british travel clinic

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• Visas and immigration
• Visit the UK

Visit the UK as a Standard Visitor

Visit for medical reasons.

You can visit the UK for up to 6 months to:

• have private medical treatment at a hospital or other medical facility
• have treatment at an NHS hospital, as long as the care is paid for by your own government under a reciprocal healthcare arrangement
• donate an organ to a family member or close friend - this includes being assessed for suitability as a donor match

You should:

• check you meet the basic eligibility requirements for a Standard Visitor and any relevant extra eligibility requirements listed below
• prepare any required documents that prove your eligibility
• check if you need a visa to visit the UK
• apply for a Standard Visitor visa online - if you need one

If you’re visiting for private medical treatment

You must prove that you:

• have a medical condition that needs private consultation or treatment in the UK
• have made arrangements for consultations or treatment
• have enough money or funding to pay for your treatment
• will leave the UK once your treatment is completed, or when your visa expires
• are not a danger to public health if you have an infectious disease, such as leprosy

Documents you must provide

You’ll need a letter written by a doctor or consultant , that confirms:

• the condition you have that needs consultation or treatment
• the estimated cost and likely duration of any treatment
• where the consultation and treatment will take place

If you’re visiting for treatment at an NHS hospital

You can visit the UK for treatment at an NHS hospital. Your treatment must be paid for by your own government under a reciprocal healthcare arrangement.

You must provide an authorisation form, issued by the government of your country, saying they will pay for your treatment.

If you’re visiting as an organ donor

You can only visit the UK to donate organs to:

• a family member who you’re genetically related to (for example your sibling or parent)
• someone you have a close personal relationship with (for example your partner or friend)

You must prove that the person you’re donating an organ to is legally allowed to be in the UK.

You’ll need a letter from the lead nurse of the transplant team, a General Medical Council registered specialist or a registered NHS consultant that confirms:

• you’re a donor match to the recipient, or you’re being tested to see if you’re a potential donor
• the recipient is genetically related to you, or in a close personal relationship with you
• when and where the transplant or tests will take place

The letter should be dated no more than 3 months before you intend to arrive in the UK.

If the recipient is not legally resident in the UK, you must provide their name, nationality and date of birth in your application.

The recipient should check if they need to apply for a Standard Visitor visa and that they meet the eligibility requirements for medical treatment.

If your treatment will last longer than 6 months

All visits for medical treatment lasting longer than 6 months require a Standard Visitor visa regardless of your nationality.

• apply for a Standard Visitor visa before you come to the UK - this lasts for up to 11 months and costs £200
• visit for up to 6 months and apply to stay for a further 6 months when you’re in the UK for a fee of £1,000

There is no limit on how many times you can extend your stay. It costs £1,000 each time you do.

Depending on where you come from, you may also need a certificate that proves you do not have tuberculosis ( TB ). Check if you’ll need to take a TB test .

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The Southwest's Travel Health Specialist

A local travel medicine specialist with appointments to suit you in exeter. our belief in healthy travel means consultations are free and our prices are low., qualified in travel medicine, experienced in travel - our advice is second to none..

Great personal service, prompt call back if you need advice, zero push for you to buy anything you don't need!! Just great, polite, fast service in a nice place!

I could not speak more highly of the services provided. I feel so welcome because the staff are so friendly and helpful. All the information I was given was very clear and I felt very reassured...

I highly recommend them over any other travel clinic I have ever been to. The clinic is clean, the staff are friendly, fast and efficient and James will go above and beyond to make sure all your...

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Preparing for your appointment at the travel clinic.

Your travel consultation will typically last one hour or longer depending on the complexity of your itinerary and wait times after the administration of your immunizations.

Please bring the following documents:

• Detailed travel itinerary for your upcoming trip. This should include all areas of travel including layovers/stop-overs.
• Immunization records.
• Completed health history form.
• Method of payment. (Payment is expected at the time of service. We accept cash, check and all major credit cards.)

You can expect that our clinical staff will also prepare for your appointment. We work to develop your personalized travel plan, prepare recommendations, and research current vaccination needs.

Cancellations:  Our team spends time researching your specific travel needs before your appointment. If you need to cancel your appointment, please contact us at least 24 hours in advance. 

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Travel Clinics of America is your best choice for receiving high-quality pre-travel care, sound travel advice, and peace of mind.

About Travel Clinics of America:

Travel Clinics of America members are trained physicians in nationwide locations with locations being added across the country rapidly. There may be a TCA physician in your neighborhood now, or in the near future. Our physicians have expert training in travel medicine and travel vaccinations. TCA doctors provide immunizations and travel safety advice for international travel, study abroad/semester at sea, immigration, foreign adoption, military readiness, disaster relief, and bioterrorism response.

Travel with confidence knowing that every precaution to protect your health has been taken.

Travel Clinics of America Offers

• Pre-Travel Vaccinations and Immunizations • Medications and Prescriptions • Disease Prevention and Education • Travel Medical Insurance

• Eastern Europe
• Western Europe
• Mexico / Caribbean

Travel Clinics of America is no longer in business and no longer taking any more clients. Please feel free to use any information as a valuable resource.

Travel clinic

If possible, you should be seen by our GP practice or a private travel clinic at least 6 to 8 weeks before you’re due to travel. Some vaccines need to be given well in advance to allow your body to develop immunity. Travel vaccinations – NHS

We include below

• Details about our practice travel clinic
• A link to information on commonly asked question on travel and holiday health

NHS choices covers what vaccines are available free on the NHS, and what you will need to pay for Overview travel vaccinations Travel vaccinations – NHS

Practice travel clinic

We offer a range of travel vaccinations.

Book appointment with the practice nurse at least 6 weeks before travel If you require any vaccinations relating to foreign travel, please complete a travel health questionnaire (this can be downloaded, completed online or collected from reception). Complete it, submit it to the surgery and call the surgery after 7 days to find out what you need and make an appointment with the practice nurse at least 6 weeks before your travel date. These vaccines have to be ordered in as they are not stock items. Some vaccinations incur a charge as they are not included in the services provided by the NHS.

Please complete the travel questionnaire form below before coming to see the nurse.

To help us offer the appropriate advice, please complete the following form before coming to see a nurse.

Download and complete the form:

• Travel-Risk-Assessment-Form You can bring the completed form to the surgery, or post or email it to us using our details found under Contact Us .

OR Complete and submit the online form:

• Travel Risk Assessment Form

Our practice policy for prescribing for patients who are going to be travelling abroad follows national guidelines and is as follows:

Up to 3 months If you are travelling abroad for up to three months and intending to return

• An NHS prescription for regular medication will be given to cover up to a maximum of 3 month period providing your GP is happy that any monitoring required is up to date and satisfactory
• You will remain registered with the practice

Over 3 months If you are travelling abroad for more than three months and/or not intending to return

• An NHS prescription up to 3 month’s supply of regular medication may be provided at your GP’s discretion. The easiest way to obtain a summary of your patient record is through taking advantage of online access to your medical record. There is information on how to obtain access under online access to your Records .
• You will be removed from the practice list if you are away for more than 3 months.

Requests for other medication to be taken abroad No other medication other than that which is taken on a regular basis will be prescribed on the NHS. Private prescriptions may be issued at your GP’s discretion for items such as ‘just in case’ treatments.

If you are already abroad If you are already abroad, no NHS prescriptions can be issued. NHS prescriptions or medication cannot be sent abroad.

National and local guidance on NHS prescriptions and travelling abroad Our practice policy is based on national and local guidance which is considered in more detail under the frequently asked questions in Holiday and Travel Health there are detailed answers covering this topic. This also includes information on over the counter medication which your pharmacist can supply you for your holiday (including a first aid kit).

Please be aware that the practice is not a Yellow Fever Vaccination Centre (YFVC), vaccines can be arranged privately via external clinics. You can search for local yellow fever vaccination centres using:

From the National Travel Health Network and Centre (NaTHNaC). Search for Yellow Fever Vaccination Centres, see “Find a YFVC”  YELLOW FEVER ZONE

Importantly when you use the NaTHNaC search engine start with just the first 2 letters of your postcode (e.g., if your postcode is AB1 2CD, then search with just AB) to ensure you are given all the possible options.  Some of the options in this search may be clearly outside your area, but if you look for your local telephone code in the right-hand column of the results you will be able to quickly pick out a local YFVC. If the search generates no local YFVC then use nearby postcodes with different 1st 2 letters.

Understand travel and holiday health

Under Holiday and Travel Health there are detailed answers to common questions which cover the areas of:

• Vaccines and medication for specific countries
• General health and safety (including with pregnancy)
• Flying (including with pregnancy)
• Prescriptions and medication (both relating to your pharmacist and the GP practice)
• Treatment abroad

Need some self-help information?

Visit Bucks Health Hub for comprehensive health information, support and contacts

Iver Medical Centre High Street Iver Buckinghamshire SL0 9NU

01753 653008

Contact Information

Monday – Friday: 8am – 6pm Wednesday: 8am – 8pm Weekends: Closed Public Holidays: Closed

01628 666326

Minecraft Road Burnham SL1 7DE

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Student Health Center

• Immunizations

Stay healthy when you travel

Planning a trip abroad? Make time for an appointment at the Student Health Center, where we offer a full range of vaccines and other preventive medications at affordable prices.

Our travel clinic is open to IU Bloomington students, faculty, and staff, as well as the general public. Many of our vaccines are not available anywhere else in Bloomington.

You must make an appointment to be seen at the travel clinic. We recommend that you come in four to six weeks before your departure date.

• Learn how to make an appointment
• See what vaccines we offer

Why come to the Student Health Center travel clinic?

We subscribe to TRAVAX, a national travel health service, which provides weekly updates on vaccine requirements, health recommendations, and regional travel warnings. We can keep you up to date with the latest information on health, political, safety, and weather conditions in the countries where you are traveling.

Our travel clinic is staffed by registered nurses who are trained in the special concerns and problems associated with international travel, and physicians are available for additional consultation.

We also have plenty of resources to help you prepare for your trip. Learn about topics like: high-altitude travel, insect precautions, Montezuma's revenge, and malaria prevention.

What to expect at your appointment

The nurse will enter your country destination into the computer and will print out the information about your countries. You and the nurse will discuss your trip, and together you will decide which vaccinations are appropriate for your destination.

A schedule of return visits will be set, if necessary, to complete the vaccination series. Most travelers will receive some or all of their shots at the first visit.

The nurse will also answer questions you have about health and safety on your trip. You will receive records of the vaccination received at the time of your visit. This may be necessary for you to carry with you on the trip or for you to get a visa.

What to bring with you

• Information on current illnesses and health problems that require regular care
• A list of medications you are currently taking or will be taking during your travels including over-the-counter medication and birth control
• Any information on your previous immunizations
• Your itinerary

Learn more about international travel

• Get information from the CDC
• Learn more about vaccines
• Read about travel health

Health Center resources and social media channels

Articles from Emerging Infectious Diseases

Volume 30, Number 5—May 2024

[PDF - 14.66 MB - 228 pages]

Research Letters

About the cover.

Crimean-Congo hemorrhagic fever (CCHF), caused by CCHF virus, is a tickborne disease that can cause a range of illness outcomes, from asymptomatic infection to fatal viral hemorrhagic fever; the disease has been described in >30 countries. We conducted a literature review to provide an overview of the virology, pathogenesis, and pathology of CCHF for clinicians. The virus life cycle and molecular interactions are complex and not fully described. Although pathogenesis and immunobiology are not yet fully understood, it is clear that multiple processes contribute to viral entry, replication, and pathological damage. Limited autopsy reports describe multiorgan involvement with extravasation and hemorrhages. Advanced understanding of CCHF virus pathogenesis and immunology will improve patient care and accelerate the development of medical countermeasures for CCHF.

Crimean-Congo hemorrhagic fever (CCHF) is a tickborne infection that can range from asymptomatic to fatal and has been described in >30 countries. Early identification and isolation of patients with suspected or confirmed CCHF and the use of appropriate prevention and control measures are essential for preventing human-to-human transmission. Here, we provide an overview of the epidemiology, clinical features, and prevention and control of CCHF. CCHF poses a continued public health threat given its wide geographic distribution, potential to spread to new regions, propensity for genetic variability, and potential for severe and fatal illness, in addition to the limited medical countermeasures for prophylaxis and treatment. A high index of suspicion, comprehensive travel and epidemiologic history, and clinical evaluation are essential for prompt diagnosis. Infection control measures can be effective in reducing the risk for transmission but require correct and consistent application.

Crimean-Congo hemorrhagic fever virus (CCHFV) is the most geographically widespread tickborne viral infection worldwide and has a fatality rate of up to 62%. Despite its widespread range and high fatality rate, no vaccines or treatments are currently approved by regulatory agencies in the United States or Europe. Supportive treatment remains the standard of care, but the use of antiviral medications developed for other viral infections have been considered. We reviewed published literature to summarize the main aspects of CCHFV infection in humans. We provide an overview of diagnostic testing and management and medical countermeasures, including investigational vaccines and limited therapeutics. CCHFV continues to pose a public health threat because of its wide geographic distribution, potential to spread to new regions, propensity for genetic variability, potential for severe and fatal illness, and limited medical countermeasures for prophylaxis and treatment. Clinicians should become familiar with available diagnostic and management tools for CCHFV infections in humans.

Jamestown Canyon virus (JCV) is a mosquitoborne orthobunyavirus in the California serogroup that circulates throughout Canada and the United States. Most JCV exposures result in asymptomatic infection or a mild febrile illness, but JCV can also cause neurologic diseases, such as meningitis and encephalitis. We describe a case series of confirmed JCV-mediated neuroinvasive disease among persons from the provinces of British Columbia, Alberta, Quebec, and Nova Scotia, Canada, during 2011–2016. We highlight the case definitions, epidemiology, unique features and clinical manifestations, disease seasonality, and outcomes for those cases. Two of the patients (from Quebec and Nova Scotia) might have acquired JCV infections during travel to the northeastern region of the United States. This case series collectively demonstrates JCV’s wide distribution and indicates the need for increased awareness of JCV as the underlying cause of meningitis/meningoencephalitis during mosquito season.

We analyzed hospital discharge records of patients with coccidioidomycosis-related codes from the International Classification of Diseases, 10th revision, Clinical Modification, to estimate the prevalence of hospital visits associated with the disease in Texas, USA. Using Texas Health Care Information Collection data for 2016–2021, we investigated the demographic characteristics and geographic distribution of the affected population, assessed prevalence of hospital visits for coccidioidomycosis, and examined how prevalence varied by demographic and geographic factors. In Texas, 709 coccidioidomycosis-related inpatient and outpatient hospital visits occurred in 2021; prevalence was 3.17 cases per 100,000 total hospital visits in 2020. Geographic location, patient sex, and race/ethnicity were associated with increases in coccidioidomycosis-related hospital visits; male, non-Hispanic Black, and Hispanic patients had the highest prevalence of coccidioidomycosis compared with other groups. Increased surveillance and healthcare provider education and outreach are needed to ensure timely and accurate diagnosis and treatment of coccidioidomycosis in Texas and elsewhere.

High incidences of congenital syphilis have been reported in areas along the Pacific coast of Colombia. In this retrospective study, conducted during 2018–2022 at a public hospital in Buenaventura, Colombia, we analyzed data from 3,378 pregnant women. The opportunity to prevent congenital syphilis was missed in 53.1% of mothers because of the lack of syphilis screening. Characteristics of higher maternal social vulnerability and late access to prenatal care decreased the probability of having > 1 syphilis screening test, thereby increasing the probability of having newborns with congenital syphilis. In addition, the opportunity to prevent congenital syphilis was missed in 41.5% of patients with syphilis because of the lack of treatment, which also increased the probability of having newborns with congenital syphilis. We demonstrate the urgent need to improve screening and treatment capabilities for maternal syphilis, particularly among pregnant women who are more socially vulnerable.

Understanding SARS-CoV-2 infection in populations at increased risk for poor health is critical to reducing disease. We describe the epidemiology of SARS-CoV-2 infection in Kakuma Refugee Camp Complex, Kenya. We performed descriptive analyses of SARS-CoV-2 infection in the camp and surrounding community during March 16, 2020‒December 31, 2021. We identified cases in accordance with national guidelines.We estimated fatality ratios and attack rates over time using locally weighted scatterplot smoothing for refugees, host community members, and national population. Of the 18,864 SARS-CoV-2 tests performed, 1,024 were positive, collected from 664 refugees and 360 host community members. Attack rates were 325.0/100,000 population (CFR 2.9%) for refugees,150.2/100,000 population (CFR 1.11%) for community, and 628.8/100,000 population (CFR 1.83%) nationwide. During 2020–2021, refugees experienced a lower attack rate but higher CFR than the national population, underscoring the need to prioritize SARS-CoV-2 mitigation measures, including vaccination.

Considering patient room shortages and prevalence of other communicable diseases, reassessing the isolation of patients with Clostridioides difficile infection (CDI) is imperative. We conducted a retrospective study to investigate the secondary CDI transmission rate in a hospital in South Korea, where patients with CDI were not isolated. Using data from a real-time locating system and electronic medical records, we investigated patients who had both direct and indirect contact with CDI index patients. The primary outcome was secondary CDI transmission, identified by whole-genome sequencing. Among 909 direct and 2,711 indirect contact cases, 2 instances of secondary transmission were observed (2 [0.05%] of 3,620 cases), 1 transmission via direct contact and 1 via environmental sources. A low level of direct contact (113 minutes) was required for secondary CDI transmission. Our findings support the adoption of exhaustive standard preventive measures, including environmental decontamination, rather than contact isolation of CDI patients in nonoutbreak settings.

During the 2022 multicountry mpox outbreak, the United Kingdom identified cases beginning in May. UK cases increased in June, peaked in July, then rapidly declined after September 2022. Public health responses included community-supported messaging and targeted mpox vaccination among eligible gay, bisexual, and other men who have sex with men (GBMSM). Using data from an online survey of GBMSM during November–December 2022, we examined self-reported mpox diagnoses, behavioral risk modification, and mpox vaccination offer and uptake. Among 1,333 participants, only 35 (2.6%) ever tested mpox-positive, but 707 (53%) reported behavior modification to avoid mpox. Among vaccine-eligible GBMSM, uptake was 69% (95% CI 65%–72%; 601/875) and was 92% (95% CI 89%–94%; 601/655) among those offered vaccine. GBMSM self-identifying as bisexual, reporting lower educational qualifications, or identifying as unemployed were less likely to be vaccinated. Equitable offer and provision of mpox vaccine are needed to minimize the risk for future outbreaks and mpox-related health inequalities.

We investigated clinically suspected measles cases that had discrepant real-time reverse transcription PCR (rRT-PCR) and measles-specific IgM test results to determine diagnoses. We performed rRT-PCR and measles-specific IgM testing on samples from 541 suspected measles cases. Of the 24 IgM-positive and rRT-PCR­–negative cases, 20 were among children who received a measles-containing vaccine within the previous 6 months; most had low IgG relative avidity indexes (RAIs). The other 4 cases were among adults who had an unknown previous measles history, unknown vaccination status, and high RAIs. We detected viral nucleic acid for viruses other than measles in 15 (62.5%) of the 24 cases with discrepant rRT-PCR and IgM test results. Measles vaccination, measles history, and contact history should be considered in suspected measles cases with discrepant rRT-PCR and IgM test results. If in doubt, measles IgG avidity and PCR testing for other febrile exanthematous viruses can help confirm or refute the diagnosis.

To determine the kinetics of hepatitis E virus (HEV) in asymptomatic persons and to evaluate viral load doubling time and half-life, we retrospectively tested samples retained from 32 HEV RNA-positive asymptomatic blood donors in Germany. Close-meshed monitoring of viral load and seroconversion in intervals of ≈4 days provided more information about the kinetics of asymptomatic HEV infections. We determined that a typical median infection began with PCR-detectable viremia at 36 days and a maximum viral load of 2.0 × 10 4 IU/mL. Viremia doubled in 2.4 days and had a half-life of 1.6 days. HEV IgM started to rise on about day 33 and peaked on day 36; IgG started to rise on about day 32 and peaked on day 53 . Although HEV IgG titers remained stable, IgM titers became undetectable in 40% of donors. Knowledge of the dynamics of HEV viremia is useful for assessing the risk for transfusion-transmitted hepatitis E.

We evaluated Q fever prevalence in blood donors and assessed the epidemiologic features of the disease in Israel in 2021. We tested serum samples for Coxeilla burnetii phase I and II IgG using immunofluorescent assay, defining a result of > 200 as seropositive. We compared geographic and demographic data. We included 1,473 participants; 188 (12.7%) were seropositive. The calculated sex- and age-adjusted national seroprevalence was 13.9% (95% CI 12.2%–15.7%). Male sex and age were independently associated with seropositivity (odds ratio [OR] 1.6, 95% CI 1.1–2.2; p = 0.005 for male sex; OR 1.2, 95% CI 1.01–1.03; p<0.001 for age). Residence in the coastal plain was independently associated with seropositivity for Q fever (OR 1.6, 95% CI 1.2–2.3; p<0.001); residence in rural and farming regions was not. Q fever is highly prevalent in Israel. The unexpected spatial distribution in the nonrural coastal plain suggests an unrecognized mode of transmission.

During December 11, 2020–March 29, 2022, the US government delivered ≈700 million doses of COVID-19 vaccine to vaccination sites, resulting in vaccination of ≈75% of US adults during that period. We evaluated accessibility of vaccination sites. Sites were accessible by walking within 15 minutes by 46.6% of persons, 30 minutes by 74.8%, 45 minutes by 82.8%, and 60 minutes by 86.7%. When limited to populations in counties with high social vulnerability, accessibility by walking was 55.3%, 81.1%, 86.7%, and 89.4%, respectively. By driving, lowest accessibility was 96.5% at 15 minutes. For urban/rural categories, the 15-minute walking accessibility between noncore and large central metropolitan areas ranged from 27.2% to 65.1%; driving accessibility was 79.9% to 99.5%. By 30 minutes driving accessibility for all urban/rural categories was >95.9%. Walking time variations across jurisdictions and between urban/rural areas indicate that potential gains could have been made by improving walkability or making transportation more readily available.

We estimated COVID-19 transmission potential and case burden by variant type in Alberta, British Columbia, and Ontario, Canada, during January 23, 2020–January 27, 2022; we also estimated the effectiveness of public health interventions to reduce transmission. We estimated time-varying reproduction number (R t ) over 7-day sliding windows and nonoverlapping time-windows determined by timing of policy changes. We calculated incidence rate ratios (IRRs) for each variant and compared rates to determine differences in burden among provinces. R t corresponding with emergence of the Delta variant increased in all 3 provinces; British Columbia had the largest increase, 43.85% (95% credible interval [CrI] 40.71%–46.84%). Across the study period, IRR was highest for Omicron (8.74 [95% CrI 8.71–8.77]) and burden highest in Alberta (IRR 1.80 [95% CrI 1.79–1.81]). Initiating public health interventions was associated with lower R t and relaxing restrictions and emergence of new variants associated with increases in R t .

We conducted a large surveillance study among members of an integrated healthcare delivery system in Pacific Northwest of the United States to estimate medical costs attributable to medically attended acute gastroenteritis (MAAGE) on the day care was sought and during 30-day follow-up. We used multivariable regression to compare costs of MAAGE and non-MAAGE cases matched on age, gender, and index time. Differences accounted for confounders, including race, ethnicity, and history of chronic underlying conditions. Analyses included 73,140 MAAGE episodes from adults and 18,617 from children who were Kaiser Permanente Northwest members during 2014–2016. Total costs were higher for MAAGE cases relative to non-MAAGE comparators as were costs on the day care was sought and costs during follow-up. Costs of MAAGE are substantial relative to the cost of usual-care medical services, and much of the burden accrues during short-term follow-up.

We investigated links between antimicrobial resistance in community-onset bacteremia and 1-year bacteremia recurrence by using the clinical data warehouse of Europe’s largest university hospital group in France. We included adult patients hospitalized with an incident community-onset Staphylococcus aureus , Escherichia coli , or Klebsiella spp. bacteremia during 2017–2019. We assessed risk factors of 1-year recurrence using Fine–Gray regression models. Of the 3,617 patients included, 291 (8.0%) had > 1 recurrence episode. Third-generation cephalosporin (3GC)-resistance was significantly associated with increased recurrence risk after incident Klebsiella spp. (hazard ratio 3.91 [95% CI 2.32–6.59]) or E. coli (hazard ratio 2.35 [95% CI 1.50–3.68]) bacteremia. Methicillin resistance in S. aureus bacteremia had no effect on recurrence risk. Although several underlying conditions and infection sources increased recurrence risk, 3GC-resistant Klebsiella spp. was associated with the greatest increase. These results demonstrate a new facet to illness induced by 3GC-resistant Klebsiella spp. and E. coli in the community setting.

We conducted a cross-sectional study in wild boar and extensively managed Iberian pig populations in a hotspot area of Crimean-Congo hemorrhagic fever virus (CCHFV) in Spain. We tested for antibodies against CCHFV by using 2 ELISAs in parallel. We assessed the presence of CCHFV RNA by means of reverse transcription quantitative PCR protocol, which detects all genotypes. A total of 113 (21.8%) of 518 suids sampled showed antibodies against CCHFV by ELISA. By species, 106 (39.7%) of 267 wild boars and 7 (2.8%) of 251 Iberian pigs analyzed were seropositive. Of the 231 Iberian pigs and 231 wild boars analyzed, none tested positive for CCHFV RNA. These findings indicate high CCHFV exposure in wild boar populations in endemic areas and confirm the susceptibility of extensively reared pigs to CCHFV, even though they may only play a limited role in the enzootic cycle.

African swine fever virus (ASFV) genotype II is endemic to Vietnam. We detected recombinant ASFV genotypes I and II (rASFV I/II) strains in domestic pigs from 6 northern provinces in Vietnam. The introduction of rASFV I/II strains could complicate ongoing ASFV control measures in the region.

In a representative sample of female children and adolescents in Germany, Toxoplasma gondii seroprevalence was 6.3% (95% CI 4.7%–8.0%). With each year of life, the chance of being seropositive increased by 1.2, indicating a strong force of infection. Social status and municipality size were found to be associated with seropositivity.

We describe the detection of Paranannizziopsis sp. fungus in a wild population of vipers in Europe. Fungal infections were severe, and 1 animal likely died from infection. Surveillance efforts are needed to better understand the threat of this pathogen to snake conservation.

We evaluated the in vitro effects of lyophilization for 2 vesicular stomatitis virus–based vaccines by using 3 stabilizing formulations and demonstrated protective immunity of lyophilized/reconstituted vaccine in guinea pigs. Lyophilization increased stability of the vaccines, but specific vesicular stomatitis virus–based vaccines will each require extensive analysis to optimize stabilizing formulations.

We report a cluster of serogroup B invasive meningococcal disease identified via genomic surveillance in older adults in England and describe the public health responses. Genomic surveillance is critical for supporting public health investigations and detecting the growing threat of serogroup B Neisseria meningitidis infections in older adults.

We detected Mayaro virus (MAYV) in 3.4% (28/822) of febrile patients tested during 2018–2021 from Roraima State, Brazil. We also isolated MAYV strains and confirmed that these cases were caused by genotype D. Improved surveillance is needed to better determine the burden of MAYV in the Amazon Region.

Across 133 confirmed mpox zoonotic index cases reported during 1970–2021 in Africa, cases occurred year-round near the equator, where climate is consistent. However, in tropical regions of the northern hemisphere under a dry/wet season cycle, cases occurred seasonally. Our findings further support the seasonality of mpox zoonotic transmission risk.

We investigated molecular evolution and spatiotemporal dynamics of atypical Legionella pneumophila serogroup 1 sequence type 1905 and determined its long-term persistence and linkage to human disease in dispersed locations, far beyond the large 2014 outbreak epicenter in Portugal. Our finding highlights the need for public health interventions to prevent further disease spread.

Norovirus is a major cause of acute gastroenteritis; GII.4 is the predominant strain in humans. Recently, 2 new GII.4 variants, Hong Kong 2019 and San Francisco 2017, were reported. Characterization using GII.4 monoclonal antibodies and serum demonstrated different antigenic profiles for the new variants compared with historical variants.

Cruise ships carrying COVID-19–vaccinated populations applied near-identical nonpharmaceutical measures during July–November 2021; passenger masking was not applied on 2 ships. Infection risk for masked passengers was 14.58 times lower than for unmasked passengers and 19.61 times lower than in the community. Unmasked passengers’ risk was slightly lower than community risk.

During a 2023 outbreak of Mycoplasma pneumoniae –associated community-acquired pneumonia among children in northern Vietnam, we analyzed M. pneumoniae isolated from nasopharyngeal samples. In almost half (6 of 13) of samples tested, we found known A2063G mutations (macrolide resistance) and a novel C2353T variant on the 23S rRNA gene.

We report the detection of Crimean-Congo hemorrhagic fever virus (CCHFV) in Corsica, France. We identified CCHFV African genotype I in ticks collected from cattle at 2 different sites in southeastern and central-western Corsica, indicating an established CCHFV circulation. Healthcare professionals and at-risk groups should be alerted to CCHFV circulation in Corsica.

In Latin America, rabies virus has persisted in a cycle between Desmodus rotundus vampire bats and cattle, potentially enhanced by deforestation. We modeled bovine rabies virus outbreaks in Costa Rica relative to land-use indicators and found spatial-temporal relationships among rabies virus outbreaks with deforestation as a predictor.

With the use of metagenomic next-generation sequencing, patients diagnosed with Whipple pneumonia are being increasingly correctly diagnosed. We report a series of 3 cases in China that showed a novel pattern of movable infiltrates and upper lung micronodules. After treatment, the 3 patients recovered, and lung infiltrates resolved.

Dogs are known to be susceptible to influenza A viruses, although information on influenza D virus (IDV) is limited. We investigated the seroprevalence of IDV in 426 dogs in the Apulia region of Italy during 2016 and 2023. A total of 14 samples were positive for IDV antibodies, suggesting exposure to IDV in dogs.

We report the detection of OXA-181 carbapenemase in an azithromycin-resistant Shigella spp. bacteria in an immunocompromised patient. The emergence of OXA-181 in Shigella spp. bacteria raises concerns about the global dissemination of carbapenem resistance in Enterobacterales and its implications for the treatment of infections caused by Shigella bacteria.

Although a vaccine against SARS-CoV-2 Omicron-XBB.1.5 variant is available worldwide and recent infection is protective, the lack of recorded infection data highlights the need to assess variant-specific antibody neutralization levels. We analyzed IgG levels against receptor-binding domain–specific SARS-CoV-2 ancestral strain as a correlate for high neutralizing titers against XBB variants.

We describe a feline sporotrichosis cluster and zoonotic transmission between one of the affected cats and a technician at a veterinary clinic in Kansas, USA. Increased awareness of sporotrichosis and the potential for zoonotic transmission could help veterinary professionals manage feline cases and take precautions to prevent human acquisition.

We report a clinical isolate of Burkholderia thailandensis 2022DZh obtained from a patient with an infected wound in southwest China. Genomic analysis indicates that this isolate clusters with B. thailandensis BPM, a human isolate from Chongqing, China. We recommend enhancing monitoring and surveillance for B. thailandensis infection in both humans and livestock.

To determine changes in Bordetella pertussis and B. parapertussis detection rates, we analyzed 1.43 million respiratory multiplex PCR test results from US facilities from 2019 through mid-2023. From mid-2022 through mid-2023, Bordetella spp. detection increased 8.5-fold; 95% of detections were B. parapertussis. While B. parapertussis rates increased, B. pertussis rates decreased.

We report a case of Sphingobium yanoikuyae bacteremia in an 89-year-old patient in Japan. No standard antimicrobial regimen has been established for S. yanoikuyae infections. However, ceftriaxone and ceftazidime treatments were effective in this case. Increased antimicrobial susceptibility data are needed to establish appropriate treatments for S. yanoikuyae .

Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.

Volume 30, Number 6—June 2024

Perspective.

• Decolonization and Pathogen Reduction to Prevent Antimicrobial Resistance and Healthcare-Associated Infections M. R. Mangalea et al.

Scedosporium spp. and Lomentospora prolificans are emerging non- Aspergillus filamentous fungi. The Scedosporiosis/lomentosporiosis Observational Study we previously conducted reported frequent fungal vascular involvement, including aortitis and peripheral arteritis. For this article, we reviewed 7 cases of Scedosporium spp. and L. prolificans arteritis from the Scedosporiosis/lomentosporiosis Observational Study and 13 cases from published literature. Underlying immunosuppression was reported in 70% (14/20) of case-patients, mainly those who had solid organ transplants (10/14). Osteoarticular localization of infection was observed in 50% (10/20) of cases; infections were frequently (7/10) contiguous with vascular infection sites. Scedosporium spp./ Lomentospora prolificans infections were diagnosed in 9 of 20 patients ≈3 months after completing treatment for nonvascular scedosporiosis/lomentosporiosis. Aneurysms were found in 8/11 aortitis and 6/10 peripheral arteritis cases. Invasive fungal disease­–related deaths were high (12/18 [67%]). The vascular tropism of Scedosporium spp. and L. prolificans indicates vascular imaging, such as computed tomography angiography, is needed to manage infections, especially for osteoarticular locations.

• An Electronic Health Record–Based Algorithm for Respiratory Virus–like Illness N. M. Cocoros et al.
• Severe Human Parainfluenza Virus Community- and Healthcare-Acquired Pneumonia in Adults at Tertiary Hospital in Seoul, South Korea, 2010–2019 J. H. Park et al.
• SARS-CoV-2 Disease Severity in Children during Pre-Delta, Delta, and Omicron Periods, Colorado L. Bankers et al.
• Effectiveness of 23-Valent Pneumococcal Polysaccharide Vaccine Against Invasive Pneumococcal Disease in Follow-Up Study, Denmark K. Nielsen et al.

The World Health Organization’s end TB strategy promotes the use of symptom and chest radiograph screening for tuberculosis (TB) disease. However, asymptomatic early states of TB beyond latent TB infection and active disease can go unrecognized using current screening criteria. We conducted a longitudinal cohort study enrolling household contacts initially free of TB disease and followed them for the occurrence of incident TB over 1 year. Among 1,747 screened contacts, 27 (52%) of the 52 persons in whom TB subsequently developed during follow-up had a baseline abnormal radiograph. Of contacts without TB symptoms, persons with an abnormal radiograph were at higher risk for subsequent TB than persons with an unremarkable radiograph (adjusted hazard ratio 15.62 [95% CI 7.74–31.54]). In young adults, we found a strong linear relationship between radiograph severity and time to TB diagnosis. Our findings suggest chest radiograph screening can extend to detecting early TB states, thereby enabling timely intervention.

We describe an unusual mortality event caused by a highly pathogenic avian influenza (HPAI) A(H5N1) virus clade 2.3.4.4b involving harbor ( Phoca vitulina ) and gray ( Halichoerus grypus ) seals in the St. Lawrence Estuary, Quebec, Canada, in 2022. Fifteen (56%) of the seals submitted for necropsy were considered to be fatally infected by HPAI H5N1 containing fully Eurasian or Eurasian/North American genome constellations. Concurrently, presence of large numbers of bird carcasses infected with HPAI H5N1 at seal haul-out sites most likely contributed to the spillover of infection to the seals. Histologic changes included meningoencephalitis (100%), fibrinosuppurative alveolitis, and multiorgan acute necrotizing inflammation. This report of fatal HPAI H5N1 infection in pinnipeds in Canada raises concerns about the expanding host of this virus, the potential for the establishment of a marine mammal reservoir, and the public health risks associated with spillover to mammals.

Nous décrivons un événement de mortalité inhabituelle causé par un virus de l’influenza aviaire hautement pathogène A(H5N1) clade 2.3.4.4b chez des phoques communs ( Phoca vitulina ) et gris ( Halichoerus grypus ) dans l’estuaire du Saint-Laurent au Québec, Canada, en 2022. Quinze (56%) des phoques soumis pour nécropsie ont été considérés comme étant fatalement infectés par le virus H5N1 de lignées eurasiennes ou de réassortiment eurasiennes/nord-américaines. Un grand nombre simultané de carcasses d’oiseaux infectés par le H5N1 sur les sites d’échouement a probablement contribué à la contamination de ces phoques. Les changements histologiques associés à cette infection incluaient: méningo-encéphalite (100%), alvéolite fibrinosuppurée et inflammation nécrosante aiguë multi-organique. Cette documentation soulève des préoccupations quant à l’émergence de virus mortels, à la possibilité d’établissement de réservoirs chez les mammifères marins, et aux risques pour la santé publique associés aux propagations du virus chez les mammifères.

• Carbapenem-Resistant and Extended-Spectrum β-Lactamase–Producing Enterobacterales Cases among Children, United States, 2016–2020 H. N. Grome et al.
• Unsuccessful Propagation of Chronic Wasting Disease Prions in Human Cerebral Organoids B. R. Groveman et al.
• Introduction of New Dengue Virus Lineages after COVID-19 Pandemic, Nicaragua, 2022 C. Cerpas et al.
• Trends in Nationally Notifiable Infectious Diseases in Humans and Animals during COVID-19 Pandemic, South Korea T. Chang et al.

During October 2022, enteric redmouth disease (ERM) affected Chinese sturgeons at a farm in Hubei, China, causing mass mortality. Affected fish exhibited characteristic red mouth and intestinal inflammation. Investigation led to isolation of a prominent bacterial strain, zhx1, from the internal organs and intestines of affected fish. Artificial infection experiments confirmed the role of zhx1 as the pathogen responsible for the deaths. The primary pathologic manifestations consisted of degeneration, necrosis, and inflammatory reactions, resulting in multiple organ dysfunction and death. Whole-genome sequencing of the bacteria identified zhx1 as Yersinia ruckeri , which possesses 135 drug-resistance genes and 443 virulence factor-related genes. Drug-susceptibility testing of zhx1 demonstrated high sensitivity to chloramphenicol and florfenicol but varying degrees of resistance to 18 other antimicrobial drugs. Identifying the pathogenic bacteria associated with ERM in Chinese sturgeons establishes a theoretical foundation for the effective prevention and control of this disease.

• Estimates of SARS-CoV-2 Hospitalization and Fatality Rates in the Pre-Vaccination Period, United States I. Griffin et al.
• Antibodies to H5N1 Influenza A Virus in Retrieving Hunting Dogs, Washington State, USA J. D. Brown et al.

We characterized the evolution and molecular characteristics of avian influenza A(H7N9) viruses isolated in China during 2021–2023. We systematically analyzed the 10-year evolution of the hemagglutinin gene to determine the evolutionary branch. Our results showed recent antigenic drift, providing crucial clues for updating the H7N9 vaccine and disease prevention and control.

• Burkholderia semiarida as Cause of Recurrent Pulmonary Infection in Immunocompetent Patient, China D. Kuang et al.
• SARS-CoV-2 in Captive Nonhuman Primates, Spain, 2020–2023 D. Cano-Terriza et al.
• Infection- and Vaccine-Induced SARS-CoV-2 Seroprevalence in Persons 0–101 Years of Age, Japan, 2023 R. Kinoshita et al.
• Zoonotic Ancylostoma ceylanicum Infection in Coyotes from the Guanacaste Conservation Area, Costa Rica, 2021 P. A. Zendejas-Heredia et al.
• Detection of Encephalitozoon cuniculi in Cerebrospinal Fluid from Immunocompetent Patients, Czech Republic B. Sak et al.

We describe group B Streptococcus linked to disease in farmed pigs and wild porcupines in Italy. Occurrence in pigs was attributed to transmission from nonpasteurized bovine milk whey. Antimicrobial-resistance profiles in isolates from porcupines suggest no common source of infection. Our findings expand the known host range for group B Streptococcus disease.

• Molecular Identification of Fonsecaea monophora , Novel Agent of Fungal Brain Abscess S. Gourav et al.

During May–July 2023, a cluster of 7 patients at local hospitals in Florida, USA, received a diagnosis of Plasmodium vivax malaria. Whole-genome sequencing of the organism from 4 patients and phylogenetic analysis with worldwide representative P. vivax genomes indicated probable single parasite introduction from Central/South America.

A fecal survey in Tamil Nadu, India, revealed 2 persons passed schistosome eggs, later identified as Schistosoma incognitum , a parasite of pigs, dogs, and rats. We investigated those cases and reviewed autochthonous schistosomiasis cases from India and Nepal. Whether the 2 new cases represent true infection or spurious passage is undetermined.

• Choanephora infundibulifera Rhinosinusitis in Man with Acute Lymphoblastic Leukemia, Tennessee, USA A. Max et al.

Highly pathogenic avian influenza H5N6 and H5N1 viruses of clade 2.3.4.4b were simultaneously introduced into South Korea at the end of 2023. An outbreak at a broiler duck farm consisted of concurrent infection by both viruses. Sharing genetic information and international surveillance of such viruses in wild birds and poultry is critical.

Because novel SARS-CoV-2 variants continue to emerge, immunogenicity of XBB.1.5 monovalent vaccines against live clinical isolates needs to be evaluated. We report boosting of IgG (2.1×), IgA (1.5×), and total IgG/A/M (1.7×) targeting the spike receptor-binding domain and neutralizing titers against WA1 (2.2×), XBB.1.5 (7.4×), EG.5.1 (10.5×), and JN.1 (4.7×) variants.

Using the GISAID EpiCoV database, we identified 256 COVID-19 patients in Japan during March 31–December 31, 2023, who had mutations in the SARS-CoV-2 nonstructural protein 5 conferring ensitrelvir resistance. Ongoing genomic surveillance is required to monitor emergence of SARS-CoV-2 mutations that are resistant to anticoronaviral drugs.

• Characterization of Cetacean Morbillivirus in Humpback Whales, Brazil D. B. de Amorim et al.
• Outbreak of Natural Severe Fever with Thrombocytopenia Syndrome Virus Infection in Farmed Minks, China Y. Wang et al.
• Geographic Variation and Environmental Predictors of Nontuberculous Mycobacteria in Laboratory Surveillance, Virginia, USA, 2021–2023 I. See et al.

Volume 30, Number 7—July 2024

• Looking Beyond the Lens of Crimean-Congo Hemorrhagic Fever in Africa O. Okesanya et al.

We report highly pathogenic avian influenza A(H5N1) virus in dairy cattle and cats in Kansas and Texas, United States, which reflects the continued spread of clade 2.3.4.4b viruses that entered the country in late 2021. Infected cattle experienced nonspecific illness, reduced feed intake and rumination, and an abrupt drop in milk production, but fatal systemic influenza infection developed in domestic cats fed raw (unpasteurized) colostrum and milk from affected cows. Cow-to-cow transmission appears to have occurred because infections were observed in cattle on Michigan, Idaho, and Ohio farms where avian influenza virus–infected cows were transported. Although the US Food and Drug Administration has indicated the commercial milk supply remains safe, the detection of influenza virus in unpasteurized bovine milk is a concern because of potential cross-species transmission. Continued surveillance of highly pathogenic avian influenza viruses in domestic production animals is needed to prevent cross-species and mammal-to-mammal transmission.

• Borrelia miyamotoi -associated Acute Meningoencephalitis, Minnesota, United States J. M. Kubiak et al.
• Treatment Outcomes for Tuberculosis Infection and Disease Among Persons Deprived of Liberty, Uganda, 2020 D. Lukoye et al.
• Pasteurella bettyae Infections in Men Who Have Sex With Men, France A. Li et al.

Beginning in 2023, we observed increased Plasmodium vivax malaria cases at an institution in Los Angeles, California, USA. Most cases were among migrants from China who traveled to the United States through South and Central America. US clinicians should be aware of possible P. vivax malaria among immigrants from China.

Medscape, LLC is pleased to provide online continuing medical education (CME) for selected journal articles, allowing clinicians the opportunity to earn CME credit. In support of improving patient care, these activities have been planned and implemented by Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. CME credit is available for one year after publication.

Active CME Articles

During October 2021–June 2023, a total of 392 cases of acute hepatitis of unknown etiology in children in the United States were reported to Centers for Disease Control and Prevention as part of national surveillance. We describe demographic and clinical characteristics, including potential involvement of adenovirus in development of acute hepatitis, of 8 fatally ill children who met reporting criteria. The children had diverse courses of illness. Two children were immunocompromised when initially brought for care. Four children tested positive for adenovirus in multiple specimen types, including 2 for whom typing was completed. One adenovirus-positive child had no known underlying conditions, supporting a potential relationship between adenovirus and acute hepatitis in previously healthy children. Our findings emphasize the importance of continued investigation to determine the mechanism of liver injury and appropriate treatment. Testing for adenovirus in similar cases could elucidate the role of the virus.

In 2022, concurrent outbreaks of hepatitis A, invasive meningococcal disease (IMD), and mpox were identified in Florida, USA, primarily among men who have sex with men. The hepatitis A outbreak (153 cases) was associated with hepatitis A virus genotype IA. The IMD outbreak (44 cases) was associated with Neisseria meningitidis serogroup C, sequence type 11, clonal complex 11. The mpox outbreak in Florida (2,845 cases) was part of a global epidemic. The hepatitis A and IMD outbreaks were concentrated in Central Florida and peaked during March–­June, whereas mpox cases were more heavily concentrated in South Florida and had peak incidence in August. HIV infection was more common (52%) among mpox cases than among hepatitis A (21%) or IMD (34%) cases. Where feasible, vaccination against hepatitis A, meningococcal disease, and mpox should be encouraged among at-risk groups and offered along with program services that target those groups.

Disseminated leishmaniasis (DL) is an emergent severe disease manifesting with multiple lesions. To determine the relationship between immune response and clinical and therapeutic outcomes, we studied 101 DL and 101 cutaneous leishmaniasis (CL) cases and determined cytokines and chemokines in supernatants of mononuclear cells stimulated with leishmania antigen. Patients were treated with meglumine antimoniate (20 mg/kg) for 20 days (CL) or 30 days (DL); 19 DL patients were instead treated with amphotericin B, miltefosine, or miltefosine and meglumine antimoniate. High levels of chemokine ligand 9 were associated with more severe DL. The cure rate for meglumine antimoniate was low for both DL (44%) and CL (60%), but healing time was longer in DL (p = 0.003). The lowest cure rate (22%) was found in DL patients with >100 lesions. However, meglumine antimoniate/miltefosine treatment cured all DL patients who received it; therefore, that combination should be considered as first choice therapy.

Streptococcus suis , a zoonotic bacterial pathogen circulated through swine, can cause severe infections in humans. Because human S. suis infections are not notifiable in most countries, incidence is underestimated. We aimed to increase insight into the molecular epidemiology of human S. suis infections in Europe. To procure data, we surveyed 7 reference laboratories and performed a systematic review of the scientific literature. We identified 236 cases of human S. suis infection from those sources and an additional 87 by scanning gray literature. We performed whole-genome sequencing to type 46 zoonotic S. suis isolates and combined them with 28 publicly available genomes in a core-genome phylogeny. Clonal complex (CC) 1 isolates accounted for 87% of typed human infections; CC20, CC25, CC87, and CC94 also caused infections. Emergence of diverse zoonotic clades and notable severity of illness in humans support classifying S. suis infection as a notifiable condition.

During January–August 2021, the Community Prevalence of SARS-CoV-2 Study used time/location sampling to recruit a cross-sectional, population-based cohort to estimate SARS-CoV-2 seroprevalence and nasal swab sample PCR positivity across 15 US communities. Survey-weighted estimates of SARS-CoV-2 infection and vaccine willingness among participants at each site were compared within demographic groups by using linear regression models with inverse variance weighting. Among 22,284 persons > 2 months of age and older, median prevalence of infection (prior, active, or both) was 12.9% across sites and similar across age groups. Within each site, average prevalence of infection was 3 percentage points higher for Black than White persons and average vaccine willingness was 10 percentage points lower for Black than White persons and 7 percentage points lower for Black persons than for persons in other racial groups. The higher prevalence of SARS-CoV-2 infection among groups with lower vaccine willingness highlights the disparate effect of COVID-19 and its complications.

Invasive fusariosis can be life-threatening, especially in immunocompromised patients who require intensive care unit (ICU) admission. We conducted a multicenter retrospective study to describe clinical and biologic characteristics, patient outcomes, and factors associated with death and response to antifungal therapy. We identified 55 patients with invasive fusariosis from 16 ICUs in France during 2002­–­­2020. The mortality rate was high (56%). Fusariosis-related pneumonia occurred in 76% of patients, often leading to acute respiratory failure. Factors associated with death included elevated sequential organ failure assessment score at ICU admission or history of allogeneic hematopoietic stem cell transplantation or hematologic malignancies. Neither voriconazole treatment nor disseminated fusariosis were strongly associated with response to therapy. Invasive fusariosis can lead to multiorgan failure and is associated with high mortality rates in ICUs. Clinicians should closely monitor ICU patients with a history of hematologic malignancies or stem cell transplantation because of higher risk for death.

Using whole-genome sequencing, we characterized Escherichia coli strains causing early-onset sepsis (EOS) in 32 neonatal cases from a 2019–2021 prospective multicenter study in France and compared them to E. coli strains collected from vaginal swab specimens from women in third-trimester gestation. We observed no major differences in phylogenetic groups or virulence profiles between the 2 collections. However, sequence type (ST) analysis showed the presence of 6/32 (19%) ST1193 strains causing EOS, the same frequency as in the highly virulent clonal group ST95. Three ST1193 strains caused meningitis, and 3 harbored extended-spectrum β-lactamase. No ST1193 strains were isolated from vaginal swab specimens. Emerging ST1193 appears to be highly prevalent, virulent, and antimicrobial resistant in neonates. However, the physiopathology of EOS caused by ST1193 has not yet been elucidated. Clinicians should be aware of the possible presence of E. coli ST1193 in prenatal and neonatal contexts and provide appropriate monitoring and treatment.

We describe detection of the previously rarely reported gram-positive bacterium Auritidibacter ignavus in 3 cases of chronic ear infections in Germany. In all 3 cases, the patients had refractory otorrhea. Although their additional symptoms varied, all patients had an ear canal stenosis and A. ignavus detected in microbiologic swab specimens. A correct identification of A. ignavus in the clinical microbiology laboratory is hampered by the inability to identify it by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Also, the bacterium might easily be overlooked because of its morphologic similarity to bacterial species of the resident skin flora. We conclude that a high index of suspicion is warranted to identify A. ignavus and that it should be particularly considered in patients with chronic external otitis who do not respond clinically to quinolone ear drop therapy.

We reviewed invasive Nocardia infections in 3 noncontiguous geographic areas in the United States during 2011–2018. Among 268 patients with invasive nocardiosis, 48.2% were from Minnesota, 32.4% from Arizona, and 19.4% from Florida. Predominant species were N. nova complex in Minnesota (33.4%), N. cyriacigeorgica in Arizona (41.4%), and N. brasiliensis in Florida (17.3%). Transplant recipients accounted for 82/268 (30.6%) patients overall: 14 (10.9%) in Minnesota, 35 (40.2%) in Arizona, and 33 (63.5%) in Florida. Manifestations included isolated pulmonary nocardiosis among 73.2% of transplant and 84.4% of non–transplant patients and central nervous system involvement among 12.2% of transplant and 3.2% of non–transplant patients. N. farcinica (20.7%) and N. cyriacigeorgica (19.5%) were the most common isolates among transplant recipients and N. cyriacigeorgica (38.0%), N. nova complex (23.7%), and N. farcinica (16.1%) among non–transplant patients. Overall antimicrobial susceptibilities were similar across the 3 study sites.

We collected stool from school-age children from 352 households living in the Black Belt region of Alabama, USA, where sanitation infrastructure is lacking. We used quantitative reverse transcription PCR to measure key pathogens in stool that may be associated with water and sanitation, as an indicator of exposure. We detected genes associated with > 1 targets in 26% of specimens, most frequently Clostridioides difficile (6.6%), atypical enteropathogenic Escherichia coli (6.1%), and enteroaggregative E. coli (3.9%). We used generalized estimating equations to assess reported risk factors for detecting > 1 pathogen in stool. We found no association between lack of sanitation and pathogen detection (adjusted risk ratio 0.95 [95% CI 0.55–1.7]) compared with specimens from children served by sewerage. However, we did observe an increased risk for pathogen detection among children living in homes with well water (adjusted risk ratio 1.7 [95% CI 1.1–2.5]) over those reporting water utility service.

Campylobacter fetus accounts for 1% of Campylobacter spp. infections, but prevalence of bacteremia and risk for death are high. To determine clinical features of C. fetus infections and risks for death, we conducted a retrospective observational study of all adult inpatients with a confirmed C. fetus infection in Nord Franche-Comté Hospital, Trevenans, France, during January 2000–December 2021. Among 991 patients with isolated Campylobacter spp. strains, we identified 39 (4%) with culture-positive C. fetus infections, of which 33 had complete records and underwent further analysis; 21 had documented bacteremia and 12 did not. Secondary localizations were reported for 7 (33%) patients with C. fetus bacteremia, of which 5 exhibited a predilection for vascular infections (including 3 with mycotic aneurysm). Another 7 (33%) patients with C. fetus bacteremia died within 30 days. Significant risk factors associated with death within 30 days were dyspnea, quick sequential organ failure assessment score > 2 at admission, and septic shock.

Group A Streptococcus (GAS) primary peritonitis is a rare cause of pediatric acute abdomen (sudden onset of severe abdominal pain); only 26 pediatric cases have been reported in the English language literature since 1980. We discuss 20 additional cases of pediatric primary peritonitis caused by GAS among patients at Starship Children’s Hospital, Auckland, New Zealand, during 2010–2022. We compare identified cases of GAS primary peritonitis to cases described in the existing pediatric literature. As rates of rates of invasive GAS increase globally, clinicians should be aware of this cause of unexplained pediatric acute abdomen.

In Mississippi, USA, infant hospitalization with congenital syphilis (CS) spiked by 1,000%, from 10 in 2016 to 110 in 2022. To determine the causes of this alarming development, we analyzed Mississippi hospital discharge data to evaluate trends, demographics, outcomes, and risk factors for infants diagnosed with CS hospitalized during 2016–2022. Of the 367 infants hospitalized with a CS diagnosis, 97.6% were newborn, 92.6% were covered by Medicaid, 71.1% were African American, and 58.0% were nonurban residents. Newborns with CS had higher odds of being affected by maternal illicit drug use, being born prematurely (<37 weeks), and having very low birthweight (<1,500 g) than those without CS. Mean length of hospital stay (14.5 days vs. 3.8 days) and mean charges ($56,802 vs. $13,945) were also higher for infants with CS than for those without. To address escalation of CS, Mississippi should invest in comprehensive prenatal care and early treatment of vulnerable populations.

Ongoing surveillance after pneumococcal conjugate vaccination (PCV) deployment is essential to inform policy decisions and monitor serotype replacement. We report serotype and disease severity trends in 3,719 adults hospitalized for pneumococcal disease in Bristol and Bath, United Kingdom, during 2006–2022. Of those cases, 1,686 were invasive pneumococcal disease (IPD); 1,501 (89.0%) had a known serotype. IPD decreased during the early COVID-19 pandemic but during 2022 gradually returned to prepandemic levels. Disease severity changed throughout this period: CURB65 severity scores and inpatient deaths decreased and ICU admissions increased. PCV7 and PCV13 serotype IPD decreased from 2006–2009 to 2021–2022. However, residual PCV13 serotype IPD remained, representing 21.7% of 2021–2022 cases, indicating that major adult PCV serotype disease still occurs despite 17 years of pediatric PCV use. Percentages of serotype 3 and 8 IPD increased, and 19F and 19A reemerged. In 2020–2022, a total of 68.2% IPD cases were potentially covered by PCV20.

Borrelia miyamotoi , transmitted by Ixodes spp. ticks, was recognized as an agent of hard tick relapsing fever in the United States in 2013. Nine state health departments in the Northeast and Midwest have conducted public health surveillance for this emerging condition by using a shared, working surveillance case definition. During 2013–2019, a total of 300 cases were identified through surveillance; 166 (55%) were classified as confirmed and 134 (45%) as possible. Median age of case-patients was 52 years (range 1–86 years); 52% were male. Most cases (70%) occurred during June–September, with a peak in August. Fever and headache were common symptoms; 28% of case-patients reported recurring fevers, 55% had arthralgia, and 16% had a rash. Thirteen percent of patients were hospitalized, and no deaths were reported. Ongoing surveillance will improve understanding of the incidence and clinical severity of this emerging disease.

During 2006–2021, Canada had 55 laboratory-confirmed outbreaks of foodborne botulism, involving 67 cases. The mean annual incidence was 0.01 case/100,000 population. Foodborne botulism in Indigenous communities accounted for 46% of all cases, which is down from 85% of all cases during 1990–2005. Among all cases, 52% were caused by botulinum neurotoxin type E, but types A (24%), B (16%), F (3%), and AB (1%) also occurred; 3% were caused by undetermined serotypes. Four outbreaks resulted from commercial products, including a 2006 international outbreak caused by carrot juice. Hospital data indicated that 78% of patients were transferred to special care units and 70% required mechanical ventilation; 7 deaths were reported. Botulinum neurotoxin type A was associated with much longer hospital stays and more time spent in special care than types B or E. Foodborne botulism often is misdiagnosed. Increased clinician awareness can improve diagnosis, which can aid epidemiologic investigations and patient treatment.

Corynebacterium ulcerans is a closely related bacterium to the diphtheria bacterium C. diphtheriae , and some C. ulcerans strains produce toxins that are similar to diphtheria toxin. C. ulcerans is widely distributed in the environment and is considered one of the most harmful pathogens to livestock and wildlife. Infection with C. ulcerans can cause respiratory or nonrespiratory symptoms in patients. Recently, the microorganism has been increasingly recognized as an emerging zoonotic agent of diphtheria-like illness in Japan. To clarify the overall clinical characteristics, treatment-related factors, and outcomes of C. ulcerans infection, we analyzed 34 cases of C. ulcerans that occurred in Japan during 2001–2020. During 2010–2020, the incidence rate of C. ulcerans infection increased markedly, and the overall mortality rate was 5.9%. It is recommended that adults be vaccinated with diphtheria toxoid vaccine to prevent the spread of this infection.

Mycolicibacterium neoaurum is a rapidly growing mycobacterium and an emerging cause of human infections. M. neoaurum infections are uncommon but likely underreported, and our understanding of the disease spectrum and optimum management is incomplete. We summarize demographic and clinical characteristics of a case of catheter-related M. neoaurum bacteremia in a child with leukemia and those of 36 previously reported episodes of M. neoaurum infection. Most infections occurred in young to middle-aged adults with serious underlying medical conditions and commonly involved medical devices. Overall, infections were not associated with severe illness or death. In contrast to other mycobacteria species, M. neoaurum was generally susceptible to multiple antimicrobial drugs and responded promptly to treatment, and infections were associated with good outcomes after relatively short therapy duration and device removal. Delays in identification and susceptibility testing were common. We recommend using combination antimicrobial drug therapy and removal of infected devices to eradicate infection.

We retrospectively reviewed consecutive cases of mucormycosis reported from a tertiary-care center in India to determine the clinical and mycologic characteristics of emerging Rhizopus homothallicus fungus. The objectives were ascertaining the proportion of R. homothallicus infection and the 30-day mortality rate in rhino-orbital mucormycosis attributable to R. homothallicus compared with R. arrhizus. R. homothallicus accounted for 43 (6.8%) of the 631 cases of mucormycosis. R. homothallicus infection was independently associated with better survival (odds ratio [OR] 0.08 [95% CI 0.02–0.36]; p = 0.001) than for R. arrhizus infection (4/41 [9.8%] vs. 104/266 [39.1%]) after adjusting for age, intracranial involvement, and surgery. We also performed antifungal-susceptibility testing, which indicated a low range of MICs for R. homothallicus against the commonly used antifungals (amphotericin B [0.03–16], itraconazole [0.03–16], posaconazole [0.03–8], and isavuconazole [0.03–16]). 18S gene sequencing and amplified length polymorphism analysis revealed distinct clustering of R. homothallicus .

Zoonotic outbreaks of sporotrichosis are increasing in Brazil. We examined and described the emergence of cat-transmitted sporotrichosis (CTS) caused by the fungal pathogen Sporothrix brasiliensis . We calculated incidence and mapped geographic distribution of cases in Curitiba, Brazil, by reviewing medical records from 216 sporotrichosis cases diagnosed during 2011–May 2022. Proven sporotrichosis was established in 84 (39%) patients and probable sporotrichosis in 132 (61%). Incidence increased from 0.3 cases/100,000 outpatient visit-years in 2011 to 21.4 cases/100,000 outpatient visit-years in 2021; of the 216 cases, 58% (n = 126) were diagnosed during 2019–2021. The main clinical form of sporotrichosis was lymphocutaneous (63%), followed by localized cutaneous (24%), ocular (10%), multisite infections (3%), and cutaneous disseminated (<0.5%). Since the first report of CTS in Curitiba in 2011, sporotrichosis has increased substantially, indicating continuous disease transmission. Clinician and public awareness of CTS and efforts to prevent transmission are needed.

Babesiosis is a globally distributed parasitic infection caused by intraerythrocytic protozoa. The full spectrum of neurologic symptoms, the underlying neuropathophysiology, and neurologic risk factors are poorly understood. Our study sought to describe the type and frequency of neurologic complications of babesiosis in a group of hospitalized patients and assess risk factors that might predispose patients to neurologic complications. We reviewed medical records of adult patients who were admitted to Yale-New Haven Hospital, New Haven, Connecticut, USA, during January 2011–October 2021 with laboratory-confirmed babesiosis. More than half of the 163 patients experienced > 1 neurologic symptoms during their hospital admissions. The most frequent symptoms were headache, confusion/delirium, and impaired consciousness. Neurologic symptoms were associated with high-grade parasitemia, renal failure, and history of diabetes mellitus. Clinicians working in endemic areas should recognize the range of symptoms associated with babesiosis, including neurologic.

Tularemia is a zoonotic infection caused by Francisella tularensis . Its most typical manifestations in humans are ulceroglandular and glandular; infections in prosthetic joints are rare. We report 3 cases of F. tularensis subspecies holarctica –related prosthetic joint infection that occurred in France during 2016–2019. We also reviewed relevant literature and found only 5 other cases of Francisella -related prosthetic joint infections worldwide, which we summarized. Among those 8 patients, clinical symptoms appeared 7 days to 19 years after the joint placement and were nonspecific to tularemia. Although positive cultures are typically obtained in only 10% of tularemia cases, strains grew in all 8 of the patients. F. tularensis was initially identified in 2 patients by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry; molecular methods were used for 6 patients. Surgical treatment in conjunction with long-term antimicrobial treatment resulted in favorable outcomes; no relapses were seen after 6 months of follow-up.

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NEWS... BUT NOT AS YOU KNOW IT

Dodgy Turkey teeth dentist dumped British man at hospital after screwing implant into his skull

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A dad of two who went to the dentist with a toothache ended up in hospital to have a dental implant removed from his brain cavity.

Ramazan Yilmaz, 40, went to a private clinic in Bursa, Turkey where the dentist who examined him said he had loose teeth which needed to be extracted.

The teeth were removed and the dentist recommended replacing them with implants – but during the surgery the dentist allegedly pierced Ramazan’s jawbone while ‘forcing’ an implant into place.

Speaking to local media, Mr Yilmaz said: ‘After experiencing discomfort with my teeth, I went to a private dental clinic in Nilüfer.

‘Following examinations there, I was informed that my bone structure was delicate, my teeth were loose, and it was advisable to undergo an implant procedure.

‘The doctor claimed to have 24 years of experience in this field and assured us of his expertise.

‘So, we entrusted him with the procedure.

‘Later, while pulling my teeth and performing the implant procedure on the same day, he informed his secretary that the device he was using was faulty.

‘He then proceeded to perform the procedure manually.

‘As he attempted to place the screw, I noticed he was exerting excessive force.

‘I pointed this out to him, mentioning that I heard a bone-cracking sound.

‘However, he reassured me that it was normal.

‘But as he continued to force the screw, it pierced through my jawbone and into the area behind the eye where the brain and spinal fluid are located.’

Ramazan ended up screaming in agony after the screw went all the way up into his cranium.

He was taken to a local hospital by the dentist, who allegedly left him there and ran away.

Ramazan underwent a CT scan before immediately being sent for surgery. The screw was finally removed from his skull after an hours-long operation.

‘When I screamed in pain, he finally took an X-ray,’ Ramazan said.

‘Realising the seriousness of the situation, he took me to the emergency department of Uludag University Hospital.

‘After examinations there, it was found that the screw had pierced into the area where the brain and spinal fluid are located.

‘Subsequently, expert physicians convened and decided to proceed with surgery.’

Ramazan was discharged days later and has since recovered – but he says the dentist has refused to refund him and he’s now taking legal action.

He explained: ‘Before the operation, they warned me that I could lose my life.

‘I made peace with my children and bid them farewell.

‘Thankfully, I emerged safely from the surgery.’

The dentist, who has not been named but is named in reports as A.D., is reportedly claiming that the incident occurred ‘due to a medical complication’.

Get in touch with our news team by emailing us at [email protected] .

For more stories like this, check our news page .

MORE : Celtic fan punches police officers on flight after ‘downing bottle of vodka’

MORE : British tourist, 21, named after falling to death from hotel balcony in Turkey

MORE : British man, 73, dies on holiday after jumping into sea to ‘cool off’

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Inside the World of Backstreet Castrators, Cutters and Eunuch-Makers

In 2018, William, a thoughtful, handsome guy in his late twenties with an eye for design and architecture, took a train up from his home in Baltimore to New York to meet a man he’d been chatting with online for a few months. They had dinner, checked into a hotel near Times Square with a nice view of the Hudson River, and got all showered up and clean. Then, the man placed a restrictive band around William’s genitals and injected them with lidocaine. Once William was fully numb, the man sliced open his scrotum, cut off one of his testicles, and cauterized the testicular artery. He would have cut out William’s remaining testicle as well, but his cauterizing tool died. So, he sutured William up instead.

This is not a horror story of an internet date gone Lifetime original movie-level wrong. The man William met was a cutter , someone who does underground surgeries on people who want to modify or remove part or all of their genitals. He had, to William’s knowledge, cut off over a dozen men’s testicles by that point, with few if any complications. William, who learned at 17 that he was born with XXY chromosomes and has intersex characteristics , identifies as a gender neutrois male, a non-binary identity, and uses he/him pronouns. He wanted this cutter to help him start a physical transition to align his body with this identity, a process he hopes will eventually leave him with a fully smooth groin.

Cutters have made sensationalist headlines on and off over the last 20 years , usually when people who sought them out turn up bloody in emergency rooms and lead authorities back to the sites of their underground operations. Just a couple of months ago , police in rural Oklahoma arrested two men for allegedly performing surgery without a license on a 28-year-old who nearly bled out during a testicle removal in their remote cabin. These stories are often chock-full of sensationalist details of alleged sadomasochist torture, jars of preserved gonads, and cannibalistic inclinations. They paint cutters as splatter movie villains—as rare psychopaths preying on vulnerable youths.

But the world of cutters, and the people who seek them out, is far more expansive and complex than that image lets on. If you know where to look—on a few select castration-focused forums like Eunuch Maker , and within some private encrypted messaging channels, for example—you can find a fair number of cutters active across the globe. Based on his own hunt for a cutter, William estimates “that there are at least a few in each state” in the U.S. alone. Many appear to fly under the radar of law enforcement officials in part because a fair number of their operations are at least successful enough to avoid the sorts of shitshows that make the news, and in part because when things do go wrong their clients make up cover stories for their injuries.

Some even continue to patronize cutters after mishaps—like William. His scrotum became infected after his hotel surgery, landing him in an emergency room on antibiotics. Yet within a matter of weeks, he went back to the same cutter to try to get his remaining testicle removed.

No one has, to The Daily Beast’s knowledge, seriously studied cutters, or people’s willingness to seek them out and cover for them despite mishaps and horror stories. However, according to several experts on gender diversity and surgeries, and to a handful of people who have pursued the kind of services cutters offer, whom The Daily Beast consulted for this article, cutters’ operations do not reflect some kind of collective pathology. Nor do they merit tabloid melodrama or major legal crackdowns. Instead, they are largely the result of society’s failure to fully acknowledge, truly respect, and adequately serve deeply marginalized gender identities.

Thanks to a rising— if piecemeal and still woefully insufficient —tide of awareness, most people today know at least the basics about binary transgender identities (i.e., male-to-female and female-to-male) and the surgeries that many, though not all , binary trans people pursue as part of their transitions. But most talk about gender still treats it solely as a binary , male or female, and involves cut-and-dry ideas about the physical traits associated with each of those labels. Even among medical experts , awareness of non-binary identities , which sit between, blend, or move beyond conceptions of male and female gender, remains low. There is also little awareness of people who still identify wholly with the gender they were assigned at birth, male or female, but for any number of reasons feel a deep need to remove some or all of their physical sex traits for a range of reasons including body integrity dysphoria ; a profound discomfort with the sexual side of their being; or pure, intangible personal preference.

People’s own diverse and often idiosyncratic experiences and conceptualizations of gender can lead them to pursue surgeries that go far beyond the “traditional,” gender binary trans trajectories we most often see in the media today. Many, like William, want what they refer to as nulloplasty , a series of surgeries that will leave them with no sex traits whatsoever—and sometimes no nipples as well. Some people born with penises and testicles want to keep the former, but lose the latter—though some choose to keep their empty scrotums. (There is a dedicated Reddit forum for the latter group to share photos of their genitals: Empty Sacks, “for those who had the balls to give theirs up.”) Others want to keep the genitalia they were born with and add new genitalia on top.

In line with their diverse gender identities and surgical desires, and ever-evolving gender vocabulary, there is no set or singular term, or set of pronouns, for these individuals—not even an umbrella term. Some identify as non-binary trans people, or as gender non-conforming trans men or women. Others identify as non-binary but not trans. A fair number still consider themselves cis binary men or women even after having all of their genitalia removed. A few talk about their surgeries as purely cosmetic body modifications, unrelated to their gender identities—like tattoos or piercings, albeit more extreme. Even two people pursuing the same surgeries for the same broad reasons may use different self-identifiers and pronouns.

“Surgery on genitalia has been done for thousands of years,” Loren Schechter , a leading gender confirmation surgeon based just outside of Chicago, told The Daily Beast, whether for medical or ritual reasons or as part of other cultures’ recognition of gender identities and experiences that are not part of the modern, Western mainstream. So, doctors know how to safely perform many of the procedures that gender diverse individuals seek.

A medical illustration by Sharaf ad-Din depicting an operation for castration, c. 1466

“An orchiectomy [or tactical excision of one or both testicles] can be done as an out-patient procedure,” said Richard Wassersug , a gender and health care researcher at the University of British Columbia with an apparent penchant for bow-ties and exacting academic precision. He was himself chemically castrated over 20 years ago to treat his prostate cancer and later chose to embrace a eunuch identity in order to help push back on the isolation and shame many castrated men feel in a society that thinks of eunuchs as historical oddities, if it thinks of them at all. (He also identifies as a cis man, though not all eunuchs do.) Now, he studies the lives of the hundreds of thousands of people born with testicles who undergo chemical or physical castrations for medical or voluntary reasons, and advocates for “these men to get the best health care possible.”

In recent years, a handful of clinics in America, Mexico, and a few other countries have started to offer diverse combinations of or variations on these surgeries to people of most, if not all, gender identities. These clinics remain scarce and often expensive, though, and thus inaccessible to the seemingly ever-growing number of people seeking their services.

But just two decades ago “even doing what’s now considered traditional binary gender surgery was quite difficult,” noted Schechter, thanks to high bias and low awareness among doctors and medical institutions. There was even less comfort with people who wanted anything else, and little literature or standard protocol on how to do so. A few surgeons, most notably Felix Spector , a Philadelphian who earned a reputation for offering clandestine abortions to patients in need in the 1940s, offered at least cheap and easy orchiectomies to people who weren’t specifically seeking trans surgeries in the late 20th century. By the end of his career in 2002, that was about half of his work. However, these surgeons faced intense scrutiny and official sanctions for their trouble. Most doctors told patients who came to them asking for non-standard gender surgeries that they were clearly mentally ill , and that no doctor would ever consider removing healthy tissue for someone who wasn’t trans.

“I was told it was medically illegal, both in the U.S. and in Canada,” said Rev. Brother Shawn Francis Benedict, a self-identified voluntary eunuch cis man who started seeking a physical castration in the 1980s.

Benedict has tried to be out and open about his identity for a couple of decades now, to help gender non-confirming people of all stripes find community and support. His openness is unusual. Most eunuchs never discuss their surgeries, and even those who do not identify as cis men often choose to pass as male in their everyday lives to avoid stigmatization. He leads the queer-affirming Ray of Hope Church in Elmira , New York, and advances queer readings of the Bible from the pulpit. Or, as he put it: “I work tirelessly to expose the false assumptions of the ‘religionists’ in the church world by communicating the now very large theological school of thought that finds no condemnation of any person of any sexual orientation or gender in the Bible.”

“I have found hundreds of books on the existence of castration, eunuchs, and other identities from every culture, every age, even every religion,” he said. “The only thing exceptional and weird about them is to be so uneducated to think that they are exceptional or weird.”

A Cult of Cybele castration clamp from Ancient Rome.

Into the 1990s and early 2000s, Benedict said, “If a person called a doctor to ask about, for example, keeping their penis and putting a vagina in behind it, that was an absolute hang-up-the-phone-on-you request.”

A few individuals have historically gotten around this by pretending that they were starting a more traditional and established binary transition, then selectively engaging with the process to achieve their desired results. But this process is often confusing, degrading, or just plain infuriating.

So, for lack of direct medical acknowledgment or aid, over the years many people have tried to remove their own testicles. Far fewer have attempted to remove their own scrotums or penises, or to modify their vulvas, as these surgeries can be far more complex and dangerous to pursue alone. But this does happen, too. Zach, a cis male who is comfortable with the gender he was assigned at birth, cut off his own glans about two years back with some lidocaine to numb his member, a sharp blade to make a cut, and rapid blood clotting agents, sterilizing gauze, and surgical staples to stop the ample bleeding and close the wound. He now regularly posts pictures of his anatomy on NSFW forums online, and seems to delight in people’s shock and fascination, sharing basic information about the procedure with those, like The Daily Beast, who ask.

Many more have attempted to do enough damage to their genitals, whether by cutting off blood flow to them long enough to kill tissue, injecting chemicals into them, or other forms of trauma, to allow them to go to an emergency room, spin some tale about a bizarre accident or kinky sex gone wrong, and functionally force doctors to safely remove offending parts. “If I ever wanted to go beyond what I can do myself, and get a total penectomy, I would be able to get it relatively easily from a medical professional, due to what I’ve already done,” Zach told The Daily Beast.

Drastic and brutal as this may seem to outsiders, it is rarely a rash decision. Most people The Daily Beast spoke to said that, in their experience, those who take action usually only do so after decades of self-examination and efforts to weigh out options. Zach, for one, has said that he’d wanted to do something like his glansectomy since he was about 13—it just felt like a deep-seated, core desire—but waited until well into his adulthood to act. That lines up with Wassersug’s research on voluntary eunuchs, who have diverse gender identities and some of whom go on to pursue other procedures, like full genital removal. In one survey , he found that these individuals waited 18 years on average between deciding they wanted a castration and taking any kind of action.

“In one of our studies, we quoted a person who said he knew by age 6 that he needed to be castrated,” said Thomas Johnson, an anthropologist who often collaborates with Wassersug. That child waited until he was in his thirties to pursue any kind of surgery. Johnson has extensive notes from interviews he’s conducted with numerous voluntary eunuchs. However, he said that academics rarely share such works on marginalized gender communities with journalists because they worry about the potential negative effects of “writings that describe them as ‘freaks.’”

Even people who make attempts much faster, and at younger ages, often do not actually show any signs of mental illness, and do not regret their decisions. “I interviewed one man who made a serious attempt at age 12,” Johnson recalled. “He was stopped only by the pain and the blood—and his mother unexpectedly walking into his room. He then went into two years of psychiatric counseling, but managed to arrange a proper surgery just after his 18th birthday. That was nearly 20 years ago. He is still happy with his choice. His only regret is that he failed at 12.”

But self-surgery is incredibly dangerous, not to mention painful, especially when done alone by someone with no prior experience or training. “The potential for shock, or making an error in the heat of the moment… accidentally not following sanitary procedures, not being able to close the wound due to fainting, and so on, is huge,” said Zach. “The healing processes can frankly be equally or more dangerous than actual cuttings, especially for penile procedures. An erection in your sleep could easily lead to death by blood loss, and the threat of an infection is ever-present.”

That is why many people, either after a failed self-surgery attempt or from the get-go, seek out cutters . It’s hard to say exactly how many cutters exist, or how active they are, in part because these individuals are, by legal and social necessity, extremely secretive, and in part because we don’t know how much demand exists for their services. Wassersug, for example, estimates that there are about 8,000 voluntary eunuchs in North America alone, and that over half of them practiced DIY surgeries or cutters’ services. These numbers could be off, as they’re just a best guess based on the communities Wassersug has access to. They don’t include people who have pursued cutters’ services but don’t identify or interact with the eunuch communities that Wassersug studies. And they don’t tell us anything about people who are still just considering going to a cutter. Still, we know enough to say cutter supply and demand are clearly non-negligible.

“I understand the choice to seek” cutters, said Schechter, who often seems to take a humble and empathetic perspective on these matters, in line with his self-proclaimed devotion to the development of a less paternalistic and judgmental medical culture. “The medical community has not always been an easy venue for people to express their identities and desires.”

Historically, people found cutters via contact networks embedded in extreme body modification or BDSM groups, or sympathetic doctors working off the books. (The Body Modification Ezine , an early online community, actually gave many people their first look at genital modifications or removals and led them to believe the thing they wanted might actually be attainable. It still hosts many images of castrations, penectomies, and other genital surgeries, as well as old interviews with cutters.) Later, chat rooms associated with these communities, and eunuch forums, became major cutter hubs.

Steve, a middle-aged cis man who’s fairly private about the details of his procedure, told The Daily Beast his journey to a cutter started after a partner took him to ModCon, an American body modification convention, in 1991 and introduced him to friends of friends. They eventually led him to a New York doctor who arranged an expensive trip to a hospital in Mexico where a doctor was willing to do a no-questions-asked, cash-up-front castration in a clinic—a common arrangement. But the procedure didn’t go well. A second trip through this network brought him to a hospital in Thailand. (Mexico and Thailand have both been hot spots for quick-and-easy but largely unregulated clinical castrations, penectomies, and similar procedures for at least a couple of decades now.) But he got too sick while there to go through with the surgery. Finally, the modification community connected him to a Canadian cutter who fully castrated him.

Many of the cutters Steve has encountered since then are, to his knowledge, medically trained, albeit only some as surgeons. A few are actually veterinarians. But William notes that a fair number are not medical experts. He’s encountered some who work in government services, some who work in banking, some who work in manufacturing. Still, they want to help—in more than a few cases because they received operations from cutters that they deeply valued. So, they study surgery as best as they can. William’s cutter told him in detail about the books he’d read and his “practice with suturing the skin back onto grapes, which requires fine stitch work.” Some cutters even offer to do procedures for free, so long as clients can buy and bring key medical supplies.

Cautious and conscientious cutters refuse to perform complicated procedures—which is why most of them only do testicle removals—and take pains to try to make sure their patients know what they’re stepping into and stay safe. Few people would seek out cutters for more complicated or risky surgeries, like penectomies, anyway.

“The risk of something going wrong is extremely high,” said William of his decision not to pursue a penectomy with a cutter. “I also don’t wish to look like Frankenstein at the end of the procedure,” with uneven flesh or highly visible scarring.

William’s cutter repeatedly talked through the details of his hotel orchiectomy and its potential implications with him, he said, right up until he was ready to make his incision. Then, the man monitored him for 48 hours after, ready with a plan to get him to an emergency room ASAP.

Planning for emergencies often involves formulating a careful cover story for one’s injury, or resolving to claim it was a DIY attempt, noted Steve, who’s seen a number of these arrangements play out in the past in communities he’s been involved with. (Some of these cover stories truck in sensationalism as well, spinning tales of sadistic kidnappers and torture. This may help people get sympathetic treatment in the short run, but it risks contributing to the popular stigmatization of queer and kink communities overall in the long run.) He stressed that he and others feel a deep sense of duty to protect the people who helped them feel whole and right in their bodies.

“Even if I was hard-pressed under oath, I couldn’t even begin to give people’s names to the authorities,” he said. “Because I never knew anyone’s names—if you understand what I mean.”

In any underground ecosystem, however, opacity and fragmentation creates a fertile space for over-promising amateurs and abusive creeps. Some just want to cause others pain —they may even find non-consensual sadism erotic. A notorious nullo man who goes by Gelding , a greyed yet still strapping bear who’s posted many nude photos online, has talked in the past about how he will only assist cutters, never performing procedures himself, because he does not trust his own motives , a bifurcated desire to help and to get off on the experience. The internet unfortunately makes it easier for people to meet random self-identified cutters on forums, rather than through established and verified contact networks, and work with them with little vetting.

Whether one ends up with a well-intentioned and trained cutter, or a bad actor looking to cause pain, medical experts stress that working with cutters instead of licensed professionals always carries a risk. They know that some feel they need to take the risk—and think it is tragic.

Over the last five years or so, Schechter notes, the field of gender surgery “has expanded our thinking beyond the gender binary.” Doctors have developed new guidelines for working with people with diverse gender identities and surgical desires, which, as Schechter put it, “place a greater importance on body autonomy and self-decision.” This shift opens experts up to diverse requests without making patients prove, over years of therapy, that they fit an established identity box, just so long as they can show they fully understand the long-term ramifications of the procedures they’re asking for. Well over a dozen gender surgery practices in America alone now openly advertise their readiness to perform all sorts of surgeries; running lists of these practices on eunuch and non-binary forums grow by the year.

“It’s nowhere near as weird and difficult to try to become a eunuch now as it was 30 years ago,” said Benedict, the castrated reverend. “Now, we have doctors who don’t even blink when you say you want to just remove your testicles, or just add a vagina. I never saw this coming.”

“I have certainly noticed an uptick in the pursuit of castration by young men in recent years,” he added, an observation that aligns with Wassersug’s findings that more “eunuch wannabes,” as he calls them, would pursue the process if it were cheaper and easier to access safely, in a clinic.

Everyone The Daily Beast spoke to for this story agreed that the greater availability of open and official care—far more than horror stories and crackdowns—has led to a drastic decline in demand for cutters, which means there are now fewer of them practicing than there were five or ten years ago. Even many forums where people used to solicit and chat with cutters, like Eunuch Archive , a major hub for people interested in voluntary castrations, now tightly police those posts and conversations, and redirect people towards licensed experts.

“At this point, cutters have been relegated to obscure forums on the deep web,” said Zach. Talks with them usually unfold only in the privacy of the most encrypted messaging platforms.

However, knowledge of new guidelines remains low and gender-aware support services for folks with less traditional surgical needs will take time to scale up, said Daniel Dugi, a gender surgeon in Portland, Oregon, who just started working beyond the world of binary trans surgeries this year. Far too many medical experts still tend to read people who are not binary trans but want to remove part or all of their genitals as mentally ill and to recommend institutionalization, noted Johnson.

Most surgeons who do more diverse procedures are still clustered in a few major urban centers, and the procedures, which can run upwards of $10,000, are not covered by most insurers. Even when they are, or when people pursue cheaper surgeries at clinics in Mexico and beyond, the costs associated with travel and recovery care can be too high for individuals living with limited means. Gender minorities are often economically and socially marginalized .

Wider lingering social stigmas against gender diversity also makes it difficult for many people to pursue official treatments, for fear of folks in their lives who they are not out to, and don’t want to come out to, figuring out what they’re doing. Even people who are secure in their identities and out to their friends may carry traumatic memories of their experiences with the medical system in the past. So, not everyone who can access legit surgery in theory really can in practice.

All of these limitations mean that, even if their ranks are declining, there is still an unfortunate need for cutters in the world. “I just talked to a man weeks ago through Eunuch Maker,” Benedict told The Daily Beast. “He lives in a red state, where health care is still not widely available. He just met a cutter in a trailer in Oklahoma… It’s just so unnecessary now, and so terrible. And yet… it is still necessary, because of the context in areas like that.”

“Regardless of how much progress we do eventually make in providing people access to quality health care,” William added, “some people will still seek out cutters” for more personal reasons.

Simply put, a number of people who seek genital modifications or removals want the experience to be erotic and intimate—a kinky, sexual experience. In fact, Zach says the only cutter he’s ever spoken to who claims to have done a full at-home penectomy “was an older man who did it to his partner about a decade ago” as part of a BDSM power play body modification dynamic.

Schechter acknowledged the potential legitimacy of this desire, while cautioning against pursuing it because of all the ways that non-professional surgeries can go wrong. But he did not have a clear idea of how to work with this sort of desire within an official medical context—how to bring these cutter users into the clinic.

However, overall Schechter believes that the existence of cutters speaks to a core reality: “People need care. And in desperate circumstances, to get that care, they may do desperate things.”

So, people active in this world argue, if tales of cutters slicing into scrotums in backwoods cabins make us uncomfortable, we shouldn’t gawp and call for major crackdowns on what may seem like unhinged predators from the outside. That sort of sensationalism only hurts the people who seek them out, they explain, as it drives cutters even further underground, making it harder to vet their knowledge and intentions, and casts the people who seek them out for lack of other care options as unhinged.

“What is important is that we have accurate information in the media about eunuchs, nullos, and other people” who go to cutters, Johnson argued, “rather than the look at the freaks sentiment that appears in nearly all popular depictions of these people and situations.” We need to fully understand and respect why people make the choices they do, and deliver the support they need.

Even more important, William said, is building a world where people “have complete control of their bodies, no matter how radical the procedures they seek or need may seem to someone else.”

A world without cutter horror stories is, simply, a world where it is safe to be whoever we are.

The names of William, Zach, and Steve have been changed in order to protect their privacy.

Read more at The Daily Beast.

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