OBJECTIVES:Lyme carditis is a rare, potentially fatal manifestation of Lyme disease. Although Lyme disease is nationally notifiable, data on clinical manifestations are not collected systematically in the United States. We developed a syndromic surveillance definition to identify patients with Lyme carditis in New York State during 2017-2021. METHODS:We developed a definition of Lyme carditis by using diagnostic codes and keywords to identify emergency department visits related to Lyme carditis through the National Syndromic Surveillance Program's BioSense Platform. We systematically abstracted information for each identified patient by reviewing medical records in New York State's regional health information exchange system. Physician reviewers independently assigned a clinical case status to each record. We mapped cases of Lyme carditis by county and described their characteristics. RESULTS:We identified records for 173 individuals; 32% (n = 55) were classified as confirmed, 16% (n = 27) as probable, and 53% (n = 91) as not a case of Lyme carditis. In total, we identified 82 cases of confirmed or probable Lyme carditis; the positive predictive value of the definition was 47%. Cases occurred in 49% of New York State counties and peaked annually in July and August. Among patients with confirmed and probable Lyme carditis, age distribution was bimodal, with incidence peaking at about ages 32 and 70 years; 71% were male. Eighty-four percent had positive 2-tiered serologic test results for Lyme disease, and second- or third-degree atrioventricular block was present in two-thirds of patients (67%). PRACTICAL IMPLICATIONS:This definition may be a useful tool to detect changing patterns of Lyme carditis in areas with a high incidence of Lyme disease.

For some patients who have Lyme disease (LD), nonspecific symptoms can persist after treatment and impair quality of life. Estimating the frequency and duration of such symptoms is challenging. Using commercial insurance claims data from 2017-2021 for enrollees residing in states where LD is common, we identified 24,503 case-patients with LD and matched them (1:5) with 122,095 control-patients with other diagnoses by demographics, medical service date, and inpatient/outpatient setting. We compared relative frequencies of diagnosis codes for pain, fatigue, and cognitive difficulties between case-patients and control-patients in the year after diagnosis. Those symptom codes occurred 5.0% more frequently among case-patients than among control-patients and comprised »11.0% of the total symptom codes among case-patients. Symptom code frequency among case-patients declined significantly in the 6-12 months after LD diagnosis and reached levels similar to control-patients by the end of the year, with the exception of fatigue.

Abstract Background Tularemia is a nationally notifiable disease and Category A potential bioterrorist threat caused by Francisella tularensis. Microbial cell-free DNA (mcfDNA) sequencing is a pathogen-agnostic diagnostic method using human plasma. mcfDNA detections of F. tularensis are not currently included in public health surveillance criteria for a tularemia case and are not automatically reported to public health jurisdictions. We reviewed recent F. tularensis mcfDNA detections to better understand their clinical and public health implications.Table 1.Francisella tularensis diagnostic test results and reported exposure histories among 15 patients with F. tularensis detected by mcfDNA sequencing — United States, 2018–2023. Methods Available residual patient samples, in which F. tularensis mcfDNA were detected by the Karius CLIA certified/CAP accredited laboratory, were sent to the Centers for Disease Control and Prevention (CDC) for F. tularensis testing by PCR. Treating clinicians and local/state public health jurisdictions where these patients lived at the time of testing were invited to complete a survey regarding clinical details and public health reporting.Table 2.Demographic and clinical characteristics of patients with Francisella tularensis detected by microbial cell-free DNA (mcfDNA) testing, as reported by the ordering clinician — United States, 2018–2023. Results During 2018–2023, mcfDNA sequencing detected F. tularensis in 15 patient samples in 6 states. CDC detected F. tularensis by PCR in 4 (31%) of 13 residual samples, all in samples with higher DNA quantities. All invited jurisdictions (n=6) and most clinicians (8/13, 62%) participated in the survey. Most cases (12/15, 80%) were reported to public health; 3 of 12 (25%) were determined not to meet the tularemia surveillance case definition, and only 1 case reported to CDC mentioned mcfDNA results. Among 11 cases with clinical information, tularemia was not suspected before receipt of mcfDNA results in 10 (91%), despite all patients reporting outdoor activities that could increase F. tularensis exposure risk. Other diagnostic tests for tularemia were positive in 7 of 11 (64%) cases; blood cultures were negative in all cases. mcfDNA results changed clinical management in all cases, resulting in antibiotic changes.Figure 1.Cross-sectional computed tomography of the lungs in a patient diagnosed with pneumonic tularemia by microbial cell-free DNA (mcfDNA) testing, showing bilateral moderate pleural effusion and right upper and middle lobe pulmonary nodules. This patient also exhibited nonspecific mediastinal and bilateral axillary lymphadenopathy and typhoidal symptoms. In this case, mcfDNA testing identified Francisella tularensis nearly 50 hours before any conventional testing confirmed the diagnosis and prompted changes in antibiotic therapy and infection prevention efforts to begin. Conclusion mcfDNA appears to be clinically impactful and highly sensitive for diagnosis of tularemia, particularly in febrile patients with consistent exposure history. New diagnostic methods may pose a challenge to public health surveillance and require changes to case definitions and reporting practices to ensure robustness of public health utility and timely prevention efforts.Figure 2.Left medial knee with 3 cm nodular ulcer with purulence and adjacent erythema at location of suspected tick bite in a patient diagnosed with ulceroglandular tularemia by microbial cell-free DNA (mcfDNA) testing. Disclosures Sarah Y. Park, MD, FAAP, Karius, Inc.: employee

Blood culture-negative endocarditis has been associated with worse outcomes when compared with blood culture-positive endocarditis, because pathogen-directed antimicrobial therapy and other management aspects have been difficult to achieve. Novel diagnostic tools, however, have changed the landscape of this syndrome and will likely improve patient outcomes. This American Heart Association scientific statement highlights these advances. The writing group, which represents a multidisciplinary team, provides an update on blood culture-negative endocarditis. Clinical scenarios representative of real-world experiences are included to assist frontline clinicians in the diagnosis and management of this syndrome.

BACKGROUND:A Lyme disease (LD) vaccine is expected to become available soon. We aimed to understand recent trends in healthcare provider (HCP) willingness to recommend LD vaccination. METHODS:Cross-sectional surveys among HCPs were conducted in 2018 and 2022. We compared willingness to recommend LD vaccination by survey year and provider characteristics. RESULTS:Among 3005 HCPs, 70.5 % reported willingness to recommend LD vaccination. This proportion was lower in 2022 than in 2018 (68 % vs 73 %; p < 0.01) and did not differ significantly by provider medical specialty. More HCPs in states with high LD incidence were willing to recommend the vaccine compared to HCPs in neighboring or low-incidence states (p < 0.01). Vaccine safety was the most frequently reported consideration for recommending LD vaccination (73 %). CONCLUSIONS:HCP willingness to recommend LD vaccination decreased from 2018 to 2022. Vaccination education tailored to HCPs that address vaccine safety will be critical for a successful LD vaccination program.

Blood culture–negative endocarditis has been associated with worse outcomes when compared with blood culture–positive endocarditis, because pathogen‐directed antimicrobial therapy and other management aspects have been difficult to achieve. Novel diagnostic tools, however, have changed the landscape of this syndrome and will likely improve patient outcomes. This American Heart Association scientific statement highlights these advances. The writing group, which represents a multidisciplinary team, provides an update on blood culture–negative endocarditis. Clinical scenarios representative of real‐world experiences are included to assist frontline clinicians in the diagnosis and management of this syndrome.

Healthcare Professionals Working in Schools (HPWS) are responsible for providing health services to students and play a role in providing education to prevent illnesses, including tickborne diseases (TBD). Providing TBD education to children has been shown to increase prevention behaviors and knowledge of TBD symptoms, but little is known regarding the current state of TBD awareness among HPWS. In spring 2019 we conducted a cross-sectional knowledge, attitudes, and practices (KAP) survey of HPWS in two states with a high incidence of Lyme disease (LD) to inform design of TBD prevention programs. The survey queried general knowledge of TBDs, school practices regarding TBDs, and availability of TBD resources. Overall, higher confidence, experience, risk perception, prior training on TBD, and more years employed as a HPWS were independently associated with knowledge of LD transmission, symptoms, and correct tick removal practices. State and local health departments should consider prioritizing engagement with HPWS to provide educational opportunities about tickborne diseases.

Bartonella quintana is a louse-borne intracellular bacterium that remains a neglected cause of bacteremia, bacillary angiomatosis, and infective endocarditis among individuals experiencing poverty. In October 2023, Health Canada notified Canadian organ transplantation programs of an outbreak of donor-derived B. quintana infection. From March to August, 2023, five cases of donor-derived B. quintana disease were acquired in Alberta, Canada from three deceased donors who had experienced homelessness. Similar cases have recently occurred in the United States: two kidney transplant recipients were infected with B. quintana derived from a common donor with a history of unstable housing. In this paper, we discuss strategies to screen organ donors and monitor transplant recipients for B. quintana infection using epidemiologic risk factors, physical examination signs, and laboratory diagnostic tests. We review the limitations of existing diagnostic tests for B. quintana and describe how these problems may be magnified in the organ transplantation context.

Bartonella quintana infection can cause severe disease that includes clinical manifestations such as endocarditis, chronic bacteremia, and vasoproliferative lesions of the skin and viscera. B. quintana bacteria is transmitted by the human body louse (Pediculus humanus corporis) and is associated with homelessness and limited access to hygienic services. We report B. quintana infection in 2 kidney transplant recipients in the United States from an organ donor who was experiencing homelessness. One infection manifested atypically, and the other was minimally symptomatic; with rapid detection, both recipients received timely treatment and recovered. B. quintana was identified retrospectively in an archived donor hematoma specimen, confirming the transmission link. Information about the organ donor's housing status was critical to this investigation. Evaluation for B. quintana infection should be considered for solid organ transplant recipients who receive organs from donors with a history of homelessness or of body lice infestation.

BACKGROUND AND AIMS:Louse-borne Bartonella quintana infection and flea-borne murine typhus are two potentially serious vector-borne diseases that have led to periodic outbreaks among people experiencing homelessness in the United States. Little is known about louse- and flea-borne disease awareness and prevention among staff who provide services to the population. We surveyed staff in seven US states to identify gaps in knowledge and prevention practices for these diseases. METHODS AND RESULTS:Surveys were administered to 333 staff at 89 homeless shelters and outreach teams in California, Colorado, Georgia, Maryland, Minnesota, New York and Washington from August 2022 to April 2023. Most participants (>68%) agreed that body lice and fleas are a problem for people experiencing homelessness. About half were aware that diseases could be transmitted by these vectors; however, most could not accurately identify which diseases. Less than a quarter of staff could describe an appropriate protocol for managing body lice or fleas. Misconceptions included that clients must isolate or be denied services until they are medically cleared. CONCLUSIONS:Our findings reveal significant knowledge gaps among staff who provide services to people experiencing homelessness in the prevention and control of louse- and flea-borne diseases. This demonstrates an urgent need for staff training to both reduce disease and prevent unnecessary restrictions on services and housing.

Background: Lyme disease (LD) is the most common vector-borne disease in the United States, with increasing incidence and geographic range. Case incidence peaks among school-aged children. New LD preventives are in clinical trials. Methods: We conducted an online survey of parents of children aged 5-18 years in states with high or emerging incidence of LD. Our primary outcome was willingness ("definitely" or "probably") for their child to receive an LD vaccine. Our secondary outcome was preference for annual monoclonal antibody injections compared to a 3dose vaccine series with boosters. Analyses were weighted to reflect parent gender, parent race/ethnicity, and child age by state. Results: Among 1,351 parent respondents, most (68.0 %) would have their child vaccinated against LD, with significantly more being willing in high compared to emerging incidence states (70.4 % versus 63.6 %, p = 0.027). Of parents who were unsure or unwilling, 33.5 % and 16.5 %, respectively, would do so with a provider recommendation. Vaccine safety concerns were among the top reasons for LD vaccine hesitancy. More parents preferred a pre-formed antibody (42.3 %) compared to a 3-dose vaccine series (34.7 %). Significant predictors of willingness to have one's child vaccinated were higher parental education; higher perceived risk of child getting LD; child spending time outdoors daily or weekly; following a regular vaccine schedule; and positive attitude towards vaccines. Significant predictors of preference for monoclonal antibody over a 3-dose vaccine series included prior awareness of LD, living in a rural area, and less positive attitudes towards vaccines. Conclusions: Two-thirds of parents in high and emerging incidence states would vaccinate their children against Lyme disease. Addressing safety concerns will be important, and a health care provider recommendation could also encourage those who are unsure or unwilling. Given the slight preference for monoclonal antibody over vaccine, particularly in rural areas, access to both may increase LD prevention.

OBJECTIVE Pet ownership among people experiencing homelessness (PEH) is common, but access to shelter, veterinary care, and flea-preventative products for PEH who own pets in the US is not well described. We sought to evaluate current knowledge of fleas and flea-borne diseases and characterize practices around pets and service animals among staff at homeless shelters and outreach organizations METHODS In-person surveys were administered to staff at homeless shelters and on outreach teams in 7 states from August 2022 to April 2023 to evaluate knowledge, attitudes, and practices and to assess homeless shelter/organizational characteristics. RESULTS Surveys were administered to 333 staff members at 60 homeless shelters and among 29 outreach teams. Seventyeight percent of homeless shelters allowed pets or service animals. Only 2% of homeless shelters and 7% of outreach teams provided veterinary care; 15% of homeless shelters and 7% of outreach teams provided flea preventatives. Nearly three-quarters of surveyed homeless shelter staff responded that no steps were taken to treat fleas at their shelters. CONCLUSIONS Veterinary care and availability of flea-preventative products are limited in homeless shelter and outreach organizations serving people experiencing homelessness. CLINICAL RELEVANCE Pets of PEH might be at an increased risk of flea infestation and flea-borne diseases because of limited access to veterinary care and preventatives. Improving knowledge and access to flea prevention, screening, and treatment are critical to ensure PEH and their pets can consistently access homeless shelters or outreach services, and to prevent flea-borne disease transmission.

Tularemia is a disease caused by Francisella tularensis, a highly infectious bacteria that can be transmitted to humans by direct contact with infected animals. Because of the potential for zoonotic transmission of F. tularensis, veterinary occupational risk is a concern. Here, we report on a human case of tularemia in a veterinarian after an accidental needlestick injury during abscess drainage in a sick dog. The veterinarian developed ulceroglandular tularemia requiring hospitalization but fully recovered after abscess drainage and a course of effective antibiotics. To systematically assess veterinary occupational transmission risk of F. tularensis, we conducted a survey of veterinary clinical staff after occupational exposure to animals with confirmed tularemia. We defined a high-risk exposure as direct contact to the infected animal's body fluids or potential aerosol inhalation without use of standard personal protective equipment (PPE). Survey data included information on 20 veterinary occupational exposures to animals with F. tularensis in 4 states. Veterinarians were the clinical staff most often exposed (40%), followed by veterinarian technicians and assistants (30% and 20%, respectively). Exposures to infected cats were most common (80%). Standard PPE was not used during 80% of exposures; a total of 7 exposures were categorized as high risk. Transmission of F. tularensis in the veterinary clinical setting is possible but overall risk is likely low. Veterinary clinical staff should use standard PPE and employ environmental precautions when handling sick animals to minimize risk of tularemia and other zoonotic infections; postexposure prophylaxis should be considered after high-risk exposures to animals with suspected or confirmed F. tularensis infection to prevent tularemia.

Louseborne Bartonella quintana infections in the United States occur almost exclusively among persons experiencing homelessness because of inadequate access to hygiene resources. Homelessness is increasing, and persons experiencing homelessness can be organ donors, despite barriers to receiving donated organs themselves. Recent reports have documented B. quintana transmission via organs transplanted from donors who had recently experienced homelessness. Those reports demonstrate the threat of severe bartonellosis in immunosuppressed organ transplant recipients after donor-derived B. quintana infection. Addressing the root causes of B. quintana transmission could improve the quality of life for persons experiencing homelessness and simultaneously mitigate risk for donor-derived B. quintana transmission. Interventions include improved access to housing, consistent access to hot water for showers and laundry, early treatment of body lice infestation and B. quintana infection, and B. quintana testing and prophylactic treatment of recipients of organs from donors who have experienced risk factors for B. quintana, including homelessness.

Tularemia is caused by the highly infectious bacterium Francisella tularensis, which is recognized as a Tier 1 bioterrorism agent. Tularemia has a range of recognized clinical manifestations, but fewer than 20 bone or joint infections from 6 countries have been reported in the literature to date. This series includes 13 cases of F. tularensis septic arthritis or osteomyelitis in the United States during 2004-2023 and describes exposures, clinical presentation, diagnosis, and outcomes for this rare but severe form of tularemia. Clinicians should consider F. tularensis in patients with compatible exposures or a history of joint replacement or immunosuppression.

Single-dose doxycycline after high-risk tick bites can prevent Lyme disease, which disproportionately affects children. We described single-dose doxycycline dispensings in an outpatient cohort in the United States. During 2010-2020, a total of 427 105 patients received >= 1 dispensing(s); most were aged >= 65 years. Lyme disease postexposure prophylaxis may be underprescribed for some groups, including children.

Background People experiencing homelessness (PEH) are underrepresented in public health and clinical research. Study methods that can improve participation by this group are needed.Methods In late 2022, the Centers for Disease Control and Prevention conducted an mpox serological survey using venipuncture among PEH in San Francisco, California. Blood collection by a minimally invasive device was offered if venipuncture was not possible or preferred. Participants who had a successful blood draw using the device were asked about device acceptability.Results Of the 209 successful blood collections, 137 (66%) were among participants who underwent venipuncture and 72 (34%) were among participants who used the device. Use of the device increased overall blood collection participation by 53%. Participants reported high acceptability and preference for the device over venipuncture.Conclusions Minimally invasive blood collection devices may increase participation and representation of PEH in serosurveys.

In a US survey of infectious disease specialists, 61 respondents reported seeing >1 Bartonella quintana infection during 2014-2024. Diagnostic challenges included limited healthcare provider awareness, inadequate testing, and inconsistent healthcare access among affected populations. Early recognition of B. quintana infections is needed to improve outcomes among affected populations.