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Public health surveillance systems likely underestimate the true prevalence and incidence of SARS-CoV-2 infection due to limited access to testing and the high proportion of subclinical infections in community-based settings. This ongoing prospective, observational study aimed to generate accurate estimates of the prevalence and incidence of, and risk factors for, SARS-CoV-2 infection among residents of a central North Carolina county. From this cohort, we collected survey data and nasal swabs every two weeks and venous blood specimens every month. Nasal swabs were tested for the presence of SARS-CoV-2 virus (evidence of active infection), and serum specimens for SARS-CoV-2-specific antibodies (evidence of prior infection). As of June 23, 2021, we have enrolled a total of 153 participants from a county with an estimated 76,285 total residents. The anticipated study duration is at least 24 months, pending the evolution of the pandemic. Study data are being shared on a monthly basis with North Carolina state health authorities and future analyses aim to compare study data to state-wide metrics over time. Overall, the use of a probability-based sampling design and a well-characterized cohort will enable collection of critical data that can be used in planning and policy decisions for North Carolina and may be informative for other states with similar demographic characteristics.

Mass-gathering epidemiology is an emerging discipline in applied public health. High-profile mass gatherings include major sporting events (eg, the Olympics, the FIFA World Cup [Fedération Internationale Football Association]), religious events (eg, the Hajj, World Youth Day), cultural festivals (eg, Glastonbury Music Festival), and US National Special Security Events (eg, political conventions), among other locally defined events. These events may impose short-term pressures on local and regional public health infrastructure. In accordance with the International Health Regulations, the World Health Organization offers guidance for public health planning, surveillance, and response during mass gatherings. Public health risks associated with mass gatherings are well documented and encompass a variety of focus areas, from environmental health hazards to infectious diseases. Because of the diverse nature of mass gatherings, different factors contribute to the health and safety risks for participants. A 2002 review of the mass-gathering medical literature categorized different variables and their possible causal relationships to health outcomes. These variables included weather, attendance, duration of event, location of event, event type, crowd mood, alcohol or drug use, crowd density, and age of attendees. Although infectious disease outbreaks and injury clusters have been reported during mass gatherings, the large number of annual events held worldwide without reports of adverse events suggests that these occurrences are relatively rare—though publication bias may have led to some underestimation. Nonetheless, a local public health agency must be prepared to enhance its surveillance capacity to detect and investigate an outbreak, mass exposure, or injury cluster that could damage the credibility of the event or exert a substantial human or economic impact.

Surveillance estimates of SARS-CoV-2 infections over time have relied on mandatory clinician and laboratory reporting. These estimates increasingly underestimated true viral incidence due to asymptomatic infections, variable access to testing, and self-administered diagnostics. To overcome these limitations, the North Carolina Department of Health and Human Services partnered with academic researchers to conduct three concurrent population-based longitudinal cohort studies in three distinct North Carolina counties to offer more accurate estimates of the incidence, prevalence, and vaccination rates for SARS-CoV-2. We enrolled and followed adult residents of three North Carolina counties from August 2020-February 2022. Demographic and health information was collected in biweekly surveys. Nasal swabs were collected biweekly and tested for SARS-CoV-2 using PCR testing. Blood samples were collected monthly and tested for antibodies to the SARS-CoV-2 nucleocapsid and spike proteins. We calculated monthly seroprevalence, sero-incidence, PCR test positivity, and vaccination uptake. We enrolled 646 participants. Routine blood samples and nasal swab samples were contributed by 639 and 642 participants, respectively. By February 2022, 98% (95% CI: 97.4-98.2) had antibodies to the SARS-CoV-2 spike protein, and 13% (95% CI: 12.4-14.2) had antibodies to the nucleocapsid protein, indicating viral exposure. PCR testing detected infection among 14% (95% CI: 13.1-15.0) of participants, but cumulative PCR test positivity was only 1.3% (95% CI: 1.2-1.4). Over half of PCR-detected infections were asymptomatic. By February 2022, 97% of participants had completed the primary vaccine series, and 52% had received a booster dose. Nearly all participants had anti-SARS-CoV-2 antibodies by the end of follow-up, primarily through vaccination. The incidence of PCR-detected infections was similar to antibody testing, but PCR test positivity substantially underestimated incident infections. These findings emphasize the importance of prospective infection monitoring via antibody testing in a comprehensive approach to tracking viral infections in the community setting.

Opioid dependence and overdose have increased to epidemic levels in the United States. The 2014 National Survey on Drug Use and Health estimated that 4.3 million persons were nonmedical users of prescription pain relievers (1). These users are 40 times more likely than the general population to use heroin or other injection drugs (2). Furthermore, CDC estimated a near quadrupling of heroin-related overdose deaths during 2002-2014 (3). Although overdose contributes most to drug-associated mortality, infectious complications of intravenous drug use constitute a major cause of morbidity leading to hospitalization (4). In addition to infections from hepatitis C virus (HCV) and human immunodeficiency virus (HIV), injecting drug users are at increased risk for acquiring invasive bacterial infections, including endocarditis (5,6). Evidence that hospitalizations for endocarditis are increasing in association with the current opioid epidemic exists (7-9). To examine trends in hospitalizations for endocarditis among persons in North Carolina with drug dependence during 2010-2015, data from the North Carolina Hospital Discharge database were analyzed. The incidence of hospital discharge diagnoses for drug dependence combined with endocarditis increased more than twelvefold from 0.2 to 2.7 per 100,000 persons per year over this 6-year period. Correspondingly, hospital costs for these patients increased eighteenfold, from $1.1 million in 2010 to $22.2 million in 2015. To reduce the risk for morbidity and mortality related to opioid-associated endocarditis, public health programs and health care systems should consider collaborating to implement syringe service programs, harm reduction strategies, and opioid treatment programs.

Ocular syphilis is an inflammatory eye disease due to Treponema pallidum infection. In the United States, syphilis rates have increased since 2000; clusters of ocular syphilis were reported in 2015. We investigated ocular syphilis in North Carolina to describe the epidemiology and clinical course of disease. We reviewed syphilis cases reported to North Carolina during 2014-2015 and abstracted information from health department interviews for cases with ocular symptoms and no other defined etiology. To assess duration and severity of ocular symptoms, we also reviewed medical records and conducted structured interviews. We compared the prevalence of ocular manifestations among reported syphilis cases by demographic and clinical characteristics. Among 4232 syphilis patients, 63 (1.5%) had ocular syphilis: 21 in 2014 and 42 in 2015, a 100% increase. Total syphilis cases increased 35% through 2015. No patient with ocular syphilis named another ocular syphilis patient as a sex partner. Patients presented in all syphilis stages; 24 (38%) were diagnosed in primary or secondary syphilis. Ocular manifestations were more prevalent among syphilis patients who were male, aged ≥40 years, white, and infected with human immunodeficiency virus. No risk behaviors were associated with ocular syphilis. Among 39 interviewed patients, 34 (87%) reported reduced vision during infection; 12 (31%) reported residual visual symptoms posttreatment. In North Carolina, ocular syphilis increased from 2014 to 2015 and may be due to increased recognition of ocular manifestations, or a true increase in ocular syphilis. Many ocular syphilis patients experienced vision loss; however, most improved posttreatment.

Pneumonia is a leading infectious disease killer worldwide, yet the burden in China is not well understood as much of the data is published in the non-English literature. We systematically reviewed the Chinese- and English-language literature for studies with primary data on pneumonia incidence and mortality in mainland China. Between 1985 and 2008, 37 studies met the inclusion criteria. The quality of the studies was highly variable. For children <5 years, incidence ranged from 0.06-0.27 episodes per person-year and mortality ranged from 184-1,223 deaths per 100,000 population. Overall incidence and mortality were stable or decreased over the study period and were higher in rural compared to urban areas. Pneumonia continues to be a major public health challenge in young children in China, and estimates of pneumonia incidence and mortality vary widely. Reliable surveillance data and new prevention efforts may be needed to achieve and document additional declines, especially in areas with higher incidence and mortality such as rural settings.

Objective: In 2016, North Carolina blood lead level (BLL) surveillance activities identified elevated BLLs among 3 children exposed to take-home lead by household members employed at a lead oxide manufacturing facility. We characterized BLLs among employees and associated children and identified risk factors for occupational and take-home lead exposure. Methods: We reviewed BLL surveillance data for 2012-2016 to identify facility employees and associated children. We considered a BLL ≥5 μg/dL elevated for adults and children and compared adult BLLs with regulatory limits and recommended health-based thresholds. We also conducted an environmental investigation and interviewed current employees about exposure controls and cleanup procedures. Results: During 2012-2016, 5 children associated with facility employees had a confirmed BLL ≥5 μg/dL. Among 77 people employed during 2012-2016, median BLLs increased from 22 μg/dL (range, 4-45 μg/dL) in 2012 to 37 μg/dL (range, 16-54 μg/dL) in 2016. All employee BLLs were <60 μg/dL, the national regulatory threshold for immediate medical removal from lead exposure; however, 55 (71%) had a BLL ≥20 μg/dL, a recommended health-based threshold for removal from lead exposure. Because of inadequate controls in the facility, areas considered clean were visibly contaminated with lead dust. Employees reported bringing personal items to work and then into their cars and homes, resulting in take-home lead exposure. Conclusions: Integration of child and adult BLL surveillance activities identified an occupational source of lead exposure among workers and associated children. Our findings support recent recommendations that implementation of updated lead standards will support better control of lead in the workplace and prevent lead from being carried home.

Background. Oseltamivir resistance among 2009 pandemic influenza A (H1N1) viruses (pH1N1) is rare. We investigated a cluster of oseltamivir-resistant pH1N1 infections in a hospital ward. Methods. We reviewed patient records and infection control measures and interviewed health care personnel (HCP) and visitors. Oseltamivir-resistant pH1N1 infections were found with real-time reverse-transcription polymerase chain reaction and pyrosequencing for the H275Y neuraminidase (NA) mutation. We compared hemagglutinin (HA) sequences from clinical samples from the outbreak with those of other surveillance viruses. Results. During the period 6-11 October 2009, 4 immunocompromised patients within a hematologyoncology ward exhibited symptoms of pHlNl infection. The likely index patient became febrile 8 days after completing a course of oseltamivir; isolation was instituted 9 days after symptom onset. Three other case patients developed symptoms 1, 3, and 5 days after the index patient. Three case patients were located in adjacent rooms. HA and NA sequences from case patients were identical. Twelve HCP and 6 visitors reported influenza symptoms during the study period. No other pHlNl isolates from the hospital or from throughout the state carried the H275Y mutation. Conclusions. Geographic proximity, temporal clustering, presence of H275Y mutation, and viral sequence homology confirmed nosocomial transmission of oseltamivir-resistant pH1N1. Diagnostic vigilance and prompt isolation may prevent nosocomial transmission of influenza.

The geographic areas in the United States most affected by the coronavirus disease 2019 (COVID-19) pandemic have changed over time. On May 7, 2020, CDC, with other federal agencies, began identifying counties with increasing COVID-19 incidence (hotspots) to better understand transmission dynamics and offer targeted support to health departments in affected communities. Data for January 22-July 15, 2020, were analyzed retrospectively (January 22-May 6) and prospectively (May 7-July 15) to detect hotspot counties. No counties met hotspot criteria during January 22-March 7, 2020. During March 8-July 15, 2020, 818 counties met hotspot criteria for ≥1 day; these counties included 80% of the U.S. population. The daily number of counties meeting hotspot criteria peaked in early April, decreased and stabilized during mid-April-early June, then increased again during late June-early July. The percentage of counties in the South and West Census regions* meeting hotspot criteria increased from 10% and 13%, respectively, during March-April to 28% and 22%, respectively, during June-July. Identification of community transmission as a contributing factor increased over time, whereas identification of outbreaks in long-term care facilities, food processing facilities, correctional facilities, or other workplaces as contributing factors decreased. Identification of hotspot counties and understanding how they change over time can help prioritize and target implementation of U.S. public health response activities.

Background. In 2003, human monkeypox was first identified in the United States. The outbreak was associated with exposure to infected prairie dogs, but the potential for person-to-person transmission was a concern. This study examines health care worker (HCW) exposure to 3 patients with confirmed monkeypox. Methods. Exposed HCWs, defined as HCWs who entered a 2-m radius surrounding case patients with confirmed monkeypox, were identified by infection-control practitioners. A self-administered questionnaire and analysis of paired serum specimens determined exposure status, immune response, and postexposure signs and symptoms of monkeypox. Results. Of 81 exposed HCWs, 57 (70%) participated in the study. Among 57 participants, 40 (70%) had ⩾1 unprotected exposure; none reported signs or symptoms consistent with monkeypox illness. One exposed HCW (2%), who had been vaccinated for smallpox within the past year, had serological evidence of recent orthopoxvirus infection; acute- and convalescent-phase serum specimens tested positive for anti-orthopoxvirus IgM. No exposed HCWs had signs and symptoms consistent with monkeypox. Conclusion. More than three-quarters of exposed HCWs reported at least 1 unprotected encounter with a patient who had monkeypox. One asymptomatic HCW showed laboratory evidence of recent orthopoxvirus infection, which was possibly attributable to either recent infection or smallpox vaccination. Transmission of monkeypox likely is a rare event in the health care setting.