Increased awareness could lead to appropriate diagnosis, prompt treatment, and better patient outcomes.

Compounding of nonsterile amino acid components of PN was initiated due to a manufacturer shortage. Failure to follow recommended compounding standards contributed to an outbreak of S. marcescens BSIs. Improved adherence to sterile compounding standards, critical examination of standards for sterile compounding from nonsterile ingredients, and more rigorous oversight of compounding pharmacies is needed to prevent future outbreaks.

Objective: To review the available evidence that examines the association between climatic and agricultural land use factors and the risks of enteric zoonoses in humans and consider information needs and possible pathways of intervention. Methods:The electronic databases PubMed, Web of Science and Embase and government websites were searched systematically for published literature that investigated the association of climatic and/or agricultural exposures with the incidence of the four most common enteric zoonotic diseases in New Zealand (campylobacteriosis, salmonellosis, cryptosporidiosis and giardiasis). ResultsThe 16 studies in the review demonstrated significant associations between climate, agricultural land use and enteric disease occurrence. The evidence suggests that enteric disease risk from environmental reservoirs is pathogen specific. In some rural regions, environmental pathogen load is considerable, with multiple opportunities for zoonotic transmission.Conclusions: Enteric disease occurrence in NZ is associated with climate variability and agricultural land use. However, these relationships interact with demographic factors to influence disease patterns.Implications: Improved understanding of how environmental and social factors interact can inform effective public health interventions under scenarios of projected environmental change.

Long-term odorous mercaptan exposures were reportedly associated with physical and psychological health complaints. Communication messages should include strategies to minimize exposures and advise those with cardiorespiratory conditions to have medications readily available. Health care practitioners should be provided information on mercaptan health effects and approaches to prevent exacerbating existing chronic diseases.

We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5·8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4·5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.

S treptococcus pneumoniae (pneumococcus) causes a spectrum of disease ranging from mild respiratory infections to severe disease, including meningitis, sepsis, and pneumonia (1). Invasive pneumococcal disease (IPD) occurs when pneumococcus invades normally sterile sites. Pneumococcus is transmitted person-to-person primarily through respiratory droplets and is a leading cause of vaccine-preventable illness and death (2). Pneumococcal colonization is a precursor to disease but does not always result in disease (3). Pneumococcal conjugate vaccine (PCV) is highly effective in preventing pneumonia in adults (4), and pneumococcal disease incidence has declined since the introduction of PCV (5). IPD outbreaks are rare but can occur in settings with close personto-person contact, such as homeless shelters ( 6) and healthcare facilities, in which underlying conditions can increase disease risk (7).On September 19, 2018, the Alabama Department of Public Health (Montgomery, AL) was notifi ed of an IPD case after identifi cation of S. pneumoniae in a blood culture from an ill patient incarcerated at a state prison. On September 24, a second case of IPD was reported in another inmate who received a diagnosis of meningitis and sepsis and died that morning. We investigated this outbreak to determine its extent, identify cases among staff and inmates, and recommend prophylactic measures to reduce spread. The StudyAt the time of the outbreak, facility A, a medium-security state prison, housed 1,276 male inmates across 6 dormitories (original capacity 650 inmates; 2018 reported capacity of 1,650 inmates) (8,9). Each dormitory contained multiple large rooms with 4-6 rows of beds for 190-255 inmates. Group activities allowed mixing of inmates from different dorms until the outbreak was recognized; activities were suspended around September 26. A clinic within facility A with a 52-member staff, including 2 nurse practitioners and a physician, provided services to inmates through self or employee referral.A suspected case was defi ned as respiratory or meningeal symptoms consistent with pneumococcal disease in an incarcerated person or a person in prolonged or close contact with anyone incarcerated at facility A during September 1-October 10, 2018 (Appendix, https://wwwnc.cdc.gov/EID/ article/27/7/20-3678-App1.pdf). Probable cases were defi ned as suspected cases with radiographicconfi rmed pneumonia, clinical sepsis, or cerebrospinal fl uid analysis suggestive of bacterial meningitis with unknown etiology. Confi rmed cases were

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To ensure timely appropriate care for low-birth-weight (LBW) infants, healthcare providers must communicate effectively with parents, even when language barriers exist. We sought to evaluate whether non-English primary language (NEPL) and professional in-person interpreter use were associated with differential hospital length of stay for LBW infants, who may incur high healthcare costs. We analyzed data for 2047 infants born between 1 January 2008 and 30 April 2013 with weight <2500 g at one hospital with high NEPL prevalence. We evaluated relationships of NEPL and in-person interpreter use on length of stay, adjusting for medical severity. Overall, 396 (19%) had NEPL parents. Fifty-three percent of NEPL parents had documented interpreter use. Length of stay ranged from 1 to 195 days (median 11). Infants of NEPL parents with no interpreter use had a 49% shorter length of stay (adjusted incidence rate ratio (IRR) 0.51, 95% confidence interval (CI) 0.43–0.61) compared to English-speakers. Infants of parents with NEPL and low interpreter use (<25% of hospital days) had a 26% longer length of stay (adjusted IRR 1.26, 95% CI 1.06–1.51). NEPL and high interpreter use (>25% of hospital days) showed a trend for an even longer length of stay. Unmeasured clinical and social/cultural factors may contribute to differences in length of stay.