Background: Due to limited therapeutic options and potential for spread, carbapenem-resistant Enterobacteriaceae (CRE)-producing New Delhi metallo-β-lactamases (NDMs) are a public health priority. We investigated the epidemiology of NDM-producing CRE reported to the CDC to clarify its distribution and relative prevalence. Methods: The CDC’s Antibiotic Resistance Laboratory Network supports molecular testing of CRE for 5 carbapenemases nationally. Although KPC is the most common carbapenemase in the United States, non-KPC carbapenemases are a growing concern. We analyzed CRE with any of 4 non-KPC plasmid-mediated carbapenemases (NDM, VIM, IMP, or OXA-48 type) isolated from specimens collected from January 1, 2017, through June 30, 2019; only a patient’s first isolate per organism–carbapenemase combination was included. We excluded isolates from specimen sources associated with colonization screening (eg, perirectal). We compared the proportion of NDM-producing CRE to all non-KPC–producing CP-CRE between period A (January to June 2018) and period B (January to June 2019). Health departments and the CDC collected additional exposure and molecular information in selected states to better describe current NDM-producing CRE epidemiology. Results: Overall, 47 states reported 1,013 non–KPC-producing CP-CRE (range/state, 1–109 isolates; median, 11 isolates); 46 states reported 631 NDM-producing CRE (range/state, 1–84; median, 6). NDM-producing CRE increased quarterly from the third quarter of 2018 through the second quarter of 2019; CP-CRE isolates with other non-KPC carbapenemases remained stable (Fig. 1). In period A, 124 of 216 emerging CP-CRE had NDM (57.1%), compared with 255 of 359 emerging CP-CRE (71.0%) during period B (P = .1179). Among NDM-producing CRE, the proportion of Enterobacter spp increased from 10.5% in 2018 to 18.4% in 2019 (P = .0467) (Fig. 2). In total, 18 states reported more NDM-producing CRE in the first 6 months of 2019 than in all of 2018. Connecticut, Ohio, and Oregon were among states that conducted detailed investigations; these 3 states identified 24 NDM-producing CRE isolates from 23 patients in period B. Overall, 5 (21.7%) of 22 patients with history available traveled internationally ≤12 months prior to culture; 17 (73.9%) acquired NDM-producing CRE domestically. Among 15 isolates sequenced, 8 (53.3%) carried NDM-5 (6 E. coli, 1 Enterobacter spp and 1 Klebsiella spp) and 7 (46.7%) carried NDM-1 (6 Enterobacter spp and 1 Klebsiella spp). Species were diverse; no single strain type was shared by >2 isolates. Conclusions: Detection of NDM-producing CRE has increased across the AR Lab Network. Among states with detailed information available, domestic acquisition was common, and no single variant or strain predominated. Aggressive public health response and further understanding of current US NDM-CRE epidemiology are needed to prevent further spread.

Disclosures: None

Funding: None

Subglacial Antarctic aquatic environments are important targets for scientific exploration due to the unique ecosystems they support and their sediments containing palaeoenvironmental records. Directly accessing these environments while preventing forward contamination and demonstrating that it has not been introduced is logistically challenging. The Whillans Ice Stream Subglacial Access Research Drilling (WISSARD) project designed, tested and implemented a microbiologically and chemically clean method of hot-water drilling that was subsequently used to access subglacial aquatic environments. We report microbiological and biogeochemical data collected from the drilling system and underlying water columns during sub-ice explorations beneath the McMurdo and Ross ice shelves and Whillans Ice Stream. Our method reduced microbial concentrations in the drill water to values three orders of magnitude lower than those observed in Whillans Subglacial Lake. Furthermore, the water chemistry and composition of microorganisms in the drill water were distinct from those in the subglacial water cavities. The submicron filtration and ultraviolet irradiation of the water provided drilling conditions that satisfied environmental recommendations made for such activities by national and international committees. Our approach to minimizing forward chemical and microbiological contamination serves as a prototype for future efforts to access subglacial aquatic environments beneath glaciers and ice sheets.

This article looks at the development of the concept of crimes against humanity at the International Criminal Tribunal for Rwanda (ICTR). It contends that the ICTR’s interpretation of crimes against humanity is generally seen by international lawyers as a commendable, but unsurprising, step in the historical development of this category. In much the same way, the ICTR’s historical account is considered to be a standard attempt by a war crimes court to relate a liberal history of crimes against humanity in a way that upholds civilized values. Yet, although the historical and legal work of the ICTR appear unexceptional, this article will argue that they do demonstrate a particular conceptual approach towards warfare, history, humanity, and the nature of international law. Moreover, this is a conceptual approach that is quite different to that taken by the International Military Tribunal at Nuremberg. The article suggests that these differences, and the invisibility of the change, are due to the ICTR’s reliance on familiar narrative tropes. These narratives were established through poststructuralist theory but could be expressed in a variety of more or (often) less theoretical forms. By exploring the influence of these narratives on the Tribunal, it is possible to examine some of the ways in which conceptual change is facilitated and knowledge is created in international law. In particular, it shows how theories that are often considered marginal to international law have had a significant impact on some of the central provisions of international humanitarian law.

Late prehistoric archaeological research in Myanmar is in a phase of rapid expansion. Recent work by the Mission Archéologique Française au Myanmar aims to establish a reliable Neolithic to Iron Age culture-historical sequence, which can then be compared to surrounding regions of Southeast Asia. Excavations at Nyaung'gan and Oakaie in central Myanmar have provided 52 new AMS dates, which allow the creation of Myanmar's first reliable prehistoric radiometric chronology. They have also identified the Neolithic to Bronze Age transition in central Myanmar, which is of critical importance in understanding long-range interactions at the national, regional and inter-regional level. This research provides the first significant step towards placing late prehistoric Myanmar in its global context.

High-profile advocates are pushing states to move away from judicial elections and toward a “merit” method because it purportedly produces the best quality judges. Quality, however, is difficult to measure empirically. Rather than attempt to measure quality, we examine whether certain types of state supreme courts are more forward-looking than others. States are likely to desire forward-looking behavior among judges because it can protect judicial legitimacy, help states to control policy, and could be more efficient than myopic behavior. Using a recent innovation in matching called covariate-balancing propensity scores, we find that the U.S. Supreme Court is equally likely to review and reverse decisions by judges regardless of their selection or retention methods. These results suggest that state supreme court justices, no matter their paths of getting to (and staying on) their courts, are roughly equal in terms of forward-looking behavior.

Do international nongovernmental organizations (INGOs) lessen the need for states to provide their own services? In the case of health, many assume that INGOs limit health spending by governments. Against the conventional wisdom, we argue that these organizations create increased demand for governmental health spending through three mechanisms: (1) indirectly affecting the policy-making climate (“climatic conditioning”), (2) aiding domestic NGO and health activists in their efforts, and (3) directly pressuring governments for increased health spending themselves. Given these mechanisms, health INGOs, although typically supplying health services of their own within a country, should augment pressure for public service provision by the state and, it follows, lead to increased state health spending. We test our argument using a new data set on health INGOs, together with a well-established model of health spending, and find ample support for our arguments. Increases in health INGOs' activities do lead to increased governmental health spending, mainly by indirectly affecting the policy-making climate and, most especially, advancing the effective efforts of domestic activists.

The Whillans Ice Stream Subglacial Access Research Drilling (WISSARD) project will test the overarching hypothesis that an active hydrological system exists beneath a West Antarctic ice stream that exerts a major control on ice dynamics, and the metabolic and phylogenetic diversity of the microbial community in subglacial water and sediment. WISSARD will explore Subglacial Lake Whillans (SLW, unofficial name) and its outflow toward the grounding line where it is thought to enter the Ross Ice Shelf seawater cavity. Introducing microbial contamination to the subglacial environment during drilling operations could compromise environmental stewardship and the science objectives of the project, consequently we developed a set of tools and procedures to directly address these issues. WISSARD hot water drilling efforts will include a custom water treatment system designed to remove micron and sub-micron sized particles (biotic and abiotic), irradiate the drilling water with germicidal ultraviolet (UV) radiation, and pasteurize the water to reduce the viability of persisting microbial contamination. Our clean access protocols also include methods to reduce microbial contamination on the surfaces of cables/hoses and down-borehole equipment using germicidal UV exposure and chemical disinfection. This paper presents experimental data showing that our protocols will meet expectations established by international agreement between participating Antarctic nations.