Increase in Detection of Respiratory Syncytial Virus Among Older Adults in Arizona : An Association With Changes in Testing Practices.

OBJECTIVES: Respiratory syncytial virus (RSV) is a common cause of respiratory illness, health care visits, and hospitalizations. Arizona, which began conducting laboratory surveillance in 2004, has noted an increase in RSV cases (defined as a laboratory-positive result) among adults aged ≥65, concurrent with increasing reports from polymerase chain reaction (PCR) testing. We assessed whether the shift in the age distribution of reported RSV cases resulted from a change in RSV testing practices. METHODS: We used data on laboratory-confirmed RSV cases reported during 2013-2017 from the statewide surveillance system to assess the frequency of test types (rapid antigen, immunofluorescence assay, PCR, and viral culture) by age groups across RSV seasons, and we used logistic regression to estimate changes in odds of receiving a PCR test. We used statewide emergency department hospital discharge data for the same period to assess testing practices regardless of test result. RESULTS: The overall proportion of PCR tests among RSV cases increased significantly, from 22% in 2013 to 55% in 2017 (P < .001). The percentage of RSV cases among adults aged ≥65 also increased significantly, from 4% in 2013 to 11% in 2017 (P < .001) of RSV cases. Adults aged ≥65 had more than 8 times the odds of positive PCR results than children aged <5, both in crude (odds ratio [OR] = 8.8; 95% CI, 7.6-10.2) and season-adjusted (adjusted OR = 8.1; 95% CI, 7.0-9.5) models. Hospital discharge data corroborated increased RSV PCR usage from 2013 to 2017. CONCLUSION: Increasing RSV rates among adults aged ≥65 are likely a result of changes in testing practices. This age group may need more targeted intervention and future vaccination.

Utilizing Electronic Laboratory Reporting Data to Assess the Burden of Hepatitis C in Arizona.

CONTEXT: Hepatitis C virus (HCV) infections must be reported to public health departments in Arizona; however, Arizona Department of Health Services has not had the resources to conduct comprehensive HCV surveillance since 2008 and thus monitoring HCV is difficult. Cases were traditionally reported via mail, fax, or telephone; however, beginning in 2009, clinical laboratories could report HCV results through electronic laboratory reporting (ELR). OBJECTIVE: To assess completeness of ELR in capturing HCV case reports and its utility for HCV surveillance and describing the current burden of HCV. DESIGN: Two components of study: (1) HCV reporting from all sources for 2 months in 2015 was de-duplicated at the patient level and cross-matched with the 1998-2008 database and 2009-2015 ELR data to identify cases newly reported during the 2-month period and calculate the proportion reported through ELR. (2) HCV ELR results during 2009-2015 were similarly de-duplicated and compared with the 1998-2008 database to identify newly reported cases. SETTING: Hepatitis C virus patients reported to Arizona Department of Health Services. PARTICIPANTS: Hepatitis C virus case patients reported during 1998-2008 and through ELR during 2009-2015. Hepatitis C virus patients through paper reports for January and June 2015. MAIN OUTCOME MEASURES: (1) Using 2 months of all HCV reporting in 2015 to examine the proportion of cases captured by ELR and the differences in the type of reports captured by ELR and non-ELR sources only. (2) Compared sex, birth year, viral load, and genotype from ELR-only data to other surveillance data. RESULTS: Electronic laboratory reporting accounted for 1260 (64%) HCV cases newly reported during the 2 months, with 698 (36%) newly identified from non-ELR sources only. Based on these findings, an estimated 11 534 HCV cases were newly reported in 2015 (172 cases per 100 000 population). During 2009-2015, a substantial amount (23%) of newly reported cases were among persons born after 1978. CONCLUSIONS: Utilizing ELR data alone can provide meaningful HCV surveillance and offers a less resource-intensive means to describe HCV burden and identify trends in newly reported cases. An assessment like this one can provide a tool for HCV monitoring in other jurisdictions that lack resources for HCV surveillance as more laboratories transition to ELR.

Dengue Knowledge, Attitudes, and Practices Among Arizona Health Care Providers, 2014-2015.

Background: Detection of local dengue transmission requires an aware and engaged medical community, as health care providers are the front line of public health surveillance. To assess the knowledge, attitude, and practice about dengue, an online survey was distributed among Arizona health care providers during 2014 and 2015. Materials and Methods: The survey consisted of a total of 10 knowledge, attitude, and practice questions divided as follows: 5 knowledge questions, 2 attitude questions, and 3 practice questions. The link to the Qualtrics survey was distributed through the Arizona Health Alert Network to a total of 4582 e-mail addresses, of which 335 participants opened the survey, and 196 completed and submitted their responses. Results: Less than half the respondents reported choosing the right dengue diagnostic test (40.4%) or understanding the epidemiology of dengue in Arizona (40.9%). Slightly more than half the respondents reported frequently asking for travel history (59%), and three-fourth of them would notify the local health department on suspicion of a dengue patient (76.1%). Survey score was associated with providers specialized in infectious diseases (1.88, 95% CI: 0.42-3.33, p = 0.01), medical doctors or doctors of osteopathic medicine (1.82, 95% CI: 0.98-2.65, p < 0.0001), and respondents who reported to have heard about the increase in dengue cases in Sonora (Mexico) in fall 2014 (1.51, 95% CI: 0.67-2.34, p = 0.0005), indicating better survey performance. Conclusions: These results indicate that education for health care providers on dengue should be improved particularly among general practice noninfectious disease providers who might be the first point of care for dengue patients. Findings suggest that additional training on clinical management, asking travel history, and notifying the local health department on suspicion of a dengue patient are needed.

Surveillance for severe acute respiratory infections in Southern Arizona, 2010-2014.

BACKGROUND: The Binational Border Infectious Disease Surveillance program began surveillance for severe acute respiratory infections (SARI) on the US-Mexico border in 2009. Here, we describe patients in Southern Arizona. METHODS: Patients admitted to five acute care hospitals that met the SARI case definition (temperature ≥37·8°C or reported fever or chills with history of cough, sore throat, or shortness of breath in a hospitalized person) were enrolled. Staff completed a standard form and collected a nasopharyngeal swab which was tested for selected respiratory viruses by reverse transcription polymerase chain reaction. RESULTS: From October 2010-September 2014, we enrolled 332 SARI patients. Fifty-two percent were male and 48% were white non-Hispanic. The median age was 63 years (47% ≥65 years and 5·2% <5 years). During hospitalization, 51 of 230 (22%) patients required intubation, 120 of 297 (40%) were admitted to intensive care unit, and 28 of 278 (10%) died. Influenza vaccination was 56%. Of 309 cases tested, 49 (16%) were positive for influenza viruses, 25 (8·1%) for human metapneumovirus, 20 (6·5%) for parainfluenza viruses, 16 (5·2%) for coronavirus, 11 (3·6%) for respiratory syncytial virus, 10 (3·2%) for rhinovirus, 4 (1·3%) for rhinovirus/enterovirus, 3 (1·0%) for enteroviruses, and 3 (1·0%) for adenovirus. Among the 49 influenza-positive specimens, 76% were influenza A (19 H3N2, 17 H1N1pdm09, and 1 not subtyped), and 24% were influenza B. CONCLUSION: Influenza viruses were a frequent cause of SARI in hospitalized patients in Southern Arizona. Monitoring respiratory illness in border populations will help better understand the etiologies. Improving influenza vaccination coverage may help prevent some SARI cases.

The role of ethnicity and travel on Hepatitis A vaccination coverage and disease incidence in Arizona at the United States-Mexico Border.

BACKGROUND: Hepatitis A (HAV) incidence has decreased in the United States, yet regional disparities persist. The role of international travel has become increasingly important in HAV transmission. We compared the relative burden of HAV in border and non-border regions in Arizona and examined the role of travel in sustaining HAV transmission. METHODS: HAV vaccination coverage was calculated by age and region, using Arizona State Immunization Information System data. Incidence, demographics, and risk factors of cases reported through Arizona's infectious disease surveillance system between 2006 and 2011 were analyzed. RESULTS: Hepatitis A incidence was higher in the border region of Arizona. Compared with the rest of Arizona, one-dose coverage in children<15 years was lower in the border region until 2008. Second dose coverage was lower in the border region, particularly among Spanish speakers. International travel among cases was generally high; however, in the border region cases were more likely to visit Mexico or South/Central America (94% vs. 80%, P value = 0.01) and be Hispanic (68% vs. 42%, P value = 0.0003). CONCLUSIONS: Rates of HAV continue to be higher in the Arizona border region; the risk appears particularly high among Hispanics with recent travel in the Americas. Border surveillance should be emphasized, along with vaccination of all travelers, to continue to decrease and control HAV.

The changing epidemiology of hepatitis A in Arizona following intensive immunization programs (1988-2007).

INTRODUCTION: Arizona had the highest hepatitis A incidence of any U.S. state during 1987-1997. In 1995, the first hepatitis A vaccines became available in the U.S. A series of hepatitis A vaccination policies and recommendations were implemented in 1996-2006. Our objective was to examine the shifting epidemiologic patterns in hepatitis A in Arizona from 1988 to 2007. METHODS: Passive surveillance reports to the Arizona Department of Health Services were used to compare hepatitis A rates by age, race/ethnicity and geographic area, before and after widespread vaccination. Reported risk factors and possible sources of infection were compared for two time periods. Age-adjusted incidence during three periods was mapped. RESULTS: Overall hepatitis A incidence in Arizona fell from 58 cases per 100,000 in 1988 to 2 per 100,000 in 2007. The proportion of reported cases among children dropped from 62% in 1994-1995 to 32% in 2006-2007. Racial/ethnic disparities between American Indians and non-Hispanic White populations have been eliminated. The geographic distribution of cases within the state has shifted. Earlier cases were likely to report contact with another hepatitis A case or childcare facilities, while later cases indicated recent international travel. CONCLUSION: A major shift in the overall burden of hepatitis A and hepatitis A transmission has occurred in Arizona since the widespread implementation of immunization policies and the concomitant rise in vaccination rates in the state. Current transmission has shifted to older age groups and disparities by race/ethnicity are now highest in Hispanic populations. Future strategies to further reduce hepatitis A transmission may require broadening recommendations to include general adult populations without previous vaccination history.

Variations in positive predictive values for rapid influenza tests for 2009 pandemic influenza a (pH1N1)--Arizona, April-October 2009.

CONTEXT: Rapid influenza diagnostic tests (RIDTs) are used for influenza screening, clinical decision making, and influenza surveillance. In August 2009, a hospital reported increased false-positive RIDT results to the Arizona Department of Health Services. Because of reported RIDT low sensitivities (40%-62%) for 2009 pandemic influenza A (pH1N1), the hospital's report raised further concerns about the specificity and clinical utility of RIDTs. OBJECTIVE: To determine the positive predictive value (PPV) of RIDTs compared with real-time reverse transcription-polymerase chain reaction assay (rRT-PCR) using Centers for Disease Control and Prevention (CDC) protocols and primers as a standard. DESIGN: A standardized survey collected information including RIDT brand/lot number, training of personnel performing test, type of laboratory, swab and specimen type, time from collection to testing, sample storage, and viral transport medium. SETTING: Arizona. PARTICIPANTS: Seven Arizona laboratories submitted positive RIDT clinical samples to Arizona State Public Health Laboratory (ASPHL) for confirmatory rRT-PCR testing. MAIN OUTCOME MEASURE: The PPV was calculated on the basis of rRT-PCR-positive results for April through October. RESULTS: Results from 600 specimens using 1 of 4 RIDTs were available. Median pH1N1 PPV was 80% (range: 62%-91%) when calculated by RIDT brand. A significant difference in PPV was identified between the 2 largest facilities, which used the same RIDT brand, BinaxNOW Influenza A&B, (Laboratories A, 33% and B, 92%, [P < .01]). The facilities reported similar testing practices except lot numbers used and timing of testing. Laboratory A used lot 003684 and performed testing within 1 hour of collection; Laboratory B used multiple lots, excluding lot 003684, and performed testing within 24 hours. Laboratory A switched RIDT brands and noted a significant PPV increase from 33% to 91% (P < .01). CONCLUSIONS: Wide PPV variability combined with documented low sensitivity among RIDTs for pH1N1 diagnosis increases concerns about their specificity and clinical and epidemiologic utility for influenza.

The effect of policy changes on hepatitis A vaccine uptake in Arizona children, 1995-2008.

OBJECTIVE: In 1995, the first hepatitis A vaccines became available for use. At that time, Arizona had the highest hepatitis A incidence of all 50 states. During that same time period, the Arizona State Immunization Information System (ASIIS) was created to collect information on all immunizations given in the state. Four state-level hepatitis A vaccination policies were enacted according to Centers for Disease Control and Prevention recommendations and local initiatives from 1996 to 2005. Our primary objective was to assess the impact of these policies on vaccine uptake in children. METHODS: Immunization records from ASIIS were used to calculate yearly coverage of children with at least one reported hepatitis A vaccination between 1995 and 2008. Proportions vaccinated were calculated by age group (12-23 months, 24-59 months, 5-9 years, 10-14 years, and 15-19 years) for three regions: Maricopa County; Apache and Navajo counties; and the remaining 12 Arizona counties, which were grouped as one to reflect different target groups for the four policies examined. We calculated percent changes from before and after each policy implementation. RESULTS: Significantly different percent changes were detected among the three regions that related to the four policies implemented. Percent change in uptake was consistently higher in the regions that were targeted for that specific policy. CONCLUSIONS: Analysis of ASIIS data revealed a major effect of hepatitis A policy recommendations on vaccine uptake in Arizona. Targeting high-risk populations through vaccine recommendations and child care entry requirements was highly successful in achieving higher vaccination coverage.

The public health impact of coccidioidomycosis in Arizona and California.

The numbers of reported cases of coccidioidomycosis in Arizona and California have risen dramatically over the past decade, with a 97.8% and 91.1% increase in incidence rates from 2001 to 2006 in the two states, respectively. Of those cases with reported race/ethnicity information, Black/African Americans in Arizona and Hispanics and African/Americans in California experienced a disproportionately higher frequency of disease compared to other racial/ethnic groups. Lack of early diagnosis continues to be a problem, particularly in suspect community-acquired pneumonia, underscoring the need for more rapid and sensitive tests. Similarly, the inability of currently available therapeutics to reduce the duration and morbidity of this disease underscores the need for improved therapeutics and a preventive vaccine.

Coccidioidomycosis: knowledge, attitudes, and practices among healthcare providers--Arizona, 2007.

Coccidioidomycosis presumably causes ≤ 33% of community-acquired pneumonias cases, although < 15% of the patients are tested for coccidioidomycosis. We assessed healthcare providers' knowledge, attitudes, and practices regarding coccidioidomycosis diagnosis and treatment in Arizona. A survey was mailed to 7,608 eligible healthcare providers licensed by the Arizona medical, osteopathic, and nursing boards in October and December 2007. We used weights to adjust for non-response and multivariate logistic regression models to identify predictors of ≥ 70% correct regarding knowledge and treatment practices. Of 1,823 (24%) respondents, 53% were physicians, 52% were male, and the mean age was 51 years. Approximately 50% reported confidence in their ability to treat coccidioidomycosis, and 21% correctly answered all four treatment questions. Predictors of ≥ 70% correct concerning knowledge and treatment practices included always counseling patients after diagnosis (adjusted odds ratio [AOR]=4.4; 95% confidence interval [CI]: 2.8-7.1); specializing in infectious diseases (AOR=2.4; 95% CI: 1.0-5.7); and having received coccidioidomycosis continuing medical education (CME) in the last year (AOR=1.8; 95% CI: 1.2-2.6). These findings demonstrate that coccidioidomycosis CME improves knowledge of disease diagnosis and management, underscoring the need for a comprehensive coccidioidomycosis education campaign for healthcare providers in Arizona.

Effect of school closure on the incidence of influenza among school-age children in Arizona.

OBJECTIVE: We assessed the impact of school closures as a viable intervention in the event of an influenza pandemic. METHODS: We evaluated the effect of scheduled, two-week winter break school closures during the 2004-2008 school years on the occurrence of influenza among children aged 5-17 years in Arizona. RESULTS: We found a consistent pattern of benefit to school-age children during winter school closures when non-school-age children and adults experienced significant increases in influenza incidence, an increase not seen among school-age children. Quantitative analysis showed that school closures may prevent or delay as much as 42% of potential influenza cases among school-age children. In addition, the ratio of illness in school-age children as compared with adults and non-school-age children decreased significantly from before to during the same school closure periods. CONCLUSION: This analysis provides evidence to suggest that school-age children may experience a slowing of influenza transmission during winter school closures compared with those not of school age. Federal, state, and local policy makers may consider these findings in their pandemic influenza and public health emergency preparedness planning efforts.

Enhanced surveillance of coccidioidomycosis, Arizona, USA, 2007-2008.

Coccidioidomycosis is endemic to the southwestern United States; 60% of nationally reported cases occur in Arizona. Although the Council of State and Territorial Epidemiologists case definition for coccidioidomycosis requires laboratory and clinical criteria, Arizona uses only laboratory criteria. To validate this case definition and characterize the effects of coccidioidomycosis in Arizona, we interviewed every tenth case-patient with coccidioidomycosis reported during January 2007-February 2008. Of 493 patients interviewed, 44% visited the emergency department, and 41% were hospitalized. Symptoms lasted a median of 120 days. Persons aware of coccidioidomycosis before seeking healthcare were more likely to receive an earlier diagnosis than those unaware of the disease (p = 0.04) and to request testing for Coccidioides spp. (p = 0.05). These findings warrant greater public and provider education. Ninety-five percent of patients interviewed met the Council of State and Territorial Epidemiologists clinical case definition, validating the Arizona laboratory-based case definition for surveillance in a coccidiodomycosis-endemic area.

Fever in patients with mixed-species malaria.

BACKGROUND: Clinical symptoms of mixed-species malaria infections have been variously reported as both less severe and more severe than those of single-species infections. METHODS: Oral temperatures were taken from and blood slides were prepared for 2308 adults who presented at outpatient malaria clinics in Tak Province (Thailand) during May-August 1998, May-July 1999, and May-June 2001 with malaria infections diagnosed by 2 expert research microscopists, each of whom was blinded to the other's reports. RESULTS: In each year, temperatures of patients with mixed Plasmodium vivax-Plasmodium falciparum infections were higher than temperatures of patients with P. vivax or P. falciparum infections. In every mixed-species case, P. falciparum parasitemia was higher than P. vivax parasitemia, but patient temperature was not correlated with the parasitemia of either species or with the total parasitemia. CONCLUSIONS: Among adults who self-report to malaria clinics in western Thailand, patients with mixed P. vivax-P. falciparum infections have higher fevers than patients with single-species infections, a distinction that cannot be attributed to differences in parasitemia. This observation warrants more detailed investigations, spanning wider ranges of ages and transmission environments.

Gametocytemia in Plasmodium vivax and Plasmodium falciparum infections.

Two expert research microscopists, each blinded to the other's reports, diagnosed single-species malaria infections in 2,141 adults presenting at outpatient malaria clinics in Tak Province, Thailand, and Iquitos, Peru, in May-August 1998, May-July 1999, and May-June 2001. Plasmodium vivax patients with gametocytemia had higher fever and higher parasitemia than those without gametocytemia; temperature correlated with parasitemia in the patients with gametocytemia. Plasmodium falciparum patients with gametocytemia had lower fever than those without gametocytemia, but similar parasitemia; temperature correlated with parasitemia in the patients without gametocytemia. Hematologic data in Thailand in 2001 showed lower platelet counts in P. vivax patients with gametocytemia than in the P. vivax patients without gametocytemia, whereas P. falciparum patients with gametocytemia had similar platelet counts but lower red blood cell counts, hemoglobin levels, hematocrit levels, and higher lymphocyte counts than patients without gametocytemia.

Hematologic and clinical indices of malaria in a semi-immune population of western Thailand.

This study examines hematologic profiles of persons with acute Plasmodium falciparum or P. vivax infection in Maesod on Thailand's western border with Myanmar compared with febrile, non-parasitemic persons also reporting to malaria clinics. Nine hundred seventy-nine subjects were malaria-negative, 414 were infected with P. falciparum, and 646 were infected with P. vivax. Persons with patent parasitemia tended to have significantly lower white blood cell, red blood cell, platelet, and hemoglobin levels than those who were malaria-negative. For the first time, a parallel trend in thrombocytopenia with parasitemia was found to be associated with both P. falciparum, and P. vivax infection. Using logistic regression, persons with platelet counts < 150,000/microL were 12-15 times more likely to have malaria than persons with platelet counts > or = 150,000/microL. This study supplements previous literature on the hematologic effects of malaria and helps define those alterations for a semi-immune population. Thrombocytopenia is identified as a key indicator of malaria in these febrile patients.

Prevalence and characteristics of children at increased risk for complications from influenza, United States, 2000.

OBJECTIVES: Annual influenza vaccination is recommended for children at high risk of complications from influenza due to underlying medical conditions, but few children are vaccinated. Vaccination also is encouraged for all children aged 6 to 23 months when feasible. This study describes the prevalence and characteristics of at-risk children nationwide. STUDY DESIGN: A descriptive analysis of the 2000 National Health Interview Survey (NHIS) was conducted among children in the United States aged 6 months through 17 years with identified high-risk conditions, and among all children aged 6 to 23 months. RESULTS: Approximately 5.2 to 10.0 million children aged 6 months through 17 years (7.4%-14.2%) had high-risk conditions indicated for influenza vaccination. Asthma accounted for the majority of conditions. An estimated 7.7 million children would be aged 6 to 23 months during influenza season. Most young children and older children at high-risk have access to and frequently utilize healthcare services. CONCLUSIONS: Existing doctor visits are important opportunities for vaccinating children with high-risk conditions, or for those aged 6 to 23 months. Additional efforts are needed to implement and evaluate efficient strategies for annual influenza vaccination of children aged 6 to 23 months and for older children with medical indications.