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RESEARCH LETTERS

Acknowledgments Investigating the Role of We thank the Pennsylvania College SHCs that participated in the Influenza-like Illness Surveillance Network (ILINet) during in Migration of 2016–2017. from South Pacific

Specimen testing at the PDH was partially supported by CDC’s to Epidemiology and Laboratory Capacity for Infectious Diseases, cooperative agreement NU50CK000375. Edson Delatorre, Jorge Fernández, Gonzalo Bello

About the Author Author affiliations: Instituto Oswaldo Cruz/Fiocruz, Rio de Janeiro, Dr. Biggs is a medical epidemiologist with the Division of Viral Brazil (E. Delatorre, G. Bello); Public Health Institute of , Diseases, National Center for Immunization and Respiratory Santiago, Chile (J. Fernández) Diseases, CDC. Her interests include respiratory virus DOI: https://doi.org/10.3201/eid2411.180586 surveillance and outbreak response.

The role of Easter Island in the dissemination of Zika virus References from the Pacific islands into the Americas remains unclear. 1. Lion T. Adenovirus infections in immunocompetent and We analyzed new Zika virus sequences from Eastern Island immunocompromised patients. Clin Microbiol Rev. 2014;27: and found that Zika virus was independently disseminated 441–62. PubMed http://dx.doi.org/10.1128/CMR.00116-13 from French into the Americas and Easter Island 2. Centers for Disease Control and Prevention. Civilian outbreak at around the same time. of adenovirus acute respiratory disease—South Dakota, 1997. MMWR Morb Mortal Wkly Rep. 1998;47:567–70. 3. Kandel R, Srinivasan A, D’Agata EM, Lu X, Erdman D, Jhung M. Outbreak of adenovirus type 4 infection in a long-term care facility ika virus is a mosquitoborne flavivirus associated with for the elderly. Infect Control Hosp Epidemiol. 2010;31:755–7. Zseveral recent outbreaks in populations in the PubMed http://dx.doi.org/10.1086/653612 Pacific and the Americas. Phylogeographic studies 4. Lewis PF, Schmidt MA, Lu X, Erdman DD, Campbell M, indicate that Zika virus strains circulating in South Pa- Thomas A, et al. A community-based outbreak of severe respiratory illness caused by human adenovirus serotype 14. cific islands and comprise a single lineage J Infect Dis. 2009;199:1427–34. PubMed http://dx.doi.org/ (ZIKVSP-AM) that arose because of sequential single viral 10.1086/598521 disseminations from Southeast into 5. Radin JM, Hawksworth AW, Blair PJ, Faix DJ, Raman R, and from the South Pacific into Latin America 1( –5). How- Russell KL, et al. Dramatic decline of respiratory illness among US military recruits after the renewed use of adenovirus vaccines. ever, whether the ancestral Zika virus strain introduced into Clin Infect Dis. 2014;59:962–8. PubMed http://dx.doi.org/ the Americas arose directly from French Polynesia or from 10.1093/cid/ciu507 another South Pacific island is unclear. 6. Lu X, Erdman DD. Molecular typing of human adenoviruses by In early 2014, a Zika virus outbreak occurred in Easter PCR and sequencing of a partial region of the hexon gene. Arch Virol. 2006;151:1587–602. PubMed http://dx.doi.org/10.1007/ Island (6), months before the first identification of Zika virus s00705-005-0722-7 in Brazil (7). Easter Island is located at the southeastern edge 7. Binder AM, Biggs HM, Haynes AK, Chommanard C, Lu X, of the , roughly equidistant from French Erdman DD, et al. Human adenovirus surveillance—, Polynesia and the mainland. Geographic posi- 2003–2016. MMWR Morb Mortal Wkly Rep. 2017;66:1039–42. PubMed http://dx.doi.org/10.15585/mmwr.mm6639a2 tion and intense touristic activity make Easter Island a poten- 8. Scott MK, Chommanard C, Lu X, Appelgate D, Grenz L, tial staging post in the spread of Zika virus from French Poly- Schneider E, et al. Human adenovirus associated with severe nesia to continental America. This hypothesis was suggested respiratory infection, Oregon, USA, 2013–2014. Emerg previously (4), but the study used a limited sequence dataset. Infect Dis. 2016;22:1044–51. PubMed http://dx.doi.org/10.3201/ eid2206.151898 We tested this hypothesis by using a more comprehensive da- 9. Kajon AE, Lamson DM, Bair CR, Lu X, Landry ML, Menegus M, taset of Zika virus sequences from the South Pacific. et al. Adenovirus type 4 respiratory infections among civilian Blood samples from suspected Zika virus–infected hu- adults, northeastern United States, 2011–2015. Emerg Infect Dis. man patients who visited the emergency unit of 2018;24:201–9. PubMed http://dx.doi.org/10.3201/eid2402.171407 10. Lamson DM, Kajon A, Shudt M, Girouard G, St George K. Hospital on Easter Island during January–May 2014 were Detection and genetic characterization of adenovirus type 14 sent to the Public Health Institute of Chile for characteriza- strain in students with influenza-like illness, New York, USA, tion, according to Ministry of Health of Chile guidelines for 2014–2015. Emerg Infect Dis. 2017;23:1194–7. http://dx.doi.org/ surveillance of transmissible diseases. The complete E and 10.3201/eid2307.161730 partial NS5 genes of 7 Zika virus strains were obtained as Address for correspondence: Holly M. Biggs, Centers for Disease previously described (6). The concatenated fragments were Control and Prevention, 1600 Clifton Rd NE, Mailstop A34, Atlanta, GA aligned with Zika virus Asian genotype sequences available 30329-4027, USA; email: [email protected] in GenBank and used for spatiotemporal viral diffusion

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 11, November 2018 2119 RESEARCH LETTERS reconstruction (online Technical Appendix, https://wwwnc. Our results indicate that French Polynesia was the cdc.gov/EID/article/24/11/18-0586-Techapp1.pdf). main hub of dissemination of the ZIKVSP-AM lineage and The overall timescale of the phylogenetic tree estimat- seeded independent outbreaks in several South Pacific is- ed for Zika virus Asian genotype strains was fully consis- lands (including Easter Island) and the Americas from late tent with previous reports (1–5; online Technical Appendix 2013 to mid-2014, coinciding with a peak in the number Table 2). Asymmetric (online Technical Appendix Figure of suspected Zika cases in French Polynesia. The long pe- 1) and symmetric (online Technical Appendix Figure 2) riod of cryptic circulation of Zika virus in the Americas, the phylogeographic models placed the most recent common early detection of Zika virus in the in December ancestor of the Asian genotype epidemic strains in South- 2014 (4), and the reported dissemination of dengue (9) and east Asia (posterior state probability [PSP] >0.96) at 1999 chikungunya (10) viruses from French Caribbean territo- (Bayesian credible interval [BCI] 1996–2002) and support ries into French Polynesia during 2013–2014 support the 2 independent disseminations from Southeast Asia into the hypothesis that Zika virus might have been introduced to Pacific region—the first in around 2007, with and circulated in the Caribbean region for several months no further spread, and the second originating the ZIKVSP- before its detection in Brazil in 2015. Human movement

AM lineage that fueled epidemics during 2013–2016 in the between overseas French territories might create an epi- South Pacific and the Americas. demiologic link for arboviral transmissions between the

The origin of the ZIKVSP-AM lineage was traced to South Pacific and the Caribbean region. French Polynesia (PSP >0.98) at 2013.3 (BCI 2012.9– 2013.6). This lineage exhibits strong geographic subdivi- Acknowledgments sion; several highly supported island-specific monophy- We thank Maria Ibanez for the excellent technical assistance. letic subclades nested among basal strains from French E.D. is funded by a postdoctoral fellowship from the Programa Polynesia (5), besides the ZIKVAM subclade (online Tech- nical Appendix Figures 1, 2). We found 2 major clades Nacional de Pós-Doutorado (PNPD)/CAPES in Brazil. within the ZIKVSP-AM; clade I (posterior probability [PP] 0.97) contains strains from French Polynesia, the About the Author Americas, , and , whereas clade Dr. Delatorre is a postdoctoral fellow at the AIDS and Molecular II (PP >0.94) encloses strains from Easter Island and the Immunology Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz . Zika virus strains from , American Sa- Foundation, Brazil. His research interests include the evolution moa, , , and the branched and phylodynamics of viruses, including Zika virus. together in a large but not well-supported (PP <0.57) monophyletic group. References French Polynesia was the most probable source loca- 1. Faria NR, Azevedo RDSDS, Kraemer MUG, Souza R, Cunha MS, tion of the Zika virus clade I strains introduced into the Hill SC, et al. Zika virus in the Americas: early epidemiological Americas (PSP 1), Vanuatu (PSP 1), and New Caledonia and genetic findings. Science. 2016;352:345–9. http://dx.doi.org/ (PSP >0.98), as well as of the clade II strain introduced 10.1126/science.aaf5036 2. Faria NR, Quick J, Claro IM, Thézé J, de Jesus JG, Giovanetti M, into Easter Island (PSP >0.77), refuting the hypothesis of et al. Establishment and cryptic transmission of Zika virus in introduction of Zika virus into the Americas through Eas- Brazil and the Americas. Nature. 2017;546:406–10. ter Island. The source location of the clade II strain of the http://dx.doi.org/10.1038/nature22401 Cook Islands was traced to French Polynesia (PSP >0.34) 3. Metsky HC, Matranga CB, Wohl S, Schaffner SF, Freije CA, Winnicki SM, et al. Zika virus evolution and spread in the Americas. or Easter Island (PSP >0.37). Our analyses indicate that Nature. 2017;546:411–5. http://dx.doi.org/10.1038/nature22402 Zika virus was introduced into Easter Island, New Caledo- 4. Lednicky J, Beau De Rochars VM, El Badry M, Loeb J, Telisma T, nia, the Cook Islands, and the Americas at around the same Chavannes S, et al. Zika virus outbreak in Haiti in 2014: molecular time (BCI 2013.6–2014.8), supporting a much longer pe- and clinical data. PLoS Negl Trop Dis. 2016;10:e0004687. 5. Dupont-Rouzeyrol M, Diancourt L, Calvez E, Vandenbogaert M, riod of undetected Zika virus transmission in the Americas O’Connor O, Teissier A, et al. Zika virus evolution on the edges of (≈15 months) (7,8) than in those South Pacific islands (<1 the Pacific Ocean.Emerg Microbes Infect. 2017;6:e111. month) (8). Zika virus also spread from French Polynesia 6. Tognarelli J, Ulloa S, Villagra E, Lagos J, Aguayo C, Fasce R, into Samoa, Fiji, Tonga, and from late et al. A report on the outbreak of Zika virus on Easter Island, South Pacific, 2014. Arch Virol. 2016;161:665–8. http://dx.doi.org/ 2015 to early 2016, probably following a stepping-stone 10.1007/s00705-015-2695-5 process (online Technical Appendix Figures 1, 2). Migra- 7. Campos GS, Bandeira AC, Sardi SI. Zika virus outbreak, Bahia, tory routes between those islands, however, were difficult Brazil. Emerg Infect Dis. 2015;21:1885–6. http://dx.doi.org/ to resolve (inconsistency between phylogeographic mod- 10.3201/eid2110.150847 8. Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika virus. els) or do not fully agree with epidemiologic data (e.g. the N Engl J Med. 2016;374:1552–63. http://dx.doi.org/10.1056/ dissemination from Tonga to Fiji) (8). NEJMra1602113

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9. Cao-Lormeau V-M, Roche C, Musso D, Mallet H-P, Dalipanda T, predominantly associated with meningitis in neonates; C. Dofai A, et al. Dengue virus type 3, South Pacific Islands, 2013. sakazakii ST12, with necrotizing enterocolitis in neonates Emerg Infect Dis. 2014;20:1034–6. http://dx.doi.org/10.3201/ eid2006.131413 (2,3). C. sakazakii is usually resistant to cephalothin and 10. Aubry M, Teissier A, Roche C, Richard V, Yan AS, Zisou K, et al. penicillin but is more sensitive to antimicrobial drugs than Chikungunya outbreak, French Polynesia, 2014. Emerg Infect Dis. are other members of the family Enterobacteriaceae. Few 2015;21:724–6. http://dx.doi.org/10.3201/eid2104.141741 reports describe drug-resistance patterns in C. sakazakii isolates (4–6). We report 1 multidrug-resistant (MDR) C. Address for correspondence: Edson Delatorre, Laboratório de AIDS sakazakii ST256 strain that caused meningitis in a neo- & Imunologia Molecular, Instituto Oswaldo Cruz - FIOCRUZ. Av. nate in China. Brasil 4365, Manguinhos, 21040-360, Rio de Janeiro, RJ, Brazil; On September 29, 2015, a 26-day-old boy, who was email: [email protected] or [email protected] born after 38 weeks’ gestation and had abdominal disten- tion, fever, and jaundice, was hospitalized in a children’s hospital in Guangzhou, China. He was fed breast milk; however, it could not be determined whether he had been exclusively breast-fed or whether the breast milk had been expressed by use of a pump. His cerebrospinal fluid con- tained numerous leukocytes, and his cerebrum contained abscesses. After a series of symptomatic treatments, includ- ing initial intravenous ceftazidime followed by meropen- Novel Multidrug-Resistant em, his clinical signs gradually improved. However, when Cronobacter sakazakii discharged from the hospital after 3 weeks, his mental and physical development were remarkably impaired. Causing Meningitis in Cronobacter, isolated from brain abscess fluid, was iden- Neonate, China, 2015 tified by using an automated VITEK 2 Compact system (bio- Mérieux, Marcy l’Etoile, ). An isolate, GZcsf-1, was Haiyan Zeng,1 Tao ,1 Wenjing He,1 determined to be C. sakazakii ST256 with serotype O1. The Jumei Zhang, Bingshao Liang, Chengsi Li, Cronobacter PubMLST (https://pubmlst.org/cronobacter/) Na Ling, Yu Ding, Shi Wu, Juan Wang, Qingping Wu contains 2 ST256 isolates: MOD1-Ls15 g, isolated from the alimentary canal of the green bottle fly, Lucilia sericata, in DOI: https://doi.org/10.3201/eid2411.180718 the United States; and 2061 (no source information), detect- Author affiliations: Guangdong Institute of Microbiology, Guangzhou, ed in France. This ST had not been reported to cause men- China (H. Zeng, T. Lei, W. He, J. Zhang, C. Li, N. Ling, S. Wu, ingitis in neonates. Susceptibility to 15 antimicrobials was Q. Wu); Guangzhou Women and Children’s Medical Center, tested by using the broth dilution method; MICs are shown Guangzhou (B. Liang); Jinan University, Guangzhou (Y. Ding); in the online Technical Appendix (https://wwwnc.cdc.gov/ South China Agricultural University, Guangzhou (J. Wang) EID/article/24/11/18-0718-Techapp1.pdf). GZcsf-1 was re- sistant to 8 antimicrobials: ampicillin, cefazolin, ceftriaxone, We report a case of meningitis in a neonate in China, aztreonam, gentamicin, tetracycline, chloramphenicol, and which was caused by a novel multidrug-resistant Crono- trimethoprim/sulfamethoxazole. bacter sakazakii strain, sequence type 256, capsular pro- The Beijing Genomics Institute performed genomic file K1:CA1. We identified genetic factors associated with and plasmid DNA sequencing by using the PacBio RS II bacterial pathogenicity and antimicrobial drug resistance in (Pacific Biosciences, Menlo Park, CA, USA) and HiSeq the genome and plasmids. Enhanced surveillance of this (Illumina, San Diego, CA, USA) platforms. The an- organism is warranted. notations were performed as previously described (7). C. sakazakii GZcsf-1 had 1 circular chromosome, 4.43 ronobacter sakazakii is a foodborne pathogen asso- Mb long, containing 56.87% GC and 2 plasmids (de- Cciated with outbreaks of life-threatening necrotiz- noted pGW1, 340,723 bp, 57.2% GC; pGW2, 135,306 ing enterocolitis, meningitis, and sepsis in neonates and bp, 54.0% GC) (GenBank accession nos. CP028974–6). infants. Although the incidence of C. sakazakii infection On the basis of the characteristics of K antigen and co- is low, fatality rates range from 40% to 80% (1). Infec- lanic acid biosynthesis encoding genes in GZcsf-1, we tions are usually limited to specific sequence types (STs) determined its capsular profile to be K1:CA1, which and complex clonal complexes (2–4). C. sakazakii ST4 is differs from the capsular profile K2:CA2, proposed to be strongly associated with C. sakazakii isolated from 1These authors contributed equally to this article. neonates with severe infection (3). The subtype I-E

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