Accessible version: https://www.cdc.gov/ncezid/what-we-do/2018-highlights/ncezid-accomplishments-2018.html

National Center for Emerging and Zoonotic Infectious Diseases NCEZID ACCOMPLISHMENTS 2O18 NCEZID ACCOMPLISHMENTS

CDC works 24/7 to protect 2O18 America from health, safety, and security threats, both foreign and in the United States. This report describes the work of CDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) in 2018. Our expert scientists, laboratories, and emergency responders work around the clock to protect people from a multitude of health threats, including antibiotic-resistant infections, foodborne outbreaks, bioterrorism, deadly diseases like Ebola and rabies, diseases that cross borders, and illnesses spread from mosquitoes, ticks, and fleas. MAKING PROGRESS IN PREVENTING INFECTIONS STOPPING ANTIBIOTIC RESISTANCE IN ITS TRACKS IN HEALTHCARE FACILITIES In April 2018, CDC unveiled a powerful approach to stopping Tracking the prevention of healthcare-associated infections new and unusual forms of antibiotic resistance (AR). The (HAIs) provides data that CDC and partners can use to improve Containment Strategy calls for public health and healthcare patient outcomes, save lives, and reduce unnecessary facilities nationwide to take action at the first signs of any healthcare costs. In 2018, two CDC reports with important data new or rare type of AR. By quickly identifying emerging AR from previous years were published — the 2016 HAI Progress pathogens and initiating aggressive infection control and Report and the 2015 HAI Prevalence Survey. These reports show screening measures, the Containment Strategy seeks to stop the that focused infection prevention efforts across the nation have in its tracks. This strategy requires a Protecting Patients from Infections from Patients Protecting spread of new or novel AR Infections from Patients Protecting successfully reduced infections in healthcare facilities. However, coordinated response among health care facilities, labs, health even with these successes, hundreds of thousands of patients departments, and CDC, including the AR Lab Network. CDC’s are still being harmed by HAIs each year, and more action is resources support containment nationwide, including seven AR needed. Although these data focus on hospitals and other acute Lab Network regional labs; 56 AR Lab Network state and local care settings, CDC also works to prevent infections from occurring labs; and more than 500 local staff. Between January 2017 in other settings such as nursing homes, dialysis facilities, and August 2018, the AR Lab Network tested almost 24,000 outpatient surgery centers, and communities. CDC continues to isolates (pure samples of germs) and CDC supported more Protecting Patients from Infections invest in and provide technical assistance to state and local health than 250 containment responses in partnership with state and departments, healthcare systems, and other partners to prevent local health departments. PARTNERING GLOBALLY TO COMBAT PREVENTING INFECTIONS THAT CAUSE SEPSIS HAIs and support innovation for continued progress. ANTIBIOTIC RESISTANCE Each year, more than 1.7 million adults in America develop sepsis ADVANCING DOMESTIC AND INTERNATIONAL During the 2018 United Nations General Assembly (UNGA), and nearly 270,000 Americans die as a result. NCEZID worked ANTIBIOTIC STEWARDSHIP STRATEGIES more than 300 influential leaders from around the world joined with partners throughout 2018 to raise awareness about sepsis and Improving the way antibiotics are used around the world helps CDC in showing their commitment to fight one of today’s greatest share scientific expertise that healthcare professionals can use to fight antibiotic resistance and ensures that these life-saving drugs global public health threats: antibiotic resistance. Each year, at least prevent and treat infections that can lead to sepsis. CDC’s Get will work when they are needed most. CDC’s Core Elements of 2 million people are infected with antibiotic-resistant bacteria Ahead of Sepsis educational effort provided new information How does CDC get and Hospital Antibiotic Stewardship Programs outline essential in the United States alone, resulting in at least 23,000 deaths. to healthcare professionals and consumers via seven public components for hospital-based programs to improve antibiotic use data on healthcare- use, commonly referred to as antibiotic stewardship programs. The Antimicrobial Resistance (AMR) Challenge was unveiled at an service announcements (PSAs). The PSAs had a potential reach associated infections? UNGA event co-hosted by the Bill & Melinda Gates Foundation, the of more than 61 million people with messages emphasizing the Hospitals across the United States have used these core elements Pew Charitable Trusts, the United Nations Foundation, Wellcome importance of early recognition and timely treatment of sepsis, and to fight antibiotic resistance—for­­ example, by training staff how Trust, and the CDC Foundation. The AMR Challenge, spearheaded preventing infections that can lead to sepsis. CDC also published CDC’s National Healthcare Safety Network to improve their antibiotic prescribing practices. CDC used these by the US Department of Health and Human Services (HHS) and the Hospital Toolkit for Adult Sepsis Surveillance, which provides (NHSN) receives secure data from more facilities’ successes and lessons learned in the United States to work with international partners to identify and implement CDC, engages pharmaceutical and health insurance companies, healthcare facilities with tools to assess adult sepsis incidence and than 21,000 healthcare facilities to track food animal producers and purchasers, medical professionals, monitor progress in their facilities. practical and sustainable strategies for international healthcare and report information on healthcare- government health officials, and other global leaders to make settings with limited resources and weakened health systems. actionable commitments to make progress in the fight against associated infections. antibiotic resistance. HHS Secretary Alex Azar unveiled the first In its Core Elements of Human Antibiotic Stewardship commitments from more than 100 organizations at the event and CDC, states, healthcare facilities, and other Programs in Resource-Limited Settings: National and more than 400 attendees joined virtually via livestream from around patient safety organizations use the data Hospital Levels, CDC provides guidance for national policies that the world. The AMR Challenge encourages a One Health approach, to identify areas where action is needed, can improve antibiotic use across the spectrum of care, including guidance specifically for acute care facilities. Such strategies must which recognizes that the health of people is connected to the health measure progress of prevention efforts, of animals and the environment. As the AMR Challenge continues ensure access to antibiotics and reduce their inappropriate use. and ultimately eliminate HAIs. through 2019, CDC remains committed to collaborating with leaders CDC is collaborating with countries, such as India and Kenya, to worldwide to combat antibiotic resistance. implement these core elements and improve antibiotic use.

4 5 TRACKING DRUG-RESISTANT SKIN INFECTIONS IN INJECTION DRUG USERS Protecting People Recent CDC studies show that people who inject drugs are at from Domestic high risk for dangerous, costly infections from skin bacteria and fungi. The CDC-funded Emerging Infections Program’s Health Threats Healthcare-Associated Infections/Community Interface found that

Protecting Patients from Infections from Patients Protecting people who inject drugs are at 16-times higher risk of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections. Moreover, the proportion of invasive MRSA infections among people who inject drugs more than doubled from 2011 through 2016. Additional field investigations conducted by CDC staff in New York, New Mexico, and Colorado identified drug Candida auris, plated on Candida CHROMagar preparation or injection practices that greatly increase infection risk. This information is giving CDC and partners insights into C. AURIS how these dangerous infections can be prevented—for example, FIGHTING THE GROWING THREAT OF , by educating people about wound care and early warning signs A DRUG-RESISTANT FUNGUS of serious infections associated with injection drug use. Candida auris is a multidrug-resistant yeast that emerged in recent years causing serious and often fatal infections in patients CDC also teams up with partners to track emergency department in the United States and around the world. C. auris is a particular (ED) visits and hospitalizations due to medication misuse. threat in healthcare facilities because the fungus can last on skin CDC’s Medication Safety Program leads the National Electronic and healthcare surfaces, like bedrails and chairs, for weeks. In Injury Surveillance System – Cooperative Adverse Drug Event fact, C. auris can spread from person to person, even by a patient Surveillance (NEISS-CADES) project, a collaboration between the who carries the germ and does not show symptoms. United States Consumer Product Safety Commission, FDA, and CDC, to track adverse drug events nationally. NEISS-CADES also NCEZID rolled out a rapid, sensitive, and accurate test to detect tracks and analyzes ED visits and emergency hospitalizations due C. auris. In 2018, this test was shared with regional labs in CDC’s to medication misuse or abuse. These data show there were an AR Lab Network to provide this testing to healthcare facilities estimated 130,000 ED visits for harm from prescription opioid nationwide. As of October 2018, the regional labs performed misuse or abuse, out of 358,000 ED visits for nonmedical use of nearly 5,000 screenings, which helped identify hidden pockets of all prescription drugs. C. auris infection and informed actions to prevent its spread and, ultimately, protect patients.

Why C. auris is a major public health concern worldwide

Candida auris is a drug-resistant fungus that causes severe guidance to help hospitals identify patients who might be infections and deaths in patients around the world. Most strains carrying C. auris on their body but do not have symptoms. detected so far are resistant to at least one drug, and more than Finding these patients is critical because it allows hospitals one-third are resistant to two of the three major drug classes used to take immediate steps to control the spread of infection to to treat fungal infections. CDC experts are working hard to other patients. respond to this emerging threat. CDC scientists are learning more about the Asian CDC is also helping countries be able to conduct laboratory longhorned tick and the CDC worked with high-priority countries to develop health threats it may pose tests and surveillance for C. auris and take appropriate steps to recommendations to help hospitals control the spread of in the United States. respond when patients become infected. drug-resistant pathogens like C. auris and provide screening 6 7 Protecting People from Domestic Health Threats people andanimals getsick. health, agriculture, andothersectorsto prevent diseases before States presents anopportunityforcollaboration betweenpublic they are topesticides. thistickintheUnited The presence of track theseticks andconductteststodeterminehow susceptible States. CDCalsoisworkingwithpartners nationwidetofindand tick colonytodeterminewhatgermsitcouldspread intheUnited and thethreats itmayposeintheUnitedStates byestablishinga CDC scientistsare learning more aboutthe Asian longhornedtick can make peopleandanimalsseriouslyill. however, theworld, inotherpartsof diseases spread bythistick any harmfulgermsintheticks collectedintheUnitedStates; and people. October2018, As of scientists hadnotidentified then, experts havefoundthetickonpets, livestock, wildlife, was discovered onasheepinNew Jersey in August 2017. Since The INVASIVE TICK DISCOVERED IN THE UNITEDSTATES respond tothese infectionsandreport casestoCDC. states, territories, industry, andothergroups todetectand costly and sometimes deadly diseases. CDC is helping by funding mosquitoes andticks isneededtoprotect peoplefrom these number rose tomore than Just over according to aCDC Vital Signsreport released inMay2018. mosquito, tick, andflea peopleintheUnitedStates whogot The number of FLEA BITESINCREASE DISEASES FROMMOSQUITO, TICK, AND deadlyand ticksvector-borne tostopthespread diseases. of Laboratory scientistsat NCEZIDstudymosquitoesaswellfleas first Asianlonghornedtickfound 27,000 illnesses were reported in2004 bites tripled between 2004 and 2016, bites tripledbetween2004and2016, 96,000 in2016 in the United States intheUnitedStates . Better control of ill from ill from , andthat consequences of RMSF and other tickborne diseases. RMSFandothertickbornediseases. consequences of frontline healthcare providers canreduce theserioushealth awareness andearly recognition promoted bythetoolkit, highlights tickbornediseases intheUnitedStates. Through RMSF,that showstheclinicalprogression of andamanualthat with quickfactsaboutRMSFdiagnosisandtreatment, agraphic United States. The toolkitincludesatraining video, apocket card diagnose, andtreat RMSF for healthcare providers thathighlightkey developed atoolkitandcontinuingeducationopportunities the firstfewdaysafter apersongetssickiscrucial. In2018, CDC diseases spread byticks Rocky Mountainspotted fever(RMSF)is RECOGNIZE A DEADLY TICKBORNE DISEASE TRAINING HEALTHCARE PROVIDERS TO Twitter handle. With more than1,100 comments retweets andmore than2,930 likes onCDC’s tweet created asensation, withmore than2,150 between ticksandpoppy seeds onamuffin. The Twitter usersifthey could spotthedifference CDC captured national interest whenitasked tick bite prevention Getting socialwith Health Threats from Domestic Protecting People . Recognizing andtreating RMSFwithin and other tickborne diseases in the andothertickbornediseases inthe one of the deadliest thedeadliest one of ways to recognize, ways torecognize,

8 9 found and safely removed a tiny tickonherbody. user reported that after seeingthetweet, she about ticksandtickborne diseases.OneTwitter resources andstarted nationwide conversations engagement withCDC’s Lyme diseaseprevention on @CDCgov, thepopularityoftweet increased Aquatic Health Code, toreduce theriskforfurtherinfections. provided them withbestpractices guidance, basedonCDC’s Model ameba. The team worked withlocalandstatehealth officials and environmental samplesthatcouldbetestedforthebrain-eating park. experts tocollectwaterandother CDCdeployedateam of developed PAM anddiedafter returning from atripto Texas surf contaminated waterentersthrough theirnose. In2018, aperson themsurvived.four of The amebausuallyinfectspeoplewhen States who have beendiagnosedwithPAM since1962. Only (PAM). 145peopleintheUnited CDC hasreceived reports of thebrain infection of Naegleria fowleri INVESTIGATING RAREBRAIN-EATING AMEBA IN TEXAS mosquito populationsandthegermstheyspread. makers aboutwhichstrategies are mosteffective inreducing 1,100 householdsintheproject. The results willinformdecision the communityandenrolled people. In2018, workers installed in thearea andthentrack mosquito-borneinfectionsin3,000 Ponce, Puerto Rico. Experts willusemosquitocontrol strategies Communities Organized toPrevent Arboviruses (COPA) project in can reduce theseinfectionsinacommunity, CDCestablishedthe chikungunya ways toprevent mosquitobitesandstopdiseases like Local officials, CDC, andpartnerscontinuallysearch forbetter has significantlyincreased in Puerto Ricooverthepastfewyears. peoplegetting sickfromThe mosquito-bornediseases numberof CONTROLLING MOSQUITOES INPUERTO RICO , and isanamebathatcancausea Zika called primary amebic meningoencephalitis calledprimaryamebicmeningoencephalitis . To mosquitocontrol measures findoutif more than1,600people over 350mosquitotraps devastating devastating dengue from over from over in in ,

Protecting People from Domestic Health Threats Protecting People from Domestic Health Threats other infectionssotheycanbequicklyidentifiedandtreated. with thegoalof disrupted, CDCandpartnersestablishedasystemtofunnel samplestoCDCforleptospirosis testing, animals urinateandcontaminatethewater. With publichealth laboratories ontheislandsseverely saw anincrease inpeoplesickwithleptospirosis, apotentiallydeadly disease spread wheninfected adisaster.of When floodshit Puerto RicoandtheUS Virgin Islandsafter thehurricanes, health officials The abilityto quicklydiagnoseandtreat infectionsiscrucialtosavinglives, especiallyintheaftermath disease outbreaks, andeducatepeoplehowtostayhealthy andsafewhentheyhadnowaterorpower. to theaffected areas destructiontomonitorandtestfordiseases, andworked inthefaceof investigate water. CDCresponders were stillhelpingthoseareas recover in2018. Expertsfrom across CDCtraveled infectious diseases destruction wascatastrophic: anestimated When HurricanesIrmaandMariarippedthrough Puerto Ricoand HEALTHRESPONDING TOFOLLOWING THREATS helping laboratories recover theircapacity , andan increased risk of infections increased riskof $90 billionindamage caused by fungi and contaminated food and causedbyfungiandcontaminatedfood to conduct diagnostic tests for this and toconductdiagnostictestsforthisand DEVASTATING HURRICANES the US Virgin Islandsin2017, , the disrupted ability to fight disrupted abilitytofight the the 10 11 and could make themsick. be contaminated with people aware thatkratom could media, andthewebtomake partners usednewsmedia, social containing kratom. CDCand of and identifiedmultiplestrains distribution networkforkratom complicated importationand The investigationuncovered a kratom inpills, powder, ortea. ill peoplereported consuming this complex investigation. Most CDC worked closelywithFDA on A multidisciplinaryteam from theoutbreak. was thesource of and asanopioidsubstitute, consumed foritsstimulanteffects were hospitalized. Kratom, aplant states through 2018, started in2017andcontinued In a people tohelpCDCprecisely identifythegermsresponsible fortheseoutbreaks. people whowere sick. ExpertsperformedDNA fingerprintingon diarrhea andlead tohospitalizationsanddeaths. Public health investigatorsusedPulseNet tofind Service investigatedseveral outbreaks of Food andDrug Administration (FDA)Agriculture’s andtheUSDepartmentof Food SafetyandInspection In 2018, CDC, statepublichealth andregulatory officials, andother DURING COLLABORATING WITH PARTNERS TO PROTECT Salmonella Salmonella got sick, and 50 of them gotsick, them and50of SALMONELLA in products inproducts 199 people in 41 199 peoplein41 outbreak that outbreak that Salmonella OUTBREAKSCAUSED BY FOOD

1-year shelf life. life. 1-year shelf market withinthecereal’s cereal thatwere onthe recalled allHoneySmacks a result, Kellogg Company cereal from aretail store. As Kellogg’s HoneySmacks contamination inunopened and confirmed thosewhobecame ill of retail stores andfrom homes thecereal in samples of Health officials collected themhospitalized. 34 of 36 states resulted in Honey Smacks cereal March linked toKellogg’s An outbreak thatbeganin Salmonella getting sick, with 135 people from 135 peoplefrom infection, afoodbornedisease thatcancause Salmonella PEOPLE Salmonella

federal agencies such as the US federal agenciessuchastheUS

potentially contaminatedmelons. medley products thathad cantaloupe, andfresh-cut fruit watermelon, honeydewmelon, Caito Foods recalled fresh-cut LLC Indianapolis, of Indiana. pre-cut melons from Caito Foods, thisoutbreak to the source of hospitalized. Investigatorstraced with across 9states In a July investigation, bacteria isolated from ill bacteriaisolatedfrom ill Salmonella were infected were infected , with 36 of them , them with36of 77 people 77 people retailers nationwide. September andwere shippedto and packaged between July and products hadbeenproduced with may havebeencontaminated including ground beef, which products, beef pounds of approximately 12.1million of Tolleson, Arizona, recalled hospitalized. JBS Tolleson, Inc., Salmonella 28 states August, In anoutbreak thatstartedin Salmonella 333 people from 333 peoplefrom were infected with were infected with and 91 were and91were . The recalled

Protecting People from Domestic Health Threats Protecting People from Domestic Health Threats more illnesses. more illnesses. theoutbreak quickly,partners helpedidentifythesource of letting uswarn thepublicandprevent to anotheroutbreak linked toleafy greens infall2017. CDC’s fastactionandcollaboration with 16 states, withnodeaths. Laboratory testingwascriticalinconnectingthisfall2018outbreak northern andcentral California. A totalof outbreak began, thisonelinked toromaine lettuce from thecentral coastalgrowing regions in Just whenpeoplewere getting usedtohavingtheirromaine saladsback, another coli infected, with96hospitalizationsandfivedeaths. The springoutbreak wasthelargest multistate water samplestaken from the Yuma growing region. A totalof sequencing, wascriticalincharacterizing theoutbreak aswellidentifyingthesamepathogenin consumers, restaurants, andretailers. CDClaboratory testing, wholegenome includingtheuseof Yuma growing region theoutbreak intheSouthwestaslikely andissued sourceawarningto of CDC, workingwithFDA andstatelocalpartners, rapidly identified romaine lettuce from the producing Beginning in April 2018, Shigatoxin- twomultistateoutbreaks of CDCinvestigatedthefirstof WARNING CONSUMERS ABOUT CONTAMINATED ROMAINELETTUCE O157outbreak since2006. E. coli

O157:H7 infectionslinked toromaine lettuce 62 casesand25hospitalizations 210 peoplefrom 36states . Duringthisinvestigation, were reported from were reported from E. coli O157:H7 O157:H7 were were E. E. 12 13 CDC such asmallvillagewasunusuallyhigh. children (not tobeconfusedwithinfluenza)thatcancause been hospitalizedforaninfectionwith southwest 2018 after finding that one child had diedAlaska and three during othersthe had summer of Scientists from CDC’s Arctic InvestigationsProgram traveled toasmallvillage(population600)in PROTECTING ASMALLDEADLY ALASKANFROMARAREAND VILLAGE BACTERIA bacterial infection. bacterial infection. sick children. Sincethen, noother children inthevillagehavebecomesickwiththispotentiallydeadly getting theinfection, includingnearly 130children andtheadultswhowere inclosecontactwiththe throughout thecommunity, pharmacistsandnursesgaveantibioticstopeopleatthehighestrisk of outbreak together andits underage5. peoplewhohadgotten sickin Scientistswere concernedbecausethenumberof . While team memberscollectedthroat swabstoexamine howthedisease wasspreading to follownewrecommendations from the PediatricsAmerican Academy of state andtribalpartners feared more children wouldbecomeseriouslyill. They Haemophilus influenzae serious illness during the summer of 2018. during thesummerof ararevillage where anoutbreakanddeadly infectionsickened of youngchildren NCEZID’s Leisha Nolen, MD, takes athroat swabfrom achildinthesmall Alaskan and type A (Hia) usually affects babies and usually affects babies and . Hia is a type of bacteria . bacteria Hiaisatypeof to stop the to stopthe worked worked

Protecting People from Domestic Health Threats STOPPING EBOLA’S SPREAD IN DEMOCRATIC PREVENTING YELLOW FEVER AROUND THE WORLD Fighting Global REPUBLIC OF THE CONGO Yellow fever is spread by infected mosquitoes and can cause On May 8, 2018, the Ministry of Health of the Democratic serious illness or death in people who have not been vaccinated. Outbreaks Republic of the Congo (DRC) reported two people infected With continual outbreaks in Africa and South America, with Ebola virus in the Equateur Province. CDC assisted the vaccination campaigns are critical to educate the public on yellow DRC government and local and international partners as they fever and the importance of the vaccine.

launched a response to the outbreak. CDC and partners used Global Outbreaks Fighting lessons learned from previous response efforts to quickly bring In Brazil, more than 1,370 yellow fever infections and over the outbreak under control. On July 25, the World Health 480 deaths were reported from July 2017 through June 2018. Organization declared an end to the outbreak, which had In response, CDC issued a travel health notice in March 2018 to sickened 54 people, 33 of whom died. alert travelers and recommend that those who have never been vaccinated against yellow fever avoid traveling to the areas of Just a week later, the DRC Ministry of Health reported another Brazil where yellow fever is a risk. CDC conducted a coordinated Ebola outbreak in North Kivu province. Serious security concerns multi-media effort to inform and encourage healthcare providers in the area make this second outbreak response particularly and travelers to plan ahead because of the limited availability of challenging. The outbreak has continued to spread and, in yellow fever vaccine in the United States. December 2018, became the second largest Ebola outbreak in history. CDC is working closely with the DRC government, Accurate diagnosis is also important, and in 2018, CDC launched the World Health Organization, and other partners to bring the an international study of a yellow fever diagnostic kit. Nine outbreak under control by supporting epidemiology, laboratory countries across Africa and South America are testing the kit to diagnostics, infection prevention and control, border protection, see how it performs and how it can be improved. emergency operations, risk communication, and vaccination strategy activities. In 2018, CDC deployed more than 90 subject matter experts to DRC and neighboring countries to coordinate activities and provide technical guidance to help the region strengthen its preparedness to respond to Ebola.

NCEZID scientists outside Uganda’s Python Cave, where they trapped and tagged bats to learn more about what areas may be at risk for Marburg virus, a close relative to Ebola virus.

14 15 Fighting Global Outbreaks and hygieneconditions. detection, andidentifyingunsafewater, sanitation targeted training forcholera surveillance and rapidly responding tooutbreaks, providing CDC iscommitted toidentifyingcholera hotspots, cholera by2030. To prevent cholera outbreaks, Zambia todevelopandlaunchtheirplansend Control, CDChashelpedKenya, Tanzania, and initiative bytheGlobal Task Force forCholera cholera vaccination. the As partof quality, cholera mortality, investigationsof and management, water evaluationandmonitoringof surveillance andlaboratory diagnostics, case including in-countrytechnicalsupportfor and Zimbabwerespondcholera, tooutbreaks of Health inMalawi, helped Ministriesof Zambia, bacteria thatcancausewaterydiarrhea. CDC water oreating foodcontaminatedwithcholera Cholera isadeadly disease spread bydrinking HEALTH IN AFRICA TO ENDCHOLERA WORKING WITH MINISTRIES OF was chlorinated andmonitored regularly (above). Bureau toensure that water at thesetapstandsinEthiopia NCEZID experts worked withtheSomaliRegional Water Ending Cholera

16 17 control of XDR typhoid fever control of were abletotake stepsto met withauthoritiesinIslamabad andKarachi andtogetherthey Country Office, andtheUSAIDmission. InOctober2018, they Health inPakistan, Aga KhanUniversityinvestigators, theCDC CDC’s typhoidexperts consultedwiththeNational Instituteof surveillance, laboratory testing, the XDR outbreak. andcontrol of Public health authoritiesinPakistan asked CDCtohelpwith XDR outbreak hadspread toPakistan’s largest city, Karachi. extensively drug-resistant, or XDR typhoid fever. By2017, the fever Hyderabad,city of Pakistan, reported an Such wasthecaseinlate2016, whenhealth officials inthe drug-resistant, people whodieismuchhigher. thepercentage of ( Without treatment, people infectedwithtyphoidfever 30%of TYPHOID FEVER HELPING PAKISTAN FIGHT DRUG-RESISTANT improve WASH practices anddeliver WASH messages. materials tostrengthen healthcarehowto workers’ knowledge of into placeaplantoimprove healthcare conditionsbydeveloping existing WASH conditions. CDCandpartnersthenhelpedput practices; and learned what providers and patients thought about knowledge about WASH; studiedtheirhandwashinghygiene management infrastructures; evaluatedhealthcare workers’ Experts assessed facilities’water, sanitation, hygiene, andwaste improve water, sanitationandhygiene(WASH) conditions. countries health in In 2018, CDCexperts worked withpartnersandministriesof about hygiene access tosafewater improvements neededtoprovide rural healthcare facilitieswith develop nationalactionplans. They are alsoworkingtomake efforts toassess theirwaterandsanitationinfrastructures and then, publichealth workers around theworldhavesteppedup became amajorhurdle intreating Ebolaandsavinglives. Since workers andpatients, safewaterandsanitation whenalackof outbreak in West Africa highlightedthecrisisfacedbyhealthcare and poorsanitationcanbeadeadly reality. The 2014-2015Ebola In manycountries, rural healthcare facilitieswithunsafewater HEALTHCARE FACILITIES SANITATION, AND HYGIENE INRURAL GLOBAL PARTNERSHIPS IMPROVE WATER, Salmonella that was more than 300 rural healthcare facilitiesinfive —Mali, Uganda, Tanzania, Ghana, andEthiopia—to Typhi) willdie. Butwhentheinfectiousstrain is resistant tomostantibiotics to prevent infectiousdiseases. , adequate sanitation improve surveillance in Pakistan. outbreak of typhoid typhoid outbreak of , and —also known as —also knownas , education education diagnosis , and and

Fighting Global Outbreaks Safeguarding Travelers & Health & Border Travelers Safeguarding Border Health

CDC’s meticulous planning and around-the-clock work behind the scenes protect people in the United States, including incoming airline passengers.

PROTECTING AIRLINE PASSENGERS IMPROVING THE QUALITY OF IMMIGRANT CDC’s long-standing coordination with federal, state, and local APPLICANTS’ MEDICAL RECORDS partners to safeguard US ports of entry from contagious diseases In 2018, the United States launched an electronic system, was put to the test in September 2018, when a commercial airline eMedical USA, to improve the quality of immigrant applicants’ from Dubai alerted JFK Airport about 100 sick passengers on records and help physicians trained and licensed to practice board. CDC’s quarantine officers worked with the US Customs and overseas (panel physicians) to detect health-related conditions Border Protection officers to rapidly isolate the plane and screen such as tuberculosis. The system improves the transfer of passengers for illness. Local partners transported ill passengers important medical information and improves CDC’s ability to to the hospital for further evaluation, where several passengers review the quality of medical exams, reducing the risk that panel tested positive for flu. The remaining passengers were screened physicians miss patients with tuberculosis immigrating into the and released. The next day, two more flights into the United States United States. CDC staff, in partnership with the US Department reported ill passengers, with one traveler testing positive for flu. of State, developed, tested, and established the eMedical These events show how CDC’s meticulous planning and around- system; trained US panel physicians and their staff in its use; and the-clock work behind the scenes protect people in the United developed the partnership agreements necessary for eMedical’s States, including recent arrivals. use. The system will eventually be used by nearly 700 US panel physicians in 150 countries.

18 19 Safeguarding Travelers & Border Health rabies, monkeypox and(shownhere) Ebolavirus. the gear theyusewhilefighting deadly diseases like NCEZID experts inthe WIRED videodemonstrated These instructionsare anothertoolexperts canuseinthefighttoend TB. professionals havethe mostup-to-datematerialstoscreen andtreat patientsfor TB. spreading the riskof TB amongtheUSpopulationisreduced. Itiscrucialthatmedical (TB). These instructionshelptoensure thatpeoplediagnosedwith TB are treated and civil surgeons intheUnitedStates to published new Tuberculosis Technical Instructionstohelppanelphysiciansoverseas and Because tuberculosis isachallengingdisease todiagnose, PROVIDING CRITICAL GUIDANCE IN THE FIGHT TO END TUBERCULOSIS detect and treat infectious forms of tuberculosis detect andtreat infectiousformsof treat, andcontrol, CDC

20 21 the sickpassenger ontheplane. Nooneelsewasinfected. investigations toidentifyandnotifythosewhowere exposed to state health departmentsresponded quicklyandconducted others whenflyingbacktotheUnited States. CDCandlocal while visitingSouth America and who couldhaveexposed United States Andesvirusinfectioninthe first knownimportedcaseof collaborated withseveral statesin2018toinvestigatethe hantavirus strain thatcanalsospread betweenpeople. CDC hantavirusfoundinSouth America,type of anditistheonly cause severe ordeadly illnesses in people. Andes virusisa Hantaviruses are foundaround theworldinrodents and THE UNITEDSTATES IMPORTED CASE OF ANDES VIRUS IN RESPONDING RAPIDLY TO THE FIRST KNOWN diseases the world’s deadliest Gearing up to fight . The illpersonwasatraveler whowasinfected

can can monkeypox, and Ebola. fighting deadly diseaseslike rabies, NCEZID experts usewhileon thefront lines published avideodetailing thegearthat stop outbreaks. In2018, WIREDmagazine dangerous pathogens, prevent illnesses and and vaccinate stray dogssothey canstudy beaten path to crawl withsnakes, trap bats, CDC diseasedetectives regularly gooffthe releasing anationalhealth alert. The couplestarted Swiss health officials identifiedthecouplewithin5hours after officials toupdatetheSwiss government aboutthesituation. and contactedCDCstaff, whothenreached outtoSwiss health rabies exposure, Health investigated theFloridaDepartmentof were from Switzerland. When notifiedaboutthispotential not givenanycontactinformationbuthadmentionedthey positive testforrabies virus The clinictested thebat, andbythetimeresults were in—a ataveterinaryclinic. tourists foundasickbatanddropped itoff While vacationinginFlorida January 2018, twoEuropean RABIES INFLORIDA EXPOSED TOFOREIGN TRAVELERS FINDING their lives exposure prophylaxis . thatsameday, andit —the couplehadleft. They had may have saved may havesaved rabies post-

Safeguarding Travelers & Border Health and EpiCapacity Building Lab 22 23 detection, prevention, infectiousdiseases. andcontrol of nationwide fundedprograms thatsupportscapacitybuildingforthe and hepatitisoutbreaks). CDC’sThis crucialinvestmentisoneof key, all infectiousdisease outbreaks nationwide(notincludingHIV, STD, departments In 2018, ELC health datasystems, andstrengthen theirdisease surveillancesystems. departments tomodernizetheirlaboratory resources, improve their Diseases Capacity forPrevention Emerging andControlInfectious of nearly aquartercentury, CDC’s fightinginfectiousdiseases,lines of buttheycannotdoitalone. For Across theUnitedStates, publichealth departmentsare onthe THE BATTLE AGAINST INFECTIOUS DISEASES SUPPORTING USHEALTH DEPARTMENTS IN (ELC) has provided direct support to state and local health (ELC) hasprovided direct supporttostateandlocalhealth awarded more than $200 million to 64 public health awarded more than$200millionto64publichealth . ELC-supported investigatemore than70%of staff Epidemiology and Laboratory Epidemiology andLaboratory front front to In 2018, CDClaboratory scientistsupdatedthemethodsthey WATER DURINGEMERGENCIES STRENGTHENING CDCLABS’CAPACITY TO TEST a smallpox emergency tosavelives. stored intheStrategic NationalStockpile andcouldbeusedduring Tecovirimat asthe approving the drug. In July 2018, theFDA approved theuseof used whentheUSFood andDrug Administration (FDA) considered thebody.infected cellandspreading totherest of These datawere virus multiplication, whichprevents thevirusfrom leaving an virus thatcausessmallpox. They confirmedthat Tecovirimat halted anewdrugcalled effectiveness of Tecovirimat (TPOXX) againstthe attack. NCEZIDscientistsconductedlaboratory teststoevaluatethe critical tosavinglives having a today haveneverhadsmallpox orbeenvaccinatedagainstit, it Smallpox APPROVED FORUSEIN THE UNITEDSTATES PAVING THE WAY FORFIRST SMALLPOX DRUG threats help during future publichealth emergencies, like hurricanes, and laboratories’ watersamples capacity toprocess incomingsurges of Level 3agents). These updatedmethods strengthened CDC they are infections inhaled or (also even known deathas Biosafety if drug totreat smallpox andpavedthewayforitsapproved use intheUnitedStates. NCEZID scientistsconductedlaboratory teststoevaluate theeffectiveness anew of could beusedinabioterrorist attack test watercontaminatedwithgerms prepare CDC to respond to a broader range of potential prepare potential CDC torespond to abroader range of posedbycontaminated water. drug waseradicated inthe1980s, butthere are stillconcerns available to treat this deadly disease would be availabletotreat thisdeadly disease wouldbe first treatment forsmallpox if smallpox ever were used in a bioterrorist smallpox everwere usedinabioterrorist if . Sincemanypeople that could cause serious thatcouldcauseserious . Tecovirimat isnow use use

Building Lab and Epi Capacity One Advanced Molecular Detection: Health the firstfive years at CDC

Coordinating

Communicating Collaborating

People who protect To achieve the best human, animal, and health outcomes for environmental health, people, animals, plants, and other partners and our environment

Five years ago, CDC had fallen behind in a critical technology: DNA sequencing. A revolution in the Using a One Health approach field was under way—next-generation sequencing (NGS)—that promised more finely detailed and

CS302365-A precise data to guide public health actions, such as detecting and responding to outbreaks. Since the to protect health for all Advanced Molecular Detection (AMD) Program began in 2014, CDC has become a leader in applying NGS to public health challenges. CDC experts are working to change the way we approach public health. Specifically, CDC wants people to know that human health isn’t just about humans—it’s closely related to the health In just five years, CDC has built aworkforce capable of applying NGS and related technologies of animals (including pets, wildlife, and livestock) and the environment that we share—an to over 50 infectious diseases. To make use of this enormous flow of genomic data, the agency has approach known as One Health. In 2018, experts from CDC’s One Health Office helped increased its high-performance computing capacity and is making increasing use of cloud strengthen global health security and capacity to prevent zoonotic diseases by collaborating services. CDC’s infectious disease laboratories now lead the way in using NGS to improve health. with partners to conduct One Health Zoonotic Disease Prioritization Workshops in multiple Moreover, state and local public health laboratories across the United States now have NGS capacity countries and, for the first time, regions. and the systems needed to support it. These advancements are helping public health agencies discover new trends in drug resistance, detect emerging outbreaks faster, and stop outbreaks more The first regional workshops were held for the Economic Community of West African States, which effectively. For example, one CDC partner supported by the Advanced Molecular Detection Program includes 15 member countries, and for US southern land border states. These regional workshops was able to confirm that a hotel hot tub in Hampton Beach, New Hampshire, was the likely source of a reflect the increased interest among partners to work together at the regional levelto prepare for Legionnaires’ disease outbreak that sickened 19 people, one of whom died. shared threats to people, animals, and the environment. CDC’s One Health experts also facilitated national workshops in Mozambique, Ghana, and Uzbekistan. In Uzbekistan, they pilot tested a new toolkit to help the country develop a One Health strategy to prevent the diseases identified as being high priorities. } Better understanding of influenza viruses to improve How AMD vaccine developments Commonly prioritized diseases worldwide include rabies, brucellosis, anthrax, and viral } Faster detection of emerging outbreaks for early hemorrhagic fevers like Ebola and Marburg. By prioritizing the efforts help zoonotic diseases that pose the intervention and control biggest health threats, countries can more efficiently build their laboratory capacity, conduct us prepare disease surveillance, plan outbreak response and preparedness activities, and create disease } More effective interventions in outbreaks prevention strategies to reduce illness and death in people and animals. for infectious } Improved insights into preventing foodborne outbreaks disease threats } Discovery of new trends in drug resistance

24 25 Looking Ahead to 2019

Preparedness Advanced Molecular Detection Preparedness to fight infectious diseases is one of NCEZID’s top priorities in 2019. NCEZID experts Advanced Molecular Detection efforts at CDC are poised to take public health infectious disease continue to strengthen preparedness efforts on many fronts: work into the future through continued innovation and new opportunities, including plans to: } In 2019, the Laboratory Response Network (LRN) will mark its 20th anniversary of working } Develop and adapt tools that combine genomic data with epidemiologic data to better support with partners to ensure that the United States can detect and respond to dangerous and detection and investigation of infectious disease outbreaks. emerging infectious diseases like H1N1 influenza, MERS, Ebola, and Zika. Moving forward, } Build a public health workforce adept in pathogen genomics and molecular epidemiology. NCEZID experts will continue to provide leadership and support to make sure that the LRN } stays well ahead of new health threats and demands. Create a sustainable DNA sequencing technology infrastructure across the United States. } in sequencing technologies, adapting relevant technologies for } Design will begin of a new, much-needed high-containment laboratory, which will allow CDC Keep up with rapid advances scientists to continue conducting leading-edge work on some of the world’s deadliest pathogens. use in public health. } } As infectious disease threats grow in the United States, the way NCEZID supports states also Develop new tests that can identify and characterize foodborne bacteria directly from patient specimens without the need for a culture (without needing to grow the bacteria in the lab). needs to grow. The Epidemiology and Laboratory Capacity for Prevention and Control This potentially means getting lab results in hours rather than days. of Emerging Infectious Diseases (ELC) Program has engaged partners across the country to make strategic improvements to ensure that its new 5-year Cooperative Agreement Antibiotic Resistance (2019–2024) gives support to prevent and control the spread of infectious disease threats in the United States. During the 2018 United Nations General Assembly, NCEZID was joined by hundreds of leaders worldwide who made commitments to tackle antibiotic resistance (AR) in five areas: Global Health } Tracking and data: Share AR data and improve data collection In 2019 and beyond, NCEZID experts know that international outbreaks like Ebola will continue, } Infection prevention and control: Reduce the spread of resistant germs especially in insecure settings like the Democratic Republic of the Congo, and they will continue } Antibiotic use: Improve appropriate antibiotic use while ensuring access to these drugs working vigilantly with many partners to protect people abroad and in the United States from these deadly outbreaks. } Environment and sanitation: Decrease antibiotics and resistance in the environment while improving sanitation Also on the horizon are efforts to prevent deaths from infectious diseases like cholera and rabies. } Vaccines, therapeutics, and diagnostics: Invest in their development and improve access For example, NCEZID will continue to collaborate with global partners to reduce cholera deaths by 90% and eliminate human deaths from dog-transmitted rabies by 2030. These commitments will have a major impact over the coming years, as NCEZID expands its activities to meet the increasing need to reduce AR not just in the United States, but globally as well. Vector-borne Diseases NCEZID and nine other federal agencies will continue working together to tackle the rising threat posed by diseases from mosquitoes, ticks and fleas. The partners will put into place aNational Strategy for Vector-borne Diseases to prioritize resources, including new technologies and funds to help states combat these diseases. By working in concert, they can start solving problems the nation faces as vector-borne diseases continue to rise.

26 27 www.cdc.gov/ncezid

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