CDC COCA Digest: May 2, 2019

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Upcoming COCA Call


Travel-associated Rickettsioses Guidance: Pre-travel Counseling, Diagnosis, Treatment, and Reporting

Date: Tuesday, May 7, 2019

Time: 2:00 - 3:00 p.m. (Eastern Time)

International travel has increased over the past 30 years, exposing travelers to wider ranges of diseases. Because of this, healthcare providers should be aware of diseases from regions far beyond their geographical area of practice. Vector-borne rickettsial diseases have an almost worldwide distribution, putting many travelers at risk.

During this COCA Call, subject matter experts will discuss the epidemiology, clinical presentation, diagnosis, and treatment of three of the most common travel-associated rickettsial diseases—African tick bite fever, Mediterranean spotted fever, and scrub typhus. The presenters will also address these diseases in the context of pre-travel and post-travel evaluations.

If you are unable to attend this live COCA Call, the webinar will be available to view under the “Call Materials” tab a few days after the call takes place. Free continuing education (CE) will still be available.

CDC News and Announcements


Measles Cases in the U.S. are Highest Since Measles was Eliminated in 2000

From January 1 to April 26, 2019, 704 measles cases have been confirmed in 22 states.

CDC Director, Dr. Robert Redfield, is calling upon clinicians to assure patients about the efficacy and safety of the measles vaccine. CDC also encourages local leaders to provide accurate, scientific-based information to counter misinformation about the safety of the measles mumps, and rubella (MMR) vaccine.

Related Links:


CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain

In a new commentary in the New England Journal of Medicine (NEJM), authors of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain (Guideline) advise against misapplication of the Guideline that can risk patient health and safety.   

CDC commends efforts by healthcare providers and systems, quality improvement organizations, payers, and states to improve opioid prescribing and reduce opioid misuse and overdose. However, some policies and practices that cite the Guideline are inconsistent with, and go beyond, its recommendations. In the NEJM commentary, the authors outline examples of misapplication of the Guideline. The authors also highlight advice from the Guideline that is sometimes overlooked but is critical for safe and effective implementation of the recommendations.

CDC is raising awareness about the following issues that could put patients at risk:

  • Misapplication of recommendations to populations outside of the Guideline’s scope. The Guideline is intended for primary care clinicians treating chronic pain for patients 18 and older. Examples of misapplication include applying the Guideline to patients in active cancer treatment, patients experiencing acute sickle cell crises, or patients experiencing post-surgical pain.
  • Misapplication of the Guideline’s dosage recommendation that results in hard limits or “cutting off” opioids. The Guideline states, “When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.” The recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.
  • The Guideline does not support abrupt tapering or sudden discontinuation of opioids. These practices can result in severe opioid withdrawal symptoms including pain and psychological distress, and some patients might seek other sources of opioids. In addition, policies that mandate hard limits conflict with the Guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient.
  • Misapplication of the Guideline’s dosage recommendation to patients receiving or starting medication-assisted treatment for opioid use disorder. The Guideline’s recommendation about dosage applies to use of opioids in the management of chronic pain, not to the use of medication-assisted treatment for opioid use disorder. The Guideline strongly recommends offering medication-assisted treatment for patients with opioid use disorder.

The Guideline was developed to ensure that primary care clinicians work with their patients to consider all safe and effective treatment options for pain management. CDC encourages clinicians to continue to use their clinical judgment, base treatment on what they know about their patients, maximize use of safe and effective non-opioid treatments, and consider the use of opioids only if their benefits are likely to outweigh their risks.

CDC continues to help inform and improve clinicians’ ability to offer safer, more effective care based on the best available science. As part of that process, CDC is evaluating the adoption, use, and public health impact of the Guideline and its related resources.

Read the entire Media Statement that was released on April 24.


Ebola in the Democratic Republic of the Congo (DRC)

An outbreak of Ebola is occurring in the North Kivu (Kivu Nord) and Ituri provinces in the DRC (see map of Ebola-affected health zones in the DRC). The DRC Ministry of Health declared this current outbreak on August 1, 2018. For the latest information on this outbreak, including updates on numbers of cases and deaths, see the World Health Organization’s (WHO) Ebola situation reports: Democratic Republic of the Congo.

North Kivu and Ituri provinces are among the most populated in DRC. These provinces share borders with other countries (Rwanda, South Sudan, and Uganda) with frequent cross-border movement for personal travel and trade. The provinces have been experiencing a prolonged humanitarian crisis and deteriorating security, which are limiting public health efforts to respond to this outbreak. The U.S. Department of State has identified this part of the country as a “reconsider travel” zone because of armed conflict.

The DRC Ministry of Health, WHO, and partners are responding to this outbreak and working to enhance illness surveillance and reporting, monitor contacts, conduct cross-border surveillance in neighboring countries, expand laboratory capacity, and vaccinate front-line health workers and contacts of people with Ebola.

CDC has published special recommendations for organizations sending workers to the outbreak area.

Additional Resources

Seasonal Influenza


2018-2019 Influenza Season Week 16 ending April 20, 2019

All data are preliminary and may change as more reports are received.

Influenza activity continues to decrease in the United States. Influenza A(H1N1)pdm09 viruses predominated from October to mid-February, and influenza A(H3N2) viruses have been more commonly identified since late February. Small numbers of influenza B viruses also have been reported. Below is a summary of the key influenza indicators for the week ending April 20, 2019:

  • Viral Surveillance: The percentage of respiratory specimens testing positive for influenza viruses in clinical laboratories decreased. During the most recent three weeks, influenza A(H3) viruses were reported more frequently than influenza A(H1N1)pdm09 viruses nationally, and in all 10 HHS Regions.
    • Virus Characterization: The majority of influenza A(H1N1)pdm09 and influenza B viruses characterized antigenically are similar to the cell-grown reference viruses representing the 2018–2019 Northern Hemisphere influenza vaccine viruses. However, the majority of influenza A(H3N2) viruses are antigenically distinguishable from A/Singapore/INFIMH-16-0019/2016 (3C.2a1), a cell-propagated reference virus representing the A(H3N2) component of 2018-19 Northern Hemisphere influenza vaccines.
    • Antiviral Resistance: The vast majority of influenza viruses tested (>99%) show susceptibility to oseltamivir and peramivir. All influenza viruses tested showed susceptibility to zanamivir.
  • Influenza-like Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) decreased to 2.1%, which is below the national baseline of 2.2%. This is the first week ILI activity was below the national baseline since mid-November 2018. Four of 10 regions reported ILI at or above their region-specific baseline level.
    • ILI State Activity Indictor Map: Puerto Rico experienced high ILI activity; one state experienced moderate ILI activity; nine states experienced low ILI activity; New York City, the District of Columbia and 40 states experienced minimal ILI activity; and the U.S. Virgin Islands had insufficient data.
  • Geographic Spread of Influenza: The geographic spread of influenza in five states was reported as widespread; Puerto Rico and 17 states reported regional activity; 19 states reported local activity; the District of Columbia, the U.S. Virgin Islands and nine states reported sporadic activity; Guam did not report.
  • Influenza-associated Hospitalizations: A cumulative rate of 64.2 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported. The highest hospitalization rate is among adults 65 years and older (214.1 hospitalizations per 100,000 population).
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza was below the system-specific epidemic threshold in the National Center for Health Statistics Mortality Surveillance System.
  • Influenza-associated Pediatric Deaths: Five influenza-associated pediatric deaths were reported to CDC during week 16.

An overview of CDC's influenza surveillance system, including methodology and detailed descriptions of each data component, is available. Read the full situational update. View the current United States flu activity map.

Additional resources, recommendations, and guidance are available for healthcare professionals.

Emergency Preparedness and Response

Natural Disaster

Health and Safety Concerns for All Disasters

See below for information about a variety of health and safety concerns for all disasters, including:  

Resources for Emergency Health Professionals

CDC offers a variety of resources and educational materials for clinicians, communicators, laboratorians, emergency planners and responders, and disaster relief volunteers to help them prepare and respond to a public health emergency. These resources include free educational materials, such as flyers, posters, stickers, and public service announcements in various languages that are suitable for printing and sharing.

Travelers' Health


The mission of CDC Travelers' Health Branch is to reduce illness and injury in U.S. residents traveling internationally or living abroad. Applying the best science, the Travelers' Health Branch provide alerts, recommendations, education, and technical support to travelers and the healthcare providers who serve them.

General Resources

CDC Health Information for International Travel (the "Yellow Book") contains the U.S. government's most current travel health guidelines, including pre-travel vaccine recommendations, destination-specific health advice, and easy-to-reference maps, tables, and charts. The CDC Yellow Book is available free online and for iOS or Android.

General Vaccine Information

Pre-travel Care Tools

Disease-specific Resources

  • Zika Interactive Map: Search by location to find out if Zika is in a particular destination.
  • Yellow Fever Travel Information: A one-stop shop for yellow fever information, including risk areas, travel notices, and vaccine availability.
  • Yellow Fever & Malaria Information by Country: Country-specific information and maps on yellow fever vaccine requirements and recommendations, as well as malaria transmission information and prophylaxis recommendations.
  • Disease directory: Information concerning specific diseases that can affect travelers.
  • Travel Notices for International Travelers: Travel notices inform travelers and clinicians about current health issues related to specific international destinations. These issues may arise from disease outbreaks, special events or gatherings, and natural disasters affecting travelers' health.

Clinical Update

  • Cholera Vaccine for Travelers (2019): In June 2016, the U.S. Food and Drug Administration approved a single-dose oral cholera vaccine (CVD 103-HgR, Vaxchora [PaxVax Corporation, Redwood City, CA]). The Advisory Committee on Immunization Practices voted to recommend cholera vaccine for adult (18–64 years) travelers to an area of toxigenic Vibrio cholerae O1 transmission. An area of active transmission is defined as an administrative subdivision where cases have been reported within the past year.

Drug-Resistant Infections in Patients Who Had Weight-Loss Surgery in Mexico

CDC has received reports of serious drug-resistant Pseudomonas aeruginosa (CRPA) infections in U.S. residents who had surgery (primarily weight-loss surgery) in Tijuana, Mexico. More than half of those infected with drug-resistant CRPA had surgery at Grand View Hospital, Tijuana. Others became infected after undergoing procedures at other hospitals and clinics in the city. Infections caused by this particular drug-resistant CRPA are rare in the United States and are difficult to treat.

What Can Clinicians Do?

  • Providers caring for patients with a history of invasive procedures in Mexico should be aware of the potential for infections caused by resistant pathogens. The pathogen implicated in the current cluster of infections is CRPA. The resistance mechanism is a metallo-β-lactamase encoded by a mobile genetic element known as the Verona integron.
  • CRPA is drug-resistant and difficult to treat, requiring prolonged courses of complex antibacterial drug combinations. Consult with an infectious disease specialist.
  • When caring for patients who have undergone invasive procedures in Mexico, obtain cultures, perform antimicrobial susceptibility testing to guide treatment, and test any carbapenem-resistant bacteria for Verona integron and other plasmid-mediated carbapenemases. Report any CRPA surgical site infections in patients who had invasive procedures in Mexico to your local or state health department.
  • When admitting patients who have a history of overnight stays in healthcare facilities outside the United States, consider performing rectal screening for carbapenemase-producing organisms. This recommendation applies to patients hospitalized outside the United States at any time during the six months before their U.S. hospital admission.
    • Consider placing such patients in isolation and taking contact precautions while awaiting screening results.
  • Mechanism testing for carbapenem-resistant bacteria and rectal screening for carbapenemases are available free of charge via the Antibiotic Resistance Laboratory Network, which can be accessed through state health department healthcare-associated infections programs.

Food, Drug, and Device Safety

MedWatch: The FDA Safety Information and Adverse Event Reporting Program—(FDA)
MedWatch is your FDA gateway for clinically important safety information and reporting serious problems with human medical products. Reports of FDA and USDA Food Recalls, Alerts, Reporting, and Resources—(HHS/USDA/FDA/CDC/NIH) lists notices of recalls and alerts from both FDA and the U.S. Department of Agriculture. Visitors to the site can report a problem or make inquiries. 

CDC Current Outbreak List

Stay up to date on the infectious disease outbreaks that CDC is currently reporting. CDC's Current Outbreak List provides a complete list of U.S. outbreaks, travel notices affecting international travelers, food safety recalls, and further sources for content about specific outbreaks.

You can also sign up to receive email updates about U.S.-based outbreaks and travel notices affecting international travelers on this page.