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CDC COCA Digest: April 3, 2019

CDC COCA Digest: April 3, 2019

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CDC Health Alert Network (HAN)


CDC HAN 419: Influenza Season Continues with an Increase in Influenza A(H3N2) Activity

On March 28, 2019, the Centers for Disease Control and Prevention (CDC) issued a Health Alert Network (HAN) advisory to notify clinicians that influenza activity remains high in the United States, with an increasing proportion of activity due to influenza A(H3N2) viruses, continued circulation of influenza A(H1N1) viruses, and low levels of influenza B viruses. Influenza should be considered as a possible diagnosis for patients with respiratory illness while local influenza activity remains elevated. Because influenza A(H3N2) viruses may be associated with severe disease in older adults, this health advisory serves as a reminder that early empiric treatment with influenza antiviral medications is recommended for hospitalized and high-risk patients, especially those 65 years and older. Antiviral treatment should be started as soon as possible after illness onset and should not wait for laboratory confirmation.

Read the full HAN Advisory.

CDC HAN 418: Update: Widespread Outbreaks of Hepatitis A among People Who Use Drugs and People Experiencing Homelessness across the United States

On March 25, 2019, CDC issued a HAN Update that further discusses the multiple states across the country that have reported outbreaks of hepatitis A, primarily among people who use drugs and people who experience homelessness.

CDC HAN 418 is an update to CDC HAN 412 released on June 11, 2018 titled “Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness.”

Since the hepatitis A outbreaks were first identified in 2016, more than 15,000 cases, 8,500 (57%) hospitalizations, and 140 deaths as a result of hepatitis A virus (HAV) infection have been reported. CDC HAN 418 recommends that public health departments, healthcare facilities, and partners and programs providing services to affected populations vaccinate at-risk groups against hepatitis A, applying the updated recommendations of the Advisory Committee on Immunization Practices (ACIP) (please see the section titled “New ACIP Recommendations since the June 2018 HAN00412 of CDC HAN 418).

Read the full HAN Update.

You can sign up to receive HAN Update Alerts by using the following steps:

  1. Go to the CDC – Quick Subscribe GovDeliveryExternal page.
  2. Enter your e-mail address and delivery preferences and click Save.
  3. Select the Emergency Preparedness and Response / Health Alert Network (HAN)check box from the Quick Subscribe window and click Save.
  4. Select your state from the state drop-down list box.
  5. Enter your five-digit zip code in the zip code text box.
  6. Select your country from the country drop-down list box and click Save.

Upcoming COCA Calls


Travel-associated Rickettsioses Guidance: Pre-travel Counseling, Diagnosis, Treatment, and Reporting

Date: Tuesday, May 7, 2019

Time: 2:00pm-3:00pm (Eastern Time)

International travel has increased over the past 30 years, exposing travelers to wider ranges of diseases. Because of this, healthcare providers should be aware of diseases from regions far beyond their geographical area of practice. Vector-borne rickettsial diseases have an almost worldwide distribution, putting many travelers at risk.

During this COCA Call, subject matter experts will discuss the epidemiology, clinical presentation, diagnosis, and treatment of three of the most common travel-associated rickettsial diseases—African tick bite fever, Mediterranean spotted fever, and scrub typhus. The presenters will also address these diseases in the context of pre-travel and post-travel evaluations.

Recent COCA Calls


Topic: Extensively Drug-resistant Salmonella Typhi Infections Emerge Among Travelers to or from Pakistan—United States, 2016–2018

Typhoid fever is caused by Salmonella enterica serotype Typhi (Typhi). Typhi is an important public health problem in developing countries. The estimated global burden of Typhi is 12 to 27 million cases annually. During 2016 – 2018, an extensively drug-resistant (XDR) Salmonella Typhi strain—only susceptible to azithromycin and carbapenems—emerged in Pakistan. More than 5,300 cases have been reported in the ongoing outbreak. During 2016 – 2018, typhoid fever was diagnosed in 29 patients in the United States with recent Pakistan travel; five of the 29 patients had XDR Typhi.

CDC recommends pre-travel vaccination and adherence to safe food and water practices to prevent typhoid fever. Empiric azithromycin should be used to treat patients with suspected, uncomplicated typhoid fever who have traveled to or from Pakistan. Carbapenems should be used for patients with suspected severe or complicated typhoid fever who have traveled to or from Pakistan. During this COCA Call, clinicians learned about CDC’s recommendations for diagnosing, managing, and preventing XDR typhoid.


Topic: Guidance for Using Intravenous Artesunate for Treating Severe Malaria in the United States

In the United States, an average of 1,700 cases of malaria are imported each year, of which, 300 are severe. Severe malaria must be treated with an intravenous (IV) antimalarial drug. Quinidine, the only FDA-approved IV antimalarial drug, is no longer available as of April 1, 2019. Intravenous artesunate, the World Health Organization (WHO)-recommended first-line treatment for severe malaria, became the first-line drug for treatment of severe malaria in the United States. Because IV artesunate is neither FDA-approved nor commercially available in the United States, CDC has made it available under an expanded access investigational new drug (IND) protocol. Effective April 1, 2019, all U.S. clinicians must call CDC to obtain IV artesunate to treat cases of severe malaria.

During this COCA Call, CDC subject matter experts discussed CDC’s guidance for use of IV artesunate for the treatment of severe malaria.

For detailed information on the criteria for IV artesunate treatment and other frequently asked questions, CDC has posted a Malaria Notice with guidance for hospitals and healthcare providers.

Archived COCA Calls are available. Free continuing education is also available for most calls. More information about free CE is available.

CDC News and Announcements

Acute Flaccid Myelitis Investigation

CDC has been thoroughly investigating the Acute Flaccid Myelitis (AFM) cases that have occurred since 2014, when a large number of cases were first reported.

CDC’s Investigation Updates

  • Most of the patients with AFM (more than 90%) had a mild respiratory illness or fever consistent with a viral infection before they developed AFM.
    • Viral infections such as those from enteroviruses are common, especially in children, and most people recover. It is unknown why a small number of people develop AFM, while most others recover. CDC is continuing to investigate this.
  • These AFM cases are not caused by poliovirus; all the stool specimens from AFM patients that CDC received tested negative for poliovirus.
  • CDC detected coxsackievirus A16, EV-A71, and EV-D68 in the spinal fluid of four of 558 confirmed cases of AFM since 2014, which points to the cause of their AFM. For all other patients, no pathogen has been detected in their spinal fluid to confirm a cause.

Visit the AFM webpage for more updates.

FAO, OIE, and WHO Launch a Guide for Countries on Taking a One Health Approach to Addressing Zoonotic Diseases

Zoonotic diseases continue to be a threat to global health, causing millions of deaths and economic losses every year. To support countries to control these diseases, the Tripartite organizations (FAO, OIE, and WHO) recently launched a guide titled “Taking a Multisectoral, One Health Approach: A Tripartite Guide to Addressing Zoonotic Diseases in Countries.”

This guide, referred to as the “Tripartite Zoonoses Guide (TZG)”, provides principles, best practices, and options to assist countries in achieving sustainable and functional collaboration at the human-animal-environment interface. It is flexible enough to be used for other health threats; for example, food safety and antimicrobial resistance (AMR). By using the TZG and its associated operational tools (which are currently being developed) countries can build or strengthen their national capacities in–

  • Multisectoral, “One Health” coordination mechanisms;
  • Strategic planning and emergency preparedness;
  • Surveillance and information sharing;
  • Coordinated investigation and response;
  • Joint risk assessment for zoonotic disease threats;
  • Risk reduction, risk communication, and community engagement; and
  • Workforce development.

Options for monitoring and evaluating the function and impact of these activities are included to support countries in their efforts to make improvements in their zoonotic disease frameworks, strategies and policies. Moreover, taking the “One Health” approach presented in the TZG helps countries to make the best use of limited resources and reduces indirect societal losses, such as impacts on livelihoods of small producers, poor nutrition, and restriction of trade and tourism.

For more information

  • OIE One Health: Protecting “One Health”
  • WHO: Strategic Partnership for International Health Regulation (2005) and Health Security (SPH)
  • FAO: Food and Agriculture Organization of the United Nations Role in Animal Health

COCA Partner News


Assistant Secretary for Preparedness and Response’s (ASPR) Biomedical Advanced Research and Development Authority (BARDA) Funds its First Marburg Virus Vaccine Development

To increase national health security against bio threats and protect public health, the United States Department of Health and Human Services (HHS) will partner with Public Health Vaccines, LLC, of Cambridge, Massachusetts, to develop a potential vaccine against Marburg virus. No licensed vaccine for this virus exists today.

The Marburg virus is part of the family of hemorrhagic fever viruses that includes Ebola. The virus causes a similar illness to that of Ebola, and occurs most often in Africa. The Marburg virus was recognized in 1967, and since then multiple outbreaks have occurred with high mortality rates, most recently in 2017. In addition to the threat of naturally occurring infection, the Marburg virus, like Ebola, is deemed a potential bioterrorism threat by the United States Department of Homeland Security.

The BARDA, part of the HHS Office of the ASPR, awarded an initial 2-year, $10 million contract to Public Health Vaccines, LLC to begin development of a vaccine to protect against Marburg infection.

“This vaccine candidate is the first BARDA has funded against the Marburg virus, and it is an important step toward meeting an urgent public health and biodefense need,” said BARDA Director, Rick Bright, Ph.D. “We will leverage our experience in establishing public-private partnerships that bring results that are critical to saving lives and protecting Americans – and possibly people across the globe – from health security threats.”

Read more here.

Seasonal Influenza


2018-2019 Influenza Season Week 8 Ending March 23, 2019

All data are preliminary and may change as more reports are received.

An overview of CDC’s influenza surveillance system, including methodology and detailed descriptions of each data component, is available.

Influenza activity decreased but remains elevated in the United States. Influenza A(H1N1)pdm09 viruses predominated from October to mid-February and influenza A(H3N2) viruses have been more commonly identified since late February. Small numbers of influenza B viruses have also been reported. Below is a summary of the key influenza indicators for the week ending March 23, 2019

  • Viral Surveillance: The percentage of respiratory specimens testing positive for influenza viruses in clinical laboratories decreased. Nationally, during the most recent three weeks, influenza A(H3) viruses were reported more frequently than influenza A(H1N1)pdm09 viruses and in all 10 HHS Regions.
    • Virus Characterization: The majority of influenza viruses characterized antigenically are similar to the cell-grown reference viruses representing the 2018–2019 Northern Hemisphere influenza vaccine viruses. However, an increasing proportion of influenza A(H3N2) viruses are antigenically distinguishable from A/Singapore/INFIMH-16-0019/2016 (3C.2a1), a cell-propagated reference virus representing the A(H3N2) component of 2018-19 Northern Hemisphere influenza vaccines.
    • Antiviral Resistance: The vast majority of influenza viruses tested (>99%) show susceptibility to oseltamivir and peramivir. All influenza viruses tested showed susceptibility to zanamivir.
  • Influenza-like Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) decreased to 3.8%, and remains above the national baseline of 2.2%. All 10 regions reported ILI at or above their region-specific baseline level.
    • ILI State Activity Indictor Map: Twenty states experienced high ILI activity; Puerto Rico and 13 states experienced moderate ILI activity; New York City, the District of Columbia and seven states experienced low ILI activity; 10 states experienced minimal ILI activity; and the U.S. Virgin Islands had insufficient data.
  • Geographic Spread of Influenza: The geographic spread of influenza in Puerto Rico and 34 states was reported as widespread; 14 states reported regional activity; the District of Columbia and two states reported local activity; the U.S. Virgin Islands reported sporadic activity; and Guam did not report.
  • Influenza-associated HospitalizationsA cumulative rate of 52.5 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported. The highest hospitalization rate is among adults 65 years and older (167.0 hospitalizations per 100,000 population).
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was above the system-specific epidemic threshold in the National Center for Health Statistics (NCHS) Mortality Surveillance System.
  • Influenza-associated Pediatric Deaths: One influenza-associated pediatric death was reported to CDC during week 12.

Read the full situational update. View the current United States flu activity map.

Healthcare professionals can find additional resources, recommendations, and guidance here.

Emergency Preparedness and Response

Natural Disaster

Health and Safety Concerns for All Disasters

See below for information on a variety of health and safety concerns for all disasters, including:

Resources for Emergency Health Professionals

CDC offers a variety of resources for clinicians, communicators, laboratorians, emergency planners and responders, and disaster relief volunteers to help them prepare and respond to a public health emergency. This section includes free educational materials including flyers, posters, stickers, and PSAs in various languages that are suitable for printing and sharing.

Click here to access the resources.

Disaster Resources and Educational Materials

Be sure to check out CDC’s educational materials including a variety of hazards listed by topic or language, PSAs for disasters, resources for emergency health professionals, and social media channels with featured apps, blogs, buttons and badges, and content available for syndication. Go here to access these free resources that are suitable for printing and sharing.

Travelers’ Health


The mission of CDC Travelers’ Health is to reduce illness and injury in U.S. residents traveling internationally or living abroad. Applying the best science, CDC’s Travelers’ Health Branch provide alerts, recommendations, education, and technical support to travelers and the healthcare providers who serve them. Visit CDC Travelers’ Health for information.

General Resources
CDC Health Information for International Travel (the Yellow Book) contains the U.S. government’s most current travel health guidelines, including pre-travel vaccine recommendations, destination-specific health advice, and easy-to-reference maps, tables, and charts. Available free online and for iOS or  Android.

General Vaccine Information

Pre-travel Care Tools

Disease-specific Resources

Clinical Update

Yellow Fever in Brazil

CDC previously recommended yellow fever vaccine for many parts of Brazil. Because of the current outbreak, CDC now also recommends yellow fever vaccine for travelers going to the areas shown in pink on the map. This includes popular tourist destinations like Ilha Grande and the cities of Rio de Janeiro and São Paulo. People who have never been vaccinated should avoid traveling to areas of Brazil where yellow fever vaccination is recommended.

More Resources:

Food, Drug, and Device Safety

MedWatch: The FDA Safety Information and Adverse Event Reporting Program—(FDA)
MedWatch is your FDA gateway for clinically important safety information and reporting serious problems with human medical products. Reports of FDA and USDA Food Recalls, Alerts, Reporting, and Resources—(HHS/USDA/FDA/CDC/NIH) lists notices of recalls and alerts from both FDA and the U.S. Department of Agriculture. Visitors to the site can report a problem or make inquiries.

CDC Current Outbreak List

Stay up to date on the infectious disease outbreaks that CDC is currently reporting. For a complete list of U.S. outbreaks, travel notices affecting international travelers, food safety recalls, and further sources for content about specific outbreaks, please go here.

You can also sign up to receive email updates about U.S.-based outbreaks and travel notices affecting international travelers on this page.

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