inpatient (IP) units and EDs (5). NHSN includes details on specimen collection and facility characteristics, in addition to limited patient identifiers, such as sex, date of birth, and name (optional to report).The Tennessee Hospital Discharge Data System (HDDS) was used to further characterize demographics and clinical characteristics of MRSA BSIs identified in NHSN. HDDS captures administrative data on patient demographics, diagnoses, and procedures performed during all IP hospitalizations and ED encounters occurring in Tennessee hospitals during January 2014–June 2018 (25). In that time frame, all hospital visits for MRSA BSI patients were identified by matching records on patient names, dates of birth, or medical record numbers when other identifiers were unavailable. Beginning in January 2016, all HDDS diagnosis codes were documented using the International Classification of Diseases (ICD), 10th Revision, Clinical Modification (ICD-10-CM). Prior to that, codes from ICD-10-CM or the ICD’s Ninth Revision, Clinical Modification (ICD-9-CM) were allowed in HDDS.Our study cohort included MRSA BSIs from patients >13 years of age with onset of infection during January 2015–December 2017 and with >1 IP or ED visit to any Tennessee hospital during July 2014–June 2018, as identified in HDDS. HDDS observations were excluded if full patient names or dates of birth were missing.VariablesWe classified a case of MRSA BSI as IDU-related if any HDDS visit in the 6 months before or after blood specimen collection contained a diagnosis code for drug use (primary or secondary). The list of ICD codes used included diagnoses for dependence, abuse, poisoning, or accidental death caused by commonly injected illicit drugs (e.g., cocaine, opioids, methamphetamine) (Appendix Table 1). These codes have been used in peer-reviewed literature to estimate IDU associated with hospitalizations for other infectious diseases, such as infective endocarditis (23,24,26).In accordance with NHSN guidelines, we classified a BSI event as CO if the culture was obtained on or before hospital day 3 and as HO if obtained on hospital day 4 or later, with the admission date being day 1 (5). We further classified CO infections as either CO-ED or CO-IP on the basis of the patient’s location at the time of culture collection. We classified same-day cultures collected in both ED and IP locations as a single CO-ED event.We also evaluated cases for the presence of other IDU-related diagnoses in the 6 months before or after blood collection, including hospitalization for MRSA BSI. Thus, these cases could have occurred as a part of the same or different disease process as the BSI event. IDU-related diagnosis codes included endocarditis, acute or chronic hepatitis C, osteomyelitis or septic arthritis, and skin and soft tissue infections (Appendix Table 2).Statistical AnalysisWe evaluated differences in baseline characteristics between IDU-related and non–IDU-related BSIs using a χ2 or Fisher exact test for categorical variables and 2-sample t-test for continuous variables. We further analyzed IDU-related MRSA BSI events by onset group, using a χ2 or Fisher exact test for categorical variables and 1-way analysis of variance for continuous variables. We performed database linkages and statistical analyses using SAS 9.4 (SAS Institute Inc., https://www.sas.comExternal Link). We defined statistical significance as p<0.05. This study was approved by the Tennessee Department of Health (TDH) Institutional Review Board (project no. 1148777-1).TopResultsAfter excluding patients <13 years of age at the time of culture, we identified 8,251 NHSN MRSA BSI cases from 7,076 patients during 2015–2017. Of those patients, 6,548 (92.5%) were located within HDDS. In total, the matched patients represented 7,646 MRSA BSI cases included in the study cohort. We identified only 1 BSI case per person in 87.5% of patients; the maximum number of BSI events per person over the study timeframe was 8. Tennessee state residents had 89.7% of BSIs.Figure. Annual cases of methicillin-resistant Staphylococcus aureus bloodstream infections in hospitals, stratified by onset type, Tennessee, USA, 2015–2017. CO, community onset; ED, emergency department; HO, hospital onset; IP, inpatient.MRSA BSI cases increased 17.7% over the study period, from 2,333 cases in 2015 to 2,746 in 2017 (Figure). Most cases (57%) were CO-ED. During 2015–2017, CO-ED BSIs increased by 51.8%, as compared with decreases in CO-IP (−17.9%) and HO (−11.4%) BSIs.IDU-related cases represented 24.1% of the study cohort; the prevalence of these cases increased from 16.1% in 2015 to 29.9% in 2017 (Table 1). The proportion of IDU-related cases was highest among the CO-ED group (26.5%) compared with other onset groups (p<0.001). Age was associated with IDU status (p<0.001); the median age of patients with IDU-related BSIs was 40 years versus 63 years for patients with non–IDU-related BSI cases. Among IDU-related cases, 69.7% of BSIs occurred in 18–49-year-olds, whereas the same age range made up only 22.4% of non–IDU-related BSIs. Gender was also correlated with IDU status (p<0.001); men accounted for a smaller proportion of IDU-related BSIs (49.5%) than non–IDU-related BSIs (59.2%). Of all MRSA BSIs, 80.4% occurred in white patients and 17.8% in black patients. The proportion of white patients was higher among IDU-related cases than among non–IDU-related cases (88.9% versus 77.7%; p<0.001). Usage of Medicare and commercial insurance was higher among non–IDU-related BSIs (63.5% vs. 11.2% for IDU-related BSIs), whereas Medicaid usage and self-pay/uninsured status were higher among IDU-related cases (31.0% vs. 33.3% for non–IDU-related cases).Among all patients with MRSA BSIs, 4,604 (61.8%) had >1 IDU-related diagnoses documented within 6 months before or after MRSA onset. Prevalence of IDU-related diagnoses was 84.2% among patients with IDU-related BSIs and 54.7% among those with non–IDU-related BSIs. The prevalence of endocarditis (40.4%), hepatitis C infections (50.7%), osteomyelitis/septic arthritis (28.1%), and skin and soft tissue infections (46.9%) were all significantly greater (p<0.001 for all) among IDU-related BSIs than among non–IDU-related BSIs (Table 2).Among IDU-related cases stratified by onset type, 62.9% were CO-ED (Table 3). The proportion of CO-ED cases increased by 18.4% during 2015–2017, whereas the proportion of CO-IP cases among IDU-related BSIs decreased by 15.5% and the proportion of HO cases among IDU-related BSIs decreased by 2.9%. CO-ED IDU-related BSIs had the youngest patients, with a median age of 38 years (p<0.001). Onset type among IDU-related BSIs was associated with insurance status (p = 0.001); the greatest usage of Medicare (37.8%) and commercial insurance (7.2%) occurred among HO cases, whereas self-pay/uninsured status was highest among CO-ED cases (36.5%). Medicaid was used most often among patients with CO-IP IDU-related BSIs (33.6%).TopDiscussionWe found an alarming increase in the extent of all MRSA BSIs in Tennessee during 2015–2017. This rise is attributed largely to the increase in the number of CO-ED cases, as CO-IP and HO cases have steadily declined. Increasing IDU over the study timeframe, as well as the high prevalence of IDU among CO-ED BSIs, suggests an association between the drug use crisis and MRSA BSIs. These trends are consistent with reports of increasing use of commonly injected drugs in Tennessee based on the surveillance of overdose deaths (14,15), which might provide an incomplete picture of current drug use practices. The use of hospital discharge billing data in our study enabled us to assess IDU among all patients entering the hospital system, including those who survived.Using this methodology, we described common demographic characteristics of MRSA BSI patients and stratified them by IDU status. Consistent with previously reported demographics associated with IDU (12), we observed that IDU in our population was more common among patients who were 18–49 years of age, female, white, and uninsured. Furthermore, although still observed in the CO-IP and HO groups, IDU and those demographics were most strongly associated with ED-onset BSIs. Our findings demonstrate a shift in patient demographics typically associated with MRSA. Whereas previous studies have shown that invasive MRSA infections occur predominantly in men >49 years of age, with a larger proportion of patients being black (27), our study highlights an emerging at-risk population.Currently, most public health MRSA BSI prevention and treatment strategies are targeted at HO infections (3,28). The results of this study provide a compelling argument to enhance our MRSA BSI reduction efforts by devoting resources and creating policies targeting CO BSIs. First, this new knowledge can be used to heighten awareness in ED staff of potential IDU among patients with clinical signs consistent with MRSA BSIs. These patients have a high prevalence of other IDU-related diagnoses, including endocarditis and hepatitis C, which might affect clinical progression and, ultimately, patient outcomes. Identifying patients at risk for IDU-related MRSA BSIs enables prompt diagnosis, treatment, and increased emphasis on feasible follow-up care solutions.A key difference between both CO groups in this study was the larger utilization of Medicaid among CO-IP IDU-related cases, compared with the higher rates of uninsurance among IDU-related CO-ED BSIs. This contrast has implications for follow-up care, because patients with IDU-related disease might be less likely to afford and pursue required follow-up treatment. In addition to the high potential for illness and death, these patients demonstrate higher rates of IDU-related infections and readmission (29), which are often also associated with uninsured status (19).Our findings also raise a question about the role of ED and IP healthcare services in facilitating treatment for drug use and addiction. Despite evidence that interventions such as medication-assisted therapy and screening, brief intervention, and referral to treatment are both feasible and effective in acute care settings (30–32), pharmacotherapies and psychotherapies are heavily underused (29,33). Implementing interventions for substance abuse in ED settings has a large potential impact on reducing CO MRSA BSIs and other devastating consequences of IDU.Our findings are subject to some limitations. The events included in our analyses were laboratory-identified cases from acute care hospitals sourced from Tennessee statewide surveillance data. In addition, only patients who were able to be matched to HDDS were included in the analyses; the match rate of 92.5% indicates a possible underrepresentation of the true burden of disease. We also recognize that because ICD codes do not differentiate between routes of administration for drug use, we might be overestimating the prevalence of IDU compared with overall substance abuse. Similarly, because of stigmas surrounding substance abuse, ICD codes documenting the practice might provide an underestimation of true prevalence. Although we were unable to access medical records to validate our approach, this series of diagnostic codes has previously been used to identify IDU related to infections and hospitalizations (23,24,26). In addition, given that hepatitis C is strongly correlated with IDU (34,35), the high prevalence of hepatitis C infections among IDU-related MRSA BSI cases in this study lends support to the validity of the diagnostic codes used. For these reasons, it is feasible that our findings are reflective not only of patterns of substance abuse, but also of IDU in Tennessee.Our study is unique in its linkage of NHSN MRSA BSI surveillance to hospital discharge data for retrospective evaluation of IDU without conducting time-consuming chart reviews. The use of statewide laboratory-based surveillance data provides the additional benefit of a more reliable, complete picture of MRSA BSIs across Tennessee. Previous studies relied on extrapolating data from smaller jurisdictions to estimate the burden of infection and describe patient characteristics, leaving the potential for inaccurate estimation and interpretation of state trends (10,27). Our technique is advantageous for state public health agencies seeking to investigate the evolving clinical and demographic risk factors associated with reportable diseases. Despite reported national trends of unchanged CO MRSA BSIs (3), with the widespread nature of the opioid epidemic, we suspect that other jurisdictions, especially those with similar population characteristics as Tennessee, might see similar trends of rising CO MRSA BSIs associated with IDU. Replicating this study elsewhere would be valuable to identify any local variations in risk factors.In summary, Tennessee is undergoing a major change in the epidemiology of MRSA BSIs, having a growing population of young, white, uninsured, female patients with CO BSIs as a consequence of IDU. Our findings can be used to inform public health policies and clinical practice, particularly in the ED setting, to introduce prevention and harm reduction strategies to reduce the widespread impacts of this deadly disease within our communities.TopDr. Parikh is an epidemiologist at the Tennessee Department of Health’s Healthcare Associated Infections and Antimicrobial Resistance Program in Nashville, Tennessee, USA. Her primary research interests include surveillance of infectious diseases.TopAcknowledgmentWe thank the acute care hospitals in Tennessee for performing surveillance and reporting MRSA BSI data to NHSN.4th article COVID-19 and Cooling Centershttps://www.cdc.gov/coronavirus/2019-ncov/php/cooling-center.htm