Date: Sat 23 Nov 2019
Source: MedPage Today [edited]

American Society of Tropical Medicine & Hygiene. Hernandez S, et al "Prevalence of Chronic Comorbidities Among People with Chagas Disease in Los Angeles, California" ASTMH 2019; Abstract 1311. (Cardiac Comorbidities Plague Chagas Disease Patients under-diagnosed, undertreated L.A. population burdened with cardiometabolic conditions)

Many patients with _Trypanosoma cruzi_ infection, or Chagas disease, in Los Angeles had multiple other comorbidities, a researcher said here.

In a multivariable analysis, both cardiomyopathy and age were significant predictors of multiple comorbidities in these patients, reported Salvador Hernandez, MD, of the Centers of Excellence for Chagas Disease in Sylmar, California.

More than half of patients with Chagas disease had 2 or more comorbidities, he noted at a presentation at the American Society of Tropical Medicine & Hygiene annual meeting.

Although Chagas disease is often thought of as a parasitic infection that predominantly affects rural areas of Latin America, Hernandez noted a large epidemiological burden of cases in the U.S., including an estimated 70,000 in California, 37,000 in Texas, 18,000 in Florida, and 17,000 in New York, none of which included undocumented individuals. However, he added that Chagas disease is severely underdiagnosed in the U.S., with less than 1% of cases diagnosed and only 1%-2% of cases treated.

Hernandez said that of patients who are infected with Chagas disease, 30%-40% will progress to the chronic phase of the disease, which does not present until 20-30 years after the initial infection. Of these cases, 60%-70% will have cardiac involvement. This starts as abnormalities on EKG, such as a right bundle branch block or a left anterior fascicular block. These symptoms are followed by slow progressive cardiomyopathy until symptoms of heart failure and sudden death from arrhythmia.

"At this final stage, the disease becomes irreversible, and treatment with anti-parasitic therapy does not alter the disease course," Hernandez noted.

Prior research from the Centers of Excellence for Chagas Disease found a wide-ranging prevalence of the infection in Los Angeles, with the highest prevalence in Latin American-born patients with non-ischemic cardiomyopathy, Latin American-born patients with pacemakers, and Latin American-born patients with ECG abnormalities.

They performed a retrospective chart review of 221 patients from their center, who were a mean age of about 56 and had been in the U.S. for an average of 37 years. More than half of the patients were women, about half were from El Salvador, with about a quarter from Mexico, and a little less than half were ages 50-69. A little over 30% of these patients had cardiomyopathy.

The most common comorbidity among these patients was hypertension (43%), followed by obesity (39.6%) and hyperlipidemia (30.6%). Only 30% of patients had no comorbidities, while 9% had 5 or more in this cohort.

Men had a significantly higher number of comorbidities compared with women (2.22 vs 1.63, respectively), and the same was observed for patients with cardiomyopathy versus patients with no cardiomyopathy (3.06 vs 1.34). Hernandez also noted that comorbidities increased with age, with patients ages 70 and older having a mean of almost 3 comorbidities compared to younger patients ages 18-39 with less than one.

Hernandez noted that Chagas disease has 30 000 new cases annually worldwide but is severely underdiagnosed in the U.S. and is predominantly seen in a population without access to healthcare. He noted that among the patients in the Center of Excellence for Chagas Disease, about 63% are living below the federal poverty level, 66% have less than a high school education, and 72% rely on public insurance in California.  "Care for Chagas disease should ideally be integrated into the primary care setting, so that when you check for hypertension or diabetes, you can properly screen and treat these patients," he said.  [Byline: Molly Walker]
[ProMED thanks Kunihiko Iizuka for alerting us to this study.

These cases are in migrants from Chagas disease-endemic areas in South and Central America. For information, see the WHO fact sheet:

Chagas disease may have an incubation period of up to 30 years from infection until cardiomyopathy develops and becomes clinically manifested. Also, infected pregnant women may pass the infection to the foetus, and pregnant women having migrated from Chagas-endemic areas should be screened. - ProMED Mod.EP]

[HealthMap/ProMED map available at:
Los Angeles, California, United States:
Date: Wed 20 Nov 2019
Source: Colorado Public Radio [edited]

All 46 schools in Mesa County [Colorado] are closing Thursday [21 Nov 2019] out of an abundance of caution as a gastrointestinal illness continues to spread through its student body. Six schools had closed as of Wednesday [20 Nov 2019] afternoon before the district-wide shutdown was announced. Schools will remain closed on Friday [22 Nov 2019] through the district's Thanksgiving break, which lasts the entire week of the holiday from [25-29 Nov 2019].

Mesa County health officials think norovirus is a possible cause of the outbreaks. The main symptom is vomiting that lasts between 12 and 24 hours, with a few reports of diarrhoea as well. Officials warned the public that when it comes to norovirus, not all cleaning liquids and hand sanitizers can kill the germs. People sick with the virus can continue to spread the illness 24 hours after symptoms have passed. Officials urged parents to keep their children at home if they show any signs of illness.  [Byline: Stina Sieg]
Communicated by:
Tony Schountz
Colorado State University
[ProMED thanks Tony Schountz for sending this alert.   Worldwide, norovirus is the leading cause of acute gastroenteritis (inflammation of the stomach or intestines or both). About 1 in 5 cases of acute gastroenteritis, which leads to diarrhoea and vomiting, is caused by norovirus (<>). Norovirus is more often the cause of acute gastroenteritis among people in developed countries. In developed countries, norovirus causes about 1 in 5 cases of acute gastroenteritis; in developing countries, it's about 1 in 6 cases. Overall, developing countries have more cases of acute gastroenteritis caused by different pathogens, such as viruses and bacteria. So, norovirus accounts for a smaller fraction of all cases in these countries.

With the widespread use of rotavirus vaccine, norovirus has surpassed rotavirus as the most common cause of acute gastroenteritis for which children need medical care in some countries, like the USA and Nicaragua. This trend is likely to continue as other countries routinely vaccinate against rotavirus.

Norovirus infections and outbreaks are usually more common in cooler winter months. About half of all cases occur from December through February in countries above the equator and June through August in countries below the equator. However, in places closer to the equator, norovirus may be less seasonal. This may be because of temperature or the timing of the rainy season but may also be associated with the birth rate. - ProMED Mod.LL]

[HealthMap/ProMED-mail map:
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Date: Wed 20 Nov 2019
Source: Nebraska TV (NTV) [edited]

The [Nebraska] Central District Health Department [CDHD] reported [Wed 20 Nov 2019], a multi-state outbreak of hepatitis A that has been linked to eating blackberries and potentially to strawberries purchased at Fresh Thyme grocery stores. The berries were distributed in 3 states [I believe they mean cases have occurred in these states - ProMED Mod.LL], including Nebraska as well as Indiana and Wisconsin. The department noted that these same berries were also distributed in Iowa, Illinois, Kentucky, Michigan, Missouri, Minnesota, Ohio, and Pennsylvania.

"The strawberries and blackberries would have been purchased at Fresh Thyme grocery stores between 9 and 30 Sep 2019. If you didn't freeze these berries you probably won't have any left. However, if you purchased and froze berries during this time period, either throw them out or return them for a refund," said Teresa Anderson, Health Director.

Hepatitis A is a contagious liver infection caused by the hepatitis A virus and can range from a mild illness lasting a few weeks to a severe illness lasting several months. Hepatitis A can cause death in some people but is rare. Hepatitis A usually spreads when a person unknowingly ingests the virus from objects, food, or drinks contaminated by small, undetected amounts of stool from an infected person, according to officials. Symptoms begin somewhere between 2 and 7 weeks after exposure. Individuals are considered most contagious during the 2 weeks before and one week after onset of symptoms. Officials said those diagnosed with hepatitis A or persons symptomatic after a known exposure should not work or prepare food for one week after symptoms begin and until symptoms are gone for longer than 24 hours.

"We continue to work with CDC and FDA officials in this investigation and will advise the public of any updates. "If you have any questions about potential exposure to hepatitis A, call your health professional or call us at CDHD. If you were recently exposed to hepatitis A virus and have not been vaccinated against hepatitis A, you might benefit from an injection of either hepatitis A vaccine or immune globulin. Your health provider can help you decide what is best based on your age," Anderson added.

Fresh Thyme Farmers Market released the following statement to NTV on [Wed 20 Nov 2019]:

"The Food and Drug Administration and the Centers for Disease Control, in conjunction with other state and local agencies, have contacted us concerning a recent hepatitis A outbreak in 3 states in the Midwest affecting an unspecified number of individuals. These agencies are investigating and believe that affected people may have consumed fresh conventional (non-organic) blackberries between [9 and 30 Sep 2019]. We are fully cooperating with these agencies on the investigation and are awaiting next steps.

"At this time, there is no reason to believe that any of the product was contaminated via handling in our stores. In addition, the agencies are ONLY concerned with product purchased between [9 and 30 Sep 2019]; product purchased or consumed outside of these dates are NOT subject to the investigation. We are working with these agencies to identify our suppliers and isolate the source of this contamination. Fresh Thyme takes the health and safety of our customers and our team members very seriously. Fresh Thyme Farmers Market has a stringent process for ensuring compliance to all local, state and federal health and hygiene regulations.

"Should any customers have any of the fresh conventional blackberries purchased between [9 and 30 Sep 2019], remaining in their refrigerators or freezers, they should be discarded immediately or returned to Fresh Thyme for a refund. In Douglas County, NE, if you purchased any of these berries between [9 and 30 Sep 2019], and still have them, please take them to the local health department for testing.  "Again, Fresh Thyme is committed to the health and safety of our customers, and we will continue to work closely with these agencies to determine the source of the contamination."
[Most of the hepatitis A outbreaks associated with berries have been related to frozen ones. The source of the berries is not stated. It would be interesting to know if the berries originated in one of the states in the USA with ongoing outbreaks of HAV and if the strain analysis matches the outbreak strain in those states. - ProMED Mod.LL]

[HealthMap/ProMED-mail maps:
Nebraska, United States: <>
Wisconsin, United States: <>
Indiana, United States: <>]
Date: Fri 15 Nov 2019
Source: Food Safety News [edited]

Authorities are investigating an ongoing outbreak of scombrotoxin fish poisoning traced to yellowfin tuna. They have blocked all incoming shipments of the fish from a Vietnamese company that has refused to initiate a recall. Public health officials have confirmed at least 47 people from unspecified states as outbreak patients. The most recent illness began 15 Oct 2019, according to an outbreak investigation notice posted today by the U.S. Food and Drug Administration. The 1st known patient became ill on 8 Aug 2019.

Scombrotoxin fish poisoning occurs when fish begins to spoil and histamine levels in it increase. Histamine cannot be destroyed by freezing or cooking. The FDA reported that all yellowfin tuna from Truong Phu Xanh Co. Ltd. of Vietnam with 2019 production dates is implicated and should be thrown away.

Stores, restaurants, and other foodservice operators are expected to pull the tuna, but the FDA wants consumers to shoulder some responsibility, too. The agency's notice tells consumers to ask whether yellowfin tuna -- also called ahi tuna -- being sold is from the specific company named by the FDA.

FDA officials have not used the agency's power to force the Vietnamese company to recall the tuna, even though the firm has been determined to have supplied the fish. "FDA asked for the supplier of yellowfin tuna associated with most of the illnesses, Truong Phu Xanh Co. Ltd. of Vietnam, to initiate a voluntary recall of all of its imported yellowfin tuna with production dates from January 2019 to the present. At this time, the firm has not recalled any product," the FDA reported today [15 Nov 2019]. "Because scombrotoxin fish poisoning causes temporary or medically reversible adverse health consequences, this incident did not meet the threshold for the use of FDA's mandatory recall authority."

Although the Vietnamese supplier has not issued a recall, some companies in the United States have posted recalls for the implicated tuna, the FDA reported. The agency, working with officials in unnamed states, gathered information from victims and entities in the supply chain that led to those 3rd-party recalls.

The FDA notice says some of the tuna could still be on the market. "Tuna from this supplier could have been sold thawed or frozen, and could have been sold as ground tuna meat, poke cubes, steaks, or loins; this product could still be within its shelf life," the notice states. Because of the outbreak investigation and findings to date, the FDA placed Truong Phu Xanh Co. Ltd. of Vietnam on "Import Alert," which means the firm's yellowfin tuna can be detained at U.S. borders and ports of entry without physical examination.

A concurrent investigation of cases of scombroid fish poisoning by the Seattle-King County Public Health Department is not related to the FDA's investigation of Truong Phu Xanh Co. Ltd., according to federal officials.

Standard tests used during enforcement activities and other kinds of foodborne illness investigations are not effective for situations of suspected scombrotoxin fish poisoning, according to the FDA's outbreak notice. The samples collected thus far by federal and state investigators cannot be linked to samples from patients by whole-genome sequencing (WGS) or pulsed-field gel electrophoresis (PFGE) analysis. Pathogens such as specific strains of _Salmonella_ or _E. coli_ are generally pinpointed with WGS or PFGE processes, but the spoilage factor in the scombroid scenario makes that impossible.

"Scombrotoxin fish poisoning occurs when fish begin to spoil, resulting in increased histamine levels," FDA's notice says. "Multiple samples have been collected and analyzed, with positive results for decomposition or high histamine levels in products imported from Truong Phu Xanh Co. Ltd."

Symptoms of scombroid poisoning can become evident within minutes to 2 hours following consumption of contaminated fish, according to the FDA. Initial signs can mimic an allergic response and include facial flushing, sweating, burning-peppery taste sensations about the mouth and throat, dizziness, nausea, and headache. Symptoms can intensify to facial rash, hives, swelling, diarrhea, and abdominal cramps. Severe reactions to the poison can include blurred vision, respiratory stress, and swelling of the tongue.  [Byline: Coral Beach]
Date: Thu 14 Nov 2019
From: Larry Lutwick <> [edited]

Over the past 5 days, our health care facility in northwest Wisconsin, USA, has seen 3 women hospitalized with _E coli_ O157 infection. All presented with significant abdominal pain without fever and watery diarrhoea which in 2 progressed to bloody diarrhoea. None of the 3 have manifested any evidence of haemolytic-uremic syndrome. Both of the women seen by the Infectious Diseases service stated that their diet contains a lot of salads.

We would appreciate any reports of upswings in the number of cases of this process in the upper Midwest USA or elsewhere.
Larry Lutwick MD
Eau Claire, Wisconsin
[Although the classical source of enterohemorrhagic _E. coli_ infections is ground beef, fresh produce as in salad ingredients are also well represented as vehicles of transmission. ProMED would appreciate any further reports as the country health departments work on this as yet small outbreak. - ProMED Mod.LL]

[HealthMap/ProMED map available at:
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