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Critical Care Medicine

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Invasive Group A Strep

New York City Health Advisory | April 7, 2023

In December 2022, the Centers for Disease Control and Prevention (CDC) issued a Health Alert Network (HAN) Health Advisory to notify clinicians and public health authorities of an increase in pediatric invasive group A streptococcal infections in several states. At that time, an increase in invasive group A streptococcal infections was not observed in New York State (NYS).

However, recent surveillance data in NYS, and in New York City (NYC), demonstrate an increase in invasive group A streptococcal infections during 2023 compared to pre-pandemic years, primarily among persons aged 65 and older, though small increases are being seen in children.

Invasive Group A Streptoccocal Infections in 2023

Statewide, including NYC, there have been over 450 cases of invasive group A streptococcal infections reported during the first three months of 2023. This is almost twice as many as the average for these same three months in the previous five years.

Providers in NYS and NYC have reported severe outcomes of invasive group A streptococcal infections, including:

  • necrotizing fasciitis
  • streptococcal toxic shock syndrome
  • death

Clinical Symptoms of Invasive Group A Strep Infections

Clinical syndromes for recently reported pediatric invasive group A streptococcal cases and non-invasive group A streptococcal cases include:

  • acute hypoxic respiratory failure secondary to pneumonia
  • empyema
  • osteomyelitis
  • septic arthritis

Health care providers are asked to raise their index of suspicion for invasive group A streptococcal infections and obtain relevant cultures when clinically indicated.


TB incidence increased during 2022, compared with that during 2020 and 2021, but remained lower than incidence during the prepandemic years; after a substantial 20.2% decline in 2020 and partial rebound (9.8% increase) in 2021, incidence appears to be returning to prepandemic levels among U.S.-born and non–U.S.-born populations.

During 2022, 8,300 TB cases were reported in the United States, compared with 7,874 during 2021. TB incidence during 2022 increased slightly to 2.5 per 100,000 persons, compared with 2.4 during 2021. Consistent with previous years (1), in 2022, California reported the highest number of TB cases (1,843) and Alaska reported the highest TB incidence (13.1)

COVID-19–associated mortality was high among persons aged ≥65 years, which might account, in part, for the lower TB incidence observed among that population. Even though the decrease in TB incidence was small, reduction of the population aged ≥65 years at risk for TB might have similar effects on TB incidence in future years.

The increase in TB incidence among children aged ≤4 years might represent both recent transmission in the United States and infection in countries with higher TB incidence. An analysis of TB incidence among indigenous persons during 2009–2019 found a higher prevalence of underlying chronic medical conditions, and TB incidence was at least 10 times higher among AI/AN and NH/OPI persons than among White persons. These factors likely contributed to the higher TB incidence in these populations in this report. Among non–U.S.-born persons with TB, the higher proportion reported <1 year after arrival in the United States might reflect greater migration from higher TB incidence areas than what existed at the beginning of the pandemic.

Although preventing TB transmission in the United States remains a priority, >80% of U.S. TB cases are attributed to reactivation of LTBI. To achieve TB elimination in the United States, the U.S. Preventive Services Task Force recommends testing and treatment among populations at higher risk for LTBI, including non–U.S.-born persons and persons in congregate living settings.

Live Tissue Associated TB Outbreak

On July 7, 2023, a state health department notified CDC that an otherwise healthy adult experienced symptoms of meningitis 5 weeks after spinal fusion surgery that incorporated a bone allograft product containing live cells; Mycobacterium tuberculosis was identified in the cerebrospinal fluid.

On July 11, a different state health department notified CDC of a patient with a persistent surgical site infection after a laminectomy that appeared to have used a similar product; drainage from the surgical site tested positive for acid-fast bacilli, and a nucleic acid amplification test confirmed the presence of M. tuberculosis. When reporting these cases to their respective public health authorities, the clinicians caring for these two patients independently noted similarities to the 2021 outbreak and asked that CDC investigate.

After receiving the first case report, CDC notified the Food and Drug Administration (FDA) and requested that the tissue establishment* quarantine (i.e., store and prohibit use of) any remaining tissue from this donor (i.e., same product lot). On July 11, the tissue establishment quarantined the 53 units that had not yet been distributed and provided a list of all health care facilities that had purchased tissue units from that lot. Eight hospitals and five dental offices in seven states (California, Louisiana, Michigan, New York, Oregon, Texas, and Virginia) received a total of 50 bone allograft units from this product lot during February 27–June 20, 2023.

This second nationwide TB outbreak in 2023 was detected when clinicians in two states recognized similarities to the 2021 outbreak and reported their concerns to their respective health departments, thereby initiating a rapid public health response that prevented as many as 53 additional surgical procedures with the implicated bone allograft material. Before the 2021 TB outbreak, which involved 113 recipients in 18 states, bone allograft–related M. tuberculosis transmission had last been reported in the United Kingdom in 1953.


New York State Department of Health: Health Advisory

DATE: January 31, 2024

TO: Hospitals, Local Health Departments, Laboratories, Emergency Rooms, Family Medicine, Pediatrics, Adolescent Medicine, Internal Medicine, Infectious Disease, Infection Control Practitioners, and Primary Care Providers

FROM: New York State Department of Health Division of Vaccine Excellence



The New York State Department of Health is forwarding a communication issued by the Centers for Disease Control and Prevention to share information about the following:

  • Outbreaks have occurred globally, and there have been recently reported cases in New York City and neighboring states (Pennsylvania and New Jersey).
  • Despite the United States having declared measles “eliminated” in 2000, outbreaks have continued to occur, including one involving hundreds of cases in New York State as recently as 2019.
  • Providers should be on alert for patients who have
  • Measles is one of the most contagious infections and individuals are contagious from four days before to four days after rash onset.
  • Report patients with suspected measles immediately to the local health department of the patient’s residence.
    • If in New York City, report persons with suspected measles immediately to the New York City Department of Health and Mental Hygiene at 866-692- 3641.
    • Do not wait for laboratory confirmation to report.
    • If you have urgent questions regarding measles during evenings, weekends, or holidays, call 866-881-2809.
  • Educate patients about measles-containing vaccines. This is especially important before international travel.
Clinical Signs and Symptoms

Measles typically presents in adults and children as an acute viral illness characterized by fever and generalized maculopapular rash. Signs and symptoms appear 7 to 21 days after initial exposure.

The prodrome may include cough, coryza, and conjunctivitis. The rash usually starts on the face, proceeds down the body, and may include the palms and soles. The rash initially appears discrete but may become confluent and lasts several days. 

Symptoms may be mild, absent, or atypical in persons who have some degree of immunity to measles virus before infection (e.g., in previously vaccinated persons).

Serious side effects of measles can include pneumonia, encephalitis, hospitalization, and death.

Transmission and Infection Control
  • To promptly identify suspected cases of measles and prevent exposures, consider screening patients for rash with fever at the point of entry of a healthcare facility and inquire about recent international or domestic travel and possible exposure to measles.
  • Immediately institute standard and airborne precautions for patients with known or suspected measles and call ahead for patients being referred to other healthcare facilities to prevent healthcare-associated exposures.
  • Place the patient in a single-patient airborne infection isolation room.
    • If a single-patient airborne infection isolation room is unavailable, place the patient in a private exam room with the door closed and have them wear a mask. After the patient leaves, it should remain vacant for at least two hours.

Suspected measles cases must be reported immediately to the local health department of the patient’s residence. The local health department in New York State (outside of New York City) can assist in arranging testing at the Wadsworth Center Laboratory, and for specimens to arrive at the lab within 24-hours of collection, when feasible.

Specimen Collection

Follow Wadsworth Center Laboratory’s tip sheet and collect either a nasopharyngeal swab or throat swab for reverse transcription polymerase chain reaction (RT-PCR), as well as a blood specimen for serology, from patients with suspected measles for testing at the lab. Follow the packaging and shipping instructions on the tip sheet. However, if sending serology only, address to: Diagnostic Immunology Laboratory at David Axelrod Institute Wadsworth, 120 New Scotland Ave, Albany, NY 12208.


Public Health Action

Those who are infected should be isolated for four days after they develop a rash; standard and airborne precautions should be followed in healthcare settings. People who are suspected to be exposed to measles who cannot readily show that they have evidence of immunity against measles should be offered post-exposure prophylaxis (PEP).

To potentially provide protection or modify the clinical course of disease among susceptible persons, either administer MMR vaccine within 72 hours of initial measles exposure, or immunoglobulin (IG) within six days of exposure. Do not administer MMR vaccine and IG simultaneously, as this practice invalidates the vaccine.

CODA NOW: CDC Clinician Outreach and Communication Activity
January 24, 2024
Stay Alert for Measles Cases

Between December 1, 2023 and January 23, 2024, the Centers for Disease Control and Prevention (CDC) was notified of 23 confirmed U.S. cases of measles, including seven direct importations of measles by international travelers and two outbreaks with more than five cases each. Most of these cases were among children and adolescents who had not received a measles-containing vaccine (MMR or MMRV), even if age eligible. 

Due to the recent cases, healthcare providers should be on alert for patients who have: (1) febrile rash illness and symptoms consistent with measles (e.g., cough, coryza, or conjunctivitis), and (2) have recently traveled abroad, especially to countries with ongoing measles outbreaks. Infected people are contagious from 4 days before the rash starts through 4 days afterwards. 

Measles cases often originate from unvaccinated or undervaccinated U.S. residents who travel internationally and then transmit the disease to people who are not vaccinated against measles. The increased number of measles importations seen in recent weeks is reflective of a rise in global measles cases and a growing global threat from the disease. 

Recommendations for Healthcare Providers 
  1. Isolate: Do not allow patients with suspected measles to remain in the waiting room or other common areas of the healthcare facility; isolate patients with suspected measles immediately, ideally in a single-patient airborne infection isolation room (AIIR) if available, or in a private room with a closed door until an AIIR is available. Healthcare providers should be adequately protected against measles and should adhere to standard and airborne precautions when evaluating suspect cases regardless of their vaccination status. 
  2. Notify: Immediately notify local or state health departments about any suspected case of measles to ensure rapid testing and investigation. Measles cases are reported by states to CDC through the National Notifiable Diseases Surveillance System (NNDSS) and can also be reported directly to CDC
  3. Test: Follow CDC’s testing recommendations and collect either a nasopharyngeal swab or throat swab for reverse transcription polymerase chain reaction (RT-PCR), as well as a blood specimen for serology from all patients with clinical features compatible with measles. RT-PCR is available at CDC, at many state public health laboratories, and through the APHL/CDC Vaccine Preventable Disease Reference Centers.
  4. Manage: In coordination with local or state health departments, provide appropriate measles post-exposure prophylaxis (PEP) to close contacts without evidence of immunity, either MMR or immunoglobulin. The choice of PEP is based on elapsed time from exposure or medical contraindications to vaccination.  
  5. Vaccinate: Make sure all your patients are up-to-date on measles vaccine, especially before international travel. People 6 months of age or older who will be traveling internationally should be protected against measles. 

For More Information: 

The Office of Emergency Risk Communication in the Office of Communications is responsible for the management of all COCA Products. 


MPOX in New York City

Since January 1, 2024, 62 people in New York City have tested positive for mpox. There have been 49 cases in the last month (January 14, 2024 to February 10, 2024).

Data are as of February 15 at 1 p.m. These data will be updated on the second Thursday of every month.