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TABLE. Demographic characteristics, risk factors, surveillance status, and clinical information for 20 patients with hepatitis C virs (HCV) infection - postal code A, Buffalo, New York, November 2004-April 2007 *

Age
Date of

Shared NoninjectionCase Interviewed (yrs) Sex Race diagnosis Reason for test IDUT needles drug use 1 Yes 17 Male White 11/3/04

Risk factors

Yes
Yestt

Yes 2

No
23 Female White 1/25/05

Symptomatic
Yes

Yes 3

No
26 Male White 3/9/05

Risk factors

Yes 4

Yes
28 Male White 12/6/05

Symptomatic

Yes
Yes

Yes
5
Yes
17 Male White 12/29/05 Risk factors

Yes Yestt

Yes 6

No
19 Male White 1/20/06 Symptomatic Yes

Yestt

Yes 7 Yes 17 Male White 1/24/06

Risk factors

Yes
Yestt

Yes
8
Yes
16 Female White 2/17/06

Risk factors

Yes
Yestt

Yes 9

Yes
21 Male White 2/23/06

Risk factors

Yes
Yestt

Yes 10

No
22 Male White 3/2/06

Risk factors

Yes 11 Yes 18 Female White 5/17/06

Risk factors

Yes
Yes

Yes
12
Yes
19 Male White 5/24/06

Risk factors

Yes
Yes

Yes 13

No

19
Male White 5/24/06

Risk factors

Yes 14

No
20 Male White 5/26/06 Symptomatic Yes

Yestt

Yes 15 Yes 17 Female White 8/14/06

Risk factors

No
No

No
16
Yes
23 Male White 10/10/06 Risk factors

Yes
Yestt

Yes 17

No
19 Male White 12/19/06 Risk factors

Yes Yestt

Yes 18

No
26 Female White 1/6/07

Risk factors

Yes
Yes

Yes
19
Female White 3/13/07

Risk factors

Yes
Yestt

Yes
Yes
19 Male White 4/26/07

Risk factors

Yes
Yestt

Yes
Data were compiled from standard surveillance forms and patient interviews.

Injection-drug use. § Alanine aminotransferase. 1 Based on surveillance case definitions (available at http://www.cdc.gov/ncphi/disss/nndss/casedef/hepatitiscacutecurrent.htm and http://www.coc g

ncphi/disss/nndss/casedef/hepatitisccurrent.htm).

Polymerase chain reaction. 11 Shared needles with a person known or believed to be HCV positive. $$ Not reported. 11 With a partner known or believed to be HCV positive.

With a sex worker.

No

17

20

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Electronic Clinical Laboratory Reporting System generates databases containing any HCV-positive laboratory reports for persons aged <30 years; these data are then sent to local health departments. Investigation is conducted by local health department staff members with NYSDOH assistance and includes complete laboratory results collection, healthcare provider interview, medical record review, and patient interview.

In February 2007, NYSDOH staff members noticed an apparent high number of newly identified HCV infections among persons aged <30 years who resided in the same postal code (postal code A), corresponding to a suburban community of Buffalo, New York. An initial retrospective review found eight cases dating back to May 2006 in persons who resided in postal code A (case numbers 11-18) (Table), one of which was in a patient who had acute hepa

titis C (7. All but one of the eight initially identified car were in persons who reported a history of IDU. Furch analysis of cases in persons residing in postal code A in cated that during November 2004-April 2007, a total :: 20 HCV-positive persons aged <30 years had been reporter Fifteen of the 20 cases were diagnosed in 2006 or 2017 The community (2000 population: 42,000) in which pescu code A is located is part of Erie County and had 47.575 reports of HCV infection per 100,000 population aged <3 years during November 2004-April 2007. During the same period, Erie County had 18.6 new reports of HCV into tion per 100,000 population; two suburban postal coda with similar populations, socioeconomic composition, a proximity to the inner city as the investigated commune had 7.0 and 4.9 new reports of HCV infection per population, respectively. Because the incidence of 12

100.

BLE. (Continued) Demographic characteristics, risk factors, surveillance status, and clinical information for 20 patients with patitis C virus (HCV) infection - postal code A, Buffalo, New York, November 2004-April 2007* History of Drug equipment sharing

Elevated high-risk or high-risk sexual Multiple Attended Jaundice ALTS History of sexual activity with another

high (at time of (at time of Disease HCV PCR** incarceration contact patient (patient no.) partners school A diagnosis) diagnosis) statusi (genotype) Yes No Yes (9)

Yes

Yes
No
_$$

Chronic + (1B)
No

Yes

Yes
Yes
Yes

Acute

sex

se

Yes 119

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orts in the community per population appeared to be :roximately twice that of the county and approximately

times greater than that of any similar suburb, further estigation to characterize the cluster was warranted. Vith initial detection of the cluster, an epidemiologic estigation was launched by NYSDOH in collaboration h ECDOH. Patients were interviewed in person by a -person team at various locales, including correctional lities, rehabilitation clinics, patient residences, and other ations. Current CDC case definitions for acute and onic hepatitis C were used.* Four (20%) of the 20 ients had evidence of elevated serum alanine transamie levels and discrete symptom onset and were classified having acute hepatitis C. Sixteen (80%) other patients e asymptomatic or had illness that did not meet the te case definition and were classified as having chronic V infection. Median age of the 20 patients was 19 years ige: 17–29 years), all were white, 15 (75%) were male,

19 (95%) reported a history of IDU. Nineteen (95%) he 20 patients attended or had attended one of the two

high schools in postal code A (high school A) (Table). Fourteen (70%) had evidence of viremia by polymerase chain reaction; three (21%) of these 14 had a viral genotype reported. NYSDOH and ECDOH staff members successfully interviewed 11 of the 20 patients (one with acute hepatitis C and 10 with chronic HCV infection) using an integrated interview tool and a chart abstraction tool developed for this investigation; the remaining nine patients could not be contacted.

At the time of interview, all of the 11 interviewed patients were aware that they had tested HCV positive. However, three (27%) of the patients interviewed believed that their test results were false and that they were no longer (or never were) HCV infected. Ten (91%) interviewed patients reported previous but not current IDU (including use of heroin, cocaine, loritabs, oxycodin, morphine, valium, or crack cocaine) and sharing of drug-use equipment; some patients shared equipment with other identified patients. All 10 patients reported purchasing heroin in the same inner-city Buffalo location. Noninjectable-drug use, reported by 10 (91%) patients, was initiated at a median age of 14 years (range: 9–17 years); IDU was initiated at a median age of 16.5 years (range: 14–26 years).

e definitions available at http://www.cdc.gov/ncphi/disss/nndss/casedef/ atitiscacutecurrent.htm and http://www.cdc.gov/ncphi/disss/nndss/casedefl atitisccurrent.htm.

At least four partnerships involving drug equipment sharing and high-risk sexual activity were reported among the 20 patients. The members of these partnerships knew other members who had experienced symptoms consistent with acute hepatitis, such as jaundice. However, documented HCV infection in these members, as evidenced by a report in the NYSDOH Chronic Hepatitis Registry, could not be verified.

Among interviewed patients, median reported number of lifetime sex partners was 10 (range: four to 100). Six (54%) patients claimed they had private health insurance, two reported having Medicaid, and three reported that they had no health insurance. Seven of the interviewed patients reported having a primary-care physician; four of these seven reported seeing a specialist for their HCV infection. None of the interviewed patients had received HCV treatment. Several barriers to potential treatment were cited, including concerns regarding the side effects of medication, lack of information regarding the availability of treatment services, lack of health insurance reimbursement, and a perceived lack of health-care providers capable or willing to treat HCV in patients with comorbidities such as IDU or mental health issues.

Several initiatives were launched by NYSDOH and ECDOH throughout Erie County to address the apparent clustering of HCV infection among injection-drug users. Staff members from NYSDOH, the NYS Office of Alcoholism and Substance Abuse Services, and ECDOH conducted cross-training sessions and developed a resource manual to help identify primary care, sexually transmitted disease (STD)/human immunodeficiency virus (HIV) screening, drug treatment, harm reduction, and HCV treatment services for patients. All interviewed patients were referred to ECDOH counselors for HIV/acquired immunodeficiency syndrome (AIDS) risk assessment and personalized intervention development. ECDOH conducted multiple events held at various community locations and ECDOH clinics, offering HCV, HIV, and STD screening, referral for services, and education on prevention, risk reduction, and family planning; these services are ongoing at all five ECDOH clinics. Presentations on hepatitis epidemiology, diagnosis and testing, and prevention were conducted at medical practices that serve high-risk communities throughout Erie County. ECDOH also collaborated with the Erie County Department of Mental Health to integrate HCV messages into existing prevention programs and implement screening programs in target areas with high HCV infection rates. Finally, ECDOH worked with school district representatives and high schools to address prevention of IDU and HCV transmission.

Reported by: L Leuchner, H Lindstrom, PhD, GR Burstein, MD.E County Dept of Health, Buffalo; KE Mulhern, EM Rocchio, MA, G Jor MS, J Schaffzin, MD, PhD, P Smith, MD, New York State Dept of Hea Editorial Note: One goal of the CDC-funded enhan: viral hepatitis surveillance protocols is high-priority folio. up of cases that are likely to represent acute HCV inte tion. Another goal is detection of clusters or outbreaks in such cases, as this report describes. The markedly elevas. number of new reports of HCV infection per population detected among persons aged <30 years in postal code : compared with the number of reports in the surroundin community, indicated an apparent cluster of receri. infected patients. Nearly all of the identified patients in the cluster reported a history of IDU, and partnership involving drug equipment sharing, which have been described previously (8), were identified among the crter. The cause of this cluster likely was IDU with share. inadequately cleaned equipment. Because the investigate targeted only cases in persons aged <30 years, more direz links among

members of this cluster involving persons a >30 years might exist within the community. Furthermor. although infections identified in persons aged <30 year are more likely to be new infections than those identified in persons aged 230 years, not all infections in the popu.. tion aged <30 years are new; a portion of the patients : this cluster likely had been infected with HCV for years.

Although the number of new reports of HCV infectie per population in postal code A was higher than the overa. Erie County number during November 2004-April 2007 this analysis could not determine whether this elevated number of reports represented a previously established and ongoing higher rate of HCV infection among persons age <30 years or a more recent phenomenon. Cases within ti apparent cluster likely are a reflection of the ongoing HC) epidemic among injection-drug users in the United States (9). Ongoing educational efforts and increased pubii awareness of hepatitis C, particularly among injection-drag users, might have led to higher rates of testing, whic yielded additional reports. Because the prioritized algoricho was not in place before January 2006, earlier reported case of HCV infection among this population might have gon: unrecognized. Continued enhanced surveillance is needeu to complement routine surveillance for HCV infections : better understand the burden of hepatitis C and to ideatify and prevent new HCV infections.

The results of this investigation demonstrate the potertial for improved and consistent national hepatitis C surveillance to identify cases for investigation, estimate the magnitude of HCV infection and disease, detect outbreaks aluate response measures, and facilitate research to inite appropriate prevention measures. Given limited ources, an enhanced surveillance approach to give high' priority to likely new cases of HCV infection, such as ose in persons aged <30 years, can be implemented to entify clusters and outbreaks. Establishing effective sysns that provide reliable data to detect HCV infections tong all populations could have a lasting effect on HCV ease control.

Acknowledgments This report is based, in part, on contributions by C Moore, Erie unty Dept of Health; L Isabella, K Kufel, R Furlani, I Jones, New k State Dept of Health. ferences Rustgi VK. The epidemiology of hepatitis C infection in the United tates. J Gastroenterol 2007;42:513–21. CDC. Changes in National Notifiable Diseases list and data presentaion. MMWR 2003;52:9. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Nter MJ. The prevalence of hepatitis C virus infection in the United tates, 1999 through 2002. Ann Int Med 2006;144:705–14. CDC. Surveillance for acute viral hepatitis—United States, 2006. AMWR 2008;57(No. SS-2). Marcellin P. Hepatitis C: the clinical spectrum of the disease. J Hepatol 999;31(Suppl 1):9–16. Garfein RS, Vlahov D, Galai N, Doherty MC, Nelson KE. Viral infecions in short-term injection drug users: the prevalence of the hepatitis ,, hepatitis B, human immunodeficiency, and human T lymphotropic iruses. Am J Public Health 1996;86:655–61. Council of State and Territorial Epidemiologists. Position statement 3-ID-05. Available at http://www.cste.org/ps/2003pdfs/2003finalpdf/ 3-id-05 revised.pdf. lahn JA, Page-Shafer K, Lum PJ, et al. Hepatitis C virus seroconversion mong young injection drug users: relationships and risks. J Infect Dis 002;186:1558-64. dlin BR, Carden MR. Injection drug users: the overlooked core of the epatitis C epidemic. Clin Infect Dis 2006;42:673-6.

in 19 states, mostly in the northeastern United States. This report describes the outbreak investigation, which identified the source of infection as dry dog food produced at a manufacturing plant in Pennsylvania. This investigation is the first to identify contaminated dry dog food as a source of human Salmonella infections. After handling pet foods, pet owners should wash their hands immediately, and infants should be kept away from pet feeding areas.

On May 8, 2007, the Pennsylvania Bureau of Laboratories reported three cases of S. Schwarzengrund infection with indistinguishable PFGE patterns to CDC's PulseNet.* On June 9, 2007, after PulseNet identified cases in Ohio and other states, CDC's OutbreakNett team was notified of a potential multistate outbreak of S. Schwarzengrund infections. During June 2007, the Pennsylvania Department of Health (PADOH) interviewed persons identified by Pulse Net as infected with the outbreak strain of S. Schwarzengrund. These initial interviews suggested exposure to dogs or dry dog food as a possible source of infection. Thirteen infected persons from Pennsylvania were questioned about dog-related exposures: eight (62%) owned one or more dogs, and the other five reported regular contact with a dog. Seven of the eight persons who owned dogs were able to recall the types of dog food they had purchased recently. Several brands had been purchased, but persons in the households of six patients recalled purchasing dog food products made by manufacturer A. These interviews suggested exposure to dogs or dry dog foods as a possible source of infection.

PADOH collected dog stool specimens and opened bags of dry dog food from the homes of the 13 Pennsylvania patients. The outbreak strain of S. Schwarzengrund was isolated from five of 13 dog stool specimens and two of 22 dry dog food specimens collected from the homes. The contaminated dry dog food bags were two different brands (brand A and brand B), both produced by manufacturer A at plant A in Pennsylvania.

In July 2007, the Ohio Department of Health also interviewed persons infected with the outbreak strain of S. Schwarzengrund and collected two dog stool specimens from one patient's home. The outbreak strain of S. Schwarzengrund was isolated from one of the dog stool specimens. The dog recently had been fed brand A dry dog food, but the bag of dog food was no longer available for testing.

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FIGURE 1. Number of cases of Salmonella Schwarzengrun infection associated with contaminated dry dog food, by stz.

United States, January 1, 2006-December 31, 2007

Epidemiologic Investigation

A case was defined as a laboratory-confirmed infection with the outbreak strain of S. Schwarzengrund in a person residing in the United States who either had symptoms beginning on or after January 1, 2006, or (if the symptom onset date was unknown) had S. Schwarzengrund isolated from a specimen on or after January 1, 2006. During January 1, 2006-December 31, 2007, a total of 70 human cases of the outbreak strain of S. Schwarzengrund were reported to CDC via PulseNet from 19 states (Figures 1 and 2). The last reported illness onset date was October 1, 2007. No illness was reported in pets.

The largest number of reported cases was in Pennsylvania (29 cases), followed by New York (nine) and Ohio (seven) (Figure 1). Among 61 ill persons whose age was available, the median age was 3 years (range: 1 month85 years), and 24 (39%) were aged <l year; of 45 persons whose sex was known, 22 (49%) were female. Of 38 ill persons for whom clinical information was available, 15 (39%) had bloody diarrhea; of 45 persons whose hospitalization status was known, 11 (24%) had been hospitalized. No deaths were reported.

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86 (60%) persons in control households (matched odos ratio (mOR] = 2.7) (Table). Dry dog or cat food produs by manufacturer A usually was chosen for purchase ti members of 19 (44%) case-patient households compared with 14 (10%) of control households (mOR = 7.8; 954 confidence interval [CI] = 2.6–27.8).

Among the 19 persons in case-patient households who usually purchased manufacturer A pet food, 11 purchased brand A, three brand B, five brand C, and three brand D. All four brands were produced at plant A. Among the four brands, brand A typically was purchased by 11 (26%) per: sons in case-patient households compared with six (409 persons in control households. In multivariable analysis. purchase of brand A was associated with illness (MOR = 23.7) (Table). In Pennsylvania alone, purchase of brand A also was associated with human illness in multivariable analysis (mOR = 15.4; CI = 2.1-infinity).

Case-Control Study

To determine the source of infections caused by the outbreak strain of S. Schwarzengrund, the OutbreakNet team coordinated a multistate case-control study during July 17September 28, 2007. Case-patient households were defined as those with at least one member infected with the outbreak strain of S. Schwarzengrund with an illness onset date or isolation date occurring during January 1, 2006August 30, 2007. For each case-patient household, one to three geographically matched control households were recruited using a reverse-digit-dialing system. Persons in each case-patient and control household were asked whether they had been exposed to dry dog or dry cat food, which brands they usually purchased, and which brands they purchased in the 2 weeks before illness onset (for cases) or the 2 weeks before interview (for controls). Data were analyzed as a matched case-control study, and a multivariable logistic analysis was conducted to control for confounding from coexposures.

One person was interviewed in each of 43 case-patient households and 144 control households in eight states: Delaware, Maine, Michigan, Minnesota, New York, North Dakota, Ohio, and Pennsylvania. Case-patient and control households were excluded from analysis where questions were not answered. Contact with a dog was reported by 34 (79%) persons in case-patient households compared with

Environmental Investigation

During 2007, plant A produced approximately 25 brands of dry pet food; specific distribution information for brands produced in plant A was not available. Plant A labeled the dry pet foods with a 1-year shelf life (i.e., sell-by date). Or July 12, 2007, PADOH staff members visited plant A and collected 144 swabs of specimens from environmental surfaces; the outbreak strain of S. Schwarzengrund was isolated from one sample. FDA tested previously unopened bags of seven brands (brands E, F, G, H, I, J, and K) of dry dog food produced at plant A. Two brands of dry dog food (E and F) yielded the outbreak strain of S. Schwarzengrund. On August 21, 2007, manufacturer A announced a voluntary recall of 50-pound bags of brand E dry dog food and

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