During 2023, 10 cases of locally acquired mosquito-transmitted (autochthonous) malaria were reported to CDC from four U.S. states after a 20-year period with no autochthonous cases. These cases highlight that although the United States eliminated malaria transmission in the early 1950s, the country remains susceptible to malaria reintroduction. This report provides operational guidance to local, state, tribal, territorial, and Federalpublic health responders on public health investigation and response to a suspected autochthonous malaria case in the United States. The guidance in this report updates the 2006 guidance (CDC. Locally acquired mosquito-transmitted malaria: a guide for investigations in the United States. Atlanta, GA: US Department of Health and Human Services, CDC; 2006) and is based on CDC subject-matter expertise, outbreak response experience from 2023, and targeted literature review. Investigations of suspected autochthonous malaria cases often raise public concern and can require substantial public health resources. Public health investigations of these cases should include epidemiologic, entomologic, and laboratory components and frequently require coordination among local, state, and Federal jurisdictions. This report provides an outline ofthe essential actions for such investigations conducted by describing the components ofthe investigation andproviding resources and tools to assist public health personnel at the local, state, and Federal level.
This report provides CDC recommendations to U.S. health care providers and preparedness personnel regarding treatment and postexposure prophylaxis (PEP) of tularemia, an uncommon but potentially serious disease caused by the gram-negative coccobacillus, Francisella tularensis. Tularemia occurs naturally in the United States and other Northern Hemisphere regions. Because F. tularensis has a low infectious inoculum, it is classified as a potential bioterrorism agent that could infect thousands of persons if intentionally released, requiring rapid, informed decision-making by public health agencies, first responders, and clinicians. To mitigate the effects of a bioterrorism attack, the U.S. government stockpiles medical countermeasures, and the 21st Century Cures Act mandates development of evidence-based guidelines for their use. Since 2001 when guidelines for tularemia treatment and PEP were last published, new animal study data and human clinical data have become available. CDC compiled a broad evidence base by conducting a series of systematic reviews of the literature on human tularemia through 2023, analyzing U.S. surveillance data, gathering outbreak reports and case series, and collecting animal data. During a series of scientific forums, evidence was presented from these investigations and additional data sources to subject matter experts, and individual expert input on proposed recommendations was solicited. The guidelines team then assessed the available evidence, considered different perspectives and feedback shared in the expert forums, and used the Grading of Recommendations, Assessment, Development and Evaluation summary of findings and the Evidence to Decision framework to formulate recommendations based on the balance of benefits and harms. Notable changes include use of a treatment and prophylaxis framework; designation of fluoroquinolones (ciprofloxacin or levofloxacin) and doxycycline as first-line treatment options for outbreaks of any size; identification of third-tier treatment options when first-line and alternative antimicrobials are unavailable or contraindicated for certain patients; and recommendations for neonates, breastfeeding infants, lactating mothers, patients with immunocompromise, and geriatric patients. These guidelines provide a summary of best practices for treatment and prophylaxis of human tularemia for both naturally occurring disease and after a bioterrorism attack. They do not include information on dispensing medical countermeasures, diagnostic testing, triage decisions, or adjunct treatments for patients with tularemia. Health care providers can use these guidelines to manage patients with naturally occurring infection and, with public health officials, prepare their organizations, clinics, hospitals, and communities to respond to a tularemia mass exposure event.
Nonoccupational postexposure prophylaxis (nPEP) for HIV is recommended when a nonoccupational (e.g., sexual, needle, or other) exposure to nonintact skin or mucous membranes that presents a substantial risk for HIV transmission has occurred, and the source has HIV without sustained viral suppression or their viral suppression information is not known. A rapid HIV test (also referred to as point-of-care) or laboratory-based antigen/antibody combination HIV test is recommended before nPEP initiation. Health care professionals should ensure the first dose of nPEP is provided as soon as possible, and ideally within 24 hours, but no later than 72 hours after exposure. The initial nPEP dose should not be delayed due to pending results of any laboratory-based testing, and the recommended length of nPEP course is 28 days. The recommendations in these guidelines update the 2016 nPEP guidelines (CDC. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV - United States, 2016. Atlanta, GA: US Department of Health and Human Services, CDC; 2017). These 2025 nPEP guidelines update recommendations and considerations for use of HIV nPEP in the United States to include newer antiretroviral (ARV) agents, updated nPEP indication considerations, and emerging nPEP implementation strategies. The guidelines also include considerations for testing and nPEP regimens for persons exposed who have received long-acting injectable ARVs in the past. Lastly, testing recommendations for persons who experienced sexual assault were updated to align with the most recent CDC sexually transmitted infection treatment guidelines. These guidelines are divided into two sections: Recommendations and CDC Guidance. The preferred regimens for most adults and adolescents are now bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine). However, the regimen can be tailored to the clinical circumstances. Medical follow-up for persons prescribed nPEP also should be tailored to the clinical situation; recommended follow-up includes a visit at 24 hours (remote or in person) with a medical provider, and clinical follow-up 4-6 weeks and 12 weeks after exposure for laboratory testing. Persons initiating nPEP should be informed that pre-exposure prophylaxis for HIV (PrEP) can reduce their risk for acquiring HIV if they will have repeat or continuing exposure to HIV after the end of the nPEP course. Health care professionals should offer PrEP options to persons with ongoing indications for PrEP and create an nPEP-to-PrEP transition plan for persons who accept PrEP.
Program evaluation is a critical tool for understanding and improving organizational activities and systems. This report updates the 1999 CDC Framework for Program Evaluation in Public Health (CDC. Framework for program evaluation in public health. MMWR Recomm Rep 1999;48[No. RR-11];1-40) by integrating major advancements in the fields of evaluation and public health, lessons learned from practical applications of the original framework, and current Federal agency policies and practices. A practical, nonprescriptive tool, the updated 2024 framework is designed to summarize and organize essential elements of program evaluation, and can be applied at any level from individual programs to broader systems by novices and experts for planning and implementing an evaluation. Although many of the key aspects from the 1999 framework remain, certain key differences exist. For example, this updated framework also includes six steps that describe the general process of evaluation planning and implementation, but some content and step names have changed (e.g., the first step has been renamed Assess context). The standards for high-quality evaluation remain central to the framework, although they have been updated to the five Federal evaluation standards. The most substantial change from the 1999 framework is the addition of three cross-cutting actions that are core tenets to incorporate within each evaluation step: engage collaboratively, advance equity, and learn from and use insights. The 2024 framework provides a guide for designing and conducting evaluation across many topics within and outside of public health that anyone involved in program evaluation efforts can use alone or in conjunction with other evaluation approaches, tools, or methods to build evidence, understand programs, and refine evidence-based decision-making to improve all program outcomes.
This report updates the 2023-24 recommendations ofthe Advisory Committee on Immunization Practices (ACIP) concerning the use ofseasonal influenza vaccines in the United States (MMWR Recomm Rep 2022;72[No. RR-2]:1-24). Routine annual influenza vaccination is recommended for all persons aged >= 6 months who do not have contraindications. Trivalent inactivated influenza vaccines (IIV3s), trivalent recombinant influenza vaccine (RIV3), and trivalent live attenuated influenza vaccine (LAIV3) are expected to be available. All persons should receive an age-appropriate influenza vaccine (i.e., one approved for their age), with the exception that solid organ transplant recipients aged 18 through 64 years who are receiving immunosuppressive medication regimens may receive either high-dose inactivated influenza vaccine (HD-IIV3) or adjuvanted inactivated influenza vaccine (aIIV3) as acceptable options (without a preference over other age-appropriate IIV3s or RIV3). Except for vaccination for adults aged >= 65 years, ACIP makes no preferential recommendation for a specific vaccine when more than one licensed and recommended vaccine is available. ACIP recommends that adults aged >= 65 years preferentially receive any one of the following higher dose or adjuvanted influenza vaccines: trivalent high-dose inactivated influenza vaccine (HD-IIV3), trivalent recombinant influenza vaccine (RIV3), or trivalentadjuvanted inactivated influenza vaccine (aIIV3). Ifnone ofthese three vaccines is available at an opportunity for vaccine administration, then any other age-appropriate influenza vaccine should be used. Primary updates to this report include the following two topics: the composition of2024-25 U.S. seasonal influenza vaccines and updated recommendations for vaccination ofadult solid organ transplant recipients. First, following a period of no confirmed detections of wild-type influenza B/Yamagata lineage viruses in global surveillance since March 2020, 2024-25 U.S. influenza vaccines will not include an influenza B/Yamagata component. All influenza vaccines available in the United States during the 2024-25 season will be trivalent vaccines containing hemagglutinin derived from 1) an influenza A/Victoria/4897/2022 (H1N1)pdm09-like virus (for egg-based vaccines) or an influenza A/Wisconsin/67/2022 (H1N1)pdm09-like virus (for cell culture-based and recombinant vaccines); 2) an influenza A/Thailand/8/2022 (H3N2)-like virus (for egg-based vaccines) or an influenza A/Massachusetts/18/2022 (H3N2)-like virus (for cell culture-based and recombinant vaccines); and 3) an influenza B/Austria/1359417/2021 (Victoria lineage)-like virus. Second, recommendations for vaccination ofadult solid organ transplant recipients have been updated to include HD-IIV3 and aIIV3 as acceptable options for solid organ transplant recipients aged 18 through 64 years who are receiving immunosuppressive medication regimens (without a preference over other age-appropriate IIV3s or RIV3). This report focuses on recommendations for the use of vaccines for the prevention and control of seasonal influenza during the 2024-25 influenza season in the United States. A brief summary of the recommendations and a link to the most recent Background Document containing additional information are available at https://www.cdc.gov/acip-recs/hcp/vaccine-specific/ flu.html?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html. These recommendations apply to U.S.-licensed influenza vaccines. Updates and other information are available from CDCs' influenza website (https://www. cdc. gov/flu). Vaccination and health care providers should check this site periodically for additional information.
