Outbreak of Tattoo-associated Nontuberculous Mycobacterial Skin Infections.

BACKGROUND: On 29 April 2015, the Florida Department of Health in Miami-Dade County (DOH Miami-Dade) was notified by a local dermatologist of 3 patients with suspected nontuberculous mycobacterial (NTM) infection after receiving tattoos at a local tattoo studio. METHODS: DOH Miami-Dade conducted interviews and offered testing, described below, to tattoo studio clients reporting rashes. Culture of clinical isolates and identification were performed at the Florida Bureau of Public Health Laboratories. Characterization of NTM was performed by the Centers for Disease Control and Prevention and the US Food and Drug Administration (FDA), respectively. Whole-genome sequencing (WGS) and single-nucleotide polymorphism (SNP) analyses were used to construct a phylogeny among 21 Mycobacterium isolates at the FDA. RESULTS: Thirty-eight of 226 interviewed clients were identified as outbreak-associated cases. Multivariate logistic regression revealed that individuals who reported gray tattoo ink in their tattoos were 8.2 times as likely to report a rash (95% confidence interval, 3.1-22.1). Multiple NTM species were identified in clinical and environmental specimens. Phylogenetic results from environmental samples and skin biopsies indicated that 2 Mycobacterium fortuitum isolates (graywash ink and a skin biopsy) and 11 Mycobacterium abscessus isolates (5 from the implicated bottle of graywash tattoo ink, 2 from tap water, and 4 from skin biopsies) were indistinguishable. In addition, Mycobacterium chelonae was isolated from 5 unopened bottles of graywash ink provided by 2 other tattoo studios in Miami-Dade County. CONCLUSIONS: WGS and SNP analyses identified the tap water and the bottle of graywash tattoo ink as the sources of the NTM infections.

Accreditation's Role in Bolstering Resilience in the Face of the Zika Virus Outbreak.

The Florida Department of Health (Department) received accreditation status as an integrated public health system from the Public Health Accreditation Board (PHAB) in 2 phases: the State Health Office received accreditation in June 2014 and the 67 county health departments received accreditation in March 2016. Six weeks after PHAB awarded accreditation to the Department as an integrated public health system in March 2016, the World Health Organization declared the Zika outbreak in the Americas a Public Health Emergency of International Concern. Even in that short time, integrated public health accreditation, along with the other components of the Department's performance management system, allowed the Department to address this public health emergency, especially in Miami-Dade County, where the impact of Zika was significant. This case report describes the local response in Miami-Dade County and supporting statewide efforts. Public health departments should consider how public health accreditation could strengthen their ability to fulfill their public health mission. This article provides rationale for state and local health departments to seek accreditation.

Local Mosquito-Borne Transmission of Zika Virus - Miami-Dade and Broward Counties, Florida, June-August 2016.

During the first 6 months of 2016, large outbreaks of Zika virus disease caused by local mosquito-borne transmission occurred in Puerto Rico and other U.S. territories, but local mosquito-borne transmission was not identified in the continental United States (1,2). As of July 22, 2016, the Florida Department of Health had identified 321 Zika virus disease cases among Florida residents and visitors, all occurring in either travelers from other countries or territories with ongoing Zika virus transmission or sexual contacts of recent travelers.* During standard case investigation of persons with compatible illness and laboratory evidence of recent Zika virus infection (i.e., a specimen positive by real-time reverse transcription-polymerase chain reaction [rRT-PCR], or positive Zika immunoglobulin M [IgM] with supporting dengue serology [negative for dengue IgM antibodies and positive for dengue IgG antibodies], or confirmation of Zika virus neutralizing antibodies by plaque reduction neutralization testing [PRNT]) (3), four persons were identified in Broward and Miami-Dade counties whose infections were attributed to likely local mosquito-borne transmission. Two of these persons worked within 120 meters (131 yards) of each other but had no other epidemiologic connections, suggesting the possibility of a local community-based outbreak. Further epidemiologic and laboratory investigations of the worksites and surrounding neighborhood identified a total of 29 persons with laboratory evidence of recent Zika virus infection and likely exposure during late June to early August, most within an approximate 6-block area. In response to limited impact on the population of Aedes aegypti mosquito vectors from initial ground-based mosquito control efforts, aerial ultralow volume spraying with the organophosphate insecticide naled was applied over a 10 square-mile area beginning in early August and alternated with aerial larviciding with Bacillus thuringiensis subspecies israelensis (Bti), a group biologic control agent, in a central 2 square-mile area. No additional cases were identified after implementation of this mosquito control strategy. No increases in emergency department (ED) patient visits associated with aerial spraying were reported, including visits for asthma, reactive airway disease, wheezing, shortness of breath, nausea, vomiting, or diarrhea. Local and state health departments serving communities where Ae. aegypti, the primary vector of Zika virus, is found should continue to actively monitor for local transmission of the virus.(†).

Performance management models for public health: Public Health Accreditation Board/Baldrige connections, alignment, and distinctions.

CONTEXT: The nationally known Malcolm Baldrige Award for Excellence ("Baldrige program") recognizes outstanding performance management and is specifically cited by the Public Health Accreditation Board (PHAB) as a potential framework for PHAB's requisite performance management system. The authors developed a crosswalk that identifies alignments between the 2 programs and is a highlight of the Quest for Exceptional Performance tool that is intended to help health departments capitalize on the connections between the 2 programs. OBJECTIVE: To provide deeper insight into the most robust connections between the 2 programs. DESIGN: The authors developed a crosswalk by listing the PHAB measures, identifying corresponding Baldrige areas to address, and assigning a rating regarding the strength of the alignment. Subsequently, they generated a matrix with numerical scores reflecting the strength of the PHAB-Baldrige alignments that were then analyzed for frequency and strength of alignment by PHAB domain and by Baldrige category. PARTICIPANTS: The tool developers and 3 public health leaders with experience in the Baldrige program contributed to both the design and the analyses. MAIN OUTCOME MEASURES: The measures used reflected both the frequency and strength of alignments. RESULTS: Of the 123 alignments identified in the crosswalk, 39 were rated as high, 40 as medium, and 44 as low. The strongest connections were in the areas of performance management, quality improvement, strategic planning, workforce development, assessment and analysis, and customer service. CONCLUSIONS: While the areas with the most frequent and strongest connections provide the most useful basis for health departments pursuing Baldrige recognition or using Baldrige criteria as a framework for performance management, all alignments could be considered for both purposes.

Revenue sources for essential services in Florida: findings and implications for organizing and funding public health.

OBJECTIVES: The Florida Public Health Practice-Based Research Network conducted the study of Florida county health departments (CHDs) to assess relationships between self-assessed performance on essential services (ESs) and sources of funding. METHODS: Primary data were collected using an online survey based on Public Health Accreditation Board standards for ES. Bivariate and multivariate analyses were conducted to assess the relationship of sources and amounts of revenue obtained from the Florida Department of Health financial system to responses to the survey of CHD capacity for ESs. RESULTS: Self-assessed CHD performance for each ES varied extensively among the CHDs and across the 10 ESs, ranging from a high of 98% CHDs completely or almost completely meeting the standards for ES 2 (Investigating Problems and Hazards) to a low of 32% completely or almost completely meeting standards for ES 10 (Research/Evidence). Medicaid revenue and fees were positively correlated with some ESs. Per capita revenue support varied extensively among the CHDs. CONCLUSIONS: Revenue for ES is decreasing and is heavily reliant on noncategorical (discretionary) revenue. This study has important implications for continued reliance on ES as an organizing construct for public health.

Symptomatic Zika Virus Infection in Infants, Children, and Adolescents Living in Puerto Rico.

Importance: Little information is available regarding Zika virus (ZIKV) infection in children. Objective: To describe patients younger than 18 years who were infected with ZIKV and were enrolled in the Sentinel Enhanced Dengue and Acute Febrile Illness Surveillance System (SEDSS). Design, Setting, and Participants: Children infected with ZIKV with 7 or fewer days of fever or emancipated minors aged 14 to 17 years with a generalized maculopapular rash, arthritis or arthralgia, or nonpurulent conjunctivitis were eligible for enrollment on or before December 31, 2016, in Puerto Rico. Patients were evaluated using ZIKV polymerase chain reaction testing at 7 or fewer days after the onset of symptoms. Available ZIKV polymerase chain reaction-positive specimens were evaluated to determine viral loads. Exposures: Confirmed polymerase chain reaction-positive ZIKV infection. Main Outcomes and Measures: Clinical characteristics and viral loads of symptomatic children with confirmed ZIKV infection. Results: Of 7191 children enrolled in SEDSS on or before December 31, 2016, only those with confirmed ZIKV infection (351 participants) were included in this study. Participants who had confirmed ZIKV infection included 25 infants (7.1%), 69 children (19.7%) aged 1 to 4 years, 95 (27.1%) aged 5 to 9 years, and 162 (46.1%) aged 10 to 17 years. Among these, 260 patients (74.1%) presented for evaluation of ZIKV infection at fewer than 3 days after the onset of symptoms, 340 (96.9%) were discharged to home after evaluation, and 349 (99.4%) had fever, 280 (79.8%) had a rash, 243 (69.2%) had facial or neck erythema, 234 (66.7%) had fatigue, 223 (63.5%) had headache, 212 (60.4%) had chills, 206 (58.7%) had pruritus, and 204 (58.1%) had conjunctival hyperemia. Of 480 specimens collected (317 serum and 163 urine specimens) from 349 children, the median number of days after the onset of symptoms was lower for children who had serum specimens (1 day [interquartile range (IQR), 1-2 days]) than for children who had urine specimens (2 [1-3] days) (P < .001). Of 131 children who had both serum and urine specimens collected on the same day, the median viral load was higher in serum than in urine (median [IQR], 23 098 [8784-88 242] copies/mL for serum vs 9966 [2815-52 774] copies/mL for urine; P = .02). When a single serum sample from each of 317 patients was analyzed, there were no statistically significant differences in median viral loads according to age, sex, or disposition. However, the median serum viral load varied significantly according to the number of days after the onset of symptoms (0 days, 106 778 [IQR, 9772-1 571 718] copies/mL; 1 day, 46 299 [10 663-255 030] copies/mL; 2 days, 20 678 [8763-42 458] copies/mL; and ≥3 days, 15 901 [5135-49 248] copies/mL; P = .001). Conclusions and Relevance: This study represents the largest study to date of ZIKV infection in the pediatric population. Most children infected with ZIKV had fever, rash, and conjunctival hyperemia. The children usually presented for evaluation at fewer than 3 days after the onset of symptoms. Viral loads for ZIKV were higher in serum vs urine specimens. Median viral loads in serum specimens differed significantly according to the number of days after the onset of symptoms.

Epidemiology of Pediatric Zika Virus Infections.

BACKGROUND AND OBJECTIVE: In July 2016, local transmission of Zika virus (ZIKV) was announced in Miami-Dade County, Florida. In this report, we describe the epidemiology of pediatric ZIKV infections in locally acquired and travel-associated cases. METHODS: All children aged 1 to 17 years tested for ZIKV between October 1, 2015, and March 29, 2017, were included. SAS 9.4 was used to analyze age, sex, race and/or ethnicity, origin of exposure, onset date, affiliation with a household cluster, clinical symptoms, hospitalizations, viremia, viruria, and antibody detection in specimens. RESULTS: Among 478 confirmed ZIKV cases in Miami-Dade County, 33 (6.9%) occurred in children (1-17 years). Twenty-seven (82.3%) cases were travel-associated. The median age of a pediatric Zika case patient was 11 years. Seventeen (51.5%) case patients were boys, and 23 (69.9%) were Hispanic. Among 31 symptomatic cases, all reported having rash, 25 (80.6%) reported fever, 9 (29.0%) reported conjunctivitis, and 7 (22.6%) reported arthralgia. Sixteen (48.5%) cases reported 2 of 4 and 8 (24.2%) reported 3 of 4 main symptoms. CONCLUSIONS: This report found that the majority of children identified during the 2016 ZIKV outbreak only presented with 2 of the 4 main symptoms. In addition, pediatric ZIKV cases were frequently associated with symptomatic household members.