Phylogenetic Analysis of Francisella tularensis Group A.II Isolates from 5 Patients with Tularemia, Arizona, USA, 2015-2017.

We examined 5 tularemia cases in Arizona, USA, during 2015-2017. All were caused by Francisella tularensis group A.II. Genetically similar isolates were found across large spatial and temporal distances, suggesting that group A.II strains are dispersed across long distances by wind and exhibit low replication rates in the environment.

Using Molecular Characterization to Support Investigations of Aquatic Facility-Associated Outbreaks of Cryptosporidiosis - Alabama, Arizona, and Ohio, 2016.

Cryptosporidiosis is a nationally notifiable gastrointestinal illness caused by parasitic protozoa of the genus Cryptosporidium, which can cause profuse, watery diarrhea that can last up to 2-3 weeks in immunocompetent patients and can lead to life-threatening wasting and malabsorption in immunocompromised patients. Fecal-oral transmission of Cryptosporidium oocysts, the parasite's infectious life stage, occurs via ingestion of contaminated recreational water, drinking water, or food, or following contact with infected persons or animals, particularly preweaned bovine calves (1). The typical incubation period is 2-10 days. Since 2004, the annual incidence of nationally notified cryptosporidiosis has risen approximately threefold in the United States (1). Cryptosporidium also has emerged as the leading etiology of nationally notified recreational water-associated outbreaks, particularly those associated with aquatic facilities (i.e., physical places that contain one or more aquatic venues [e.g., pools] and support infrastructure) (2). As of February 24, 2017, a total of 13 (54%) of 24 states reporting provisional data detected at least 32 aquatic facility-associated cryptosporidiosis outbreaks in 2016. In comparison, 20 such outbreaks were voluntarily reported to CDC via the National Outbreak Reporting System for 2011, 16 for 2012, 13 for 2013, and 16 for 2014. This report highlights cryptosporidiosis outbreaks associated with aquatic facilities in three states (Alabama, Arizona, and Ohio) in 2016. This report also illustrates the use of CryptoNet, the first U.S. molecularly based surveillance system for a parasitic disease, to further elucidate Cryptosporidium chains of transmission and cryptosporidiosis epidemiology. CryptoNet data can be used to optimize evidence-based prevention strategies. Not swimming when ill with diarrhea is key to preventing and controlling aquatic facility-associated cryptosporidiosis outbreaks (https://www.cdc.gov/healthywater/swimming/swimmers/steps-healthy-swimming.html).

Transmission of Balamuthia mandrillaris by Organ Transplantation.

BACKGROUND: During 2009 and 2010, 2 clusters of organ transplant-transmitted Balamuthia mandrillaris, a free-living ameba, were detected by recognition of severe unexpected illness in multiple recipients from the same donor. METHODS: We investigated all recipients and the 2 donors through interview, medical record review, and testing of available specimens retrospectively. Surviving recipients were tested and treated prospectively. RESULTS: In the 2009 cluster of illness, 2 kidney recipients were infected and 1 died. The donor had Balamuthia encephalitis confirmed on autopsy. In the 2010 cluster, the liver and kidney-pancreas recipients developed Balamuthia encephalitis and died. The donor had a clinical syndrome consistent with Balamuthia infection and serologic evidence of infection. In both clusters, the 2 asymptomatic recipients were treated expectantly and survived; 1 asymptomatic recipient in each cluster had serologic evidence of exposure that decreased over time. Both donors had been presumptively diagnosed with other neurologic diseases prior to organ procurement. CONCLUSIONS: Balamuthia can be transmitted through organ transplantation with an observed incubation time of 17-24 days. Clinicians should be aware of Balamuthia as a cause of encephalitis with high rate of fatality, and should notify public health departments and evaluate transplant recipients from donors with signs of possible encephalitis to facilitate early diagnosis and targeted treatment. Organ procurement organizations and transplant centers should be aware of the potential for Balamuthia infection in donors with possible encephalitis and also assess donors carefully for signs of neurologic infection that may have been misdiagnosed as stroke or as noninfectious forms of encephalitis.

Notes from the Field: Tickborne Relapsing Fever Outbreak at an Outdoor Education Camp - Arizona, 2014.

Tickborne relapsing fever (TBRF) is a bacterial infection characterized by recurring episodes of fever, headache, muscle and joint aches, and nausea. In North America, TBRF primarily is caused by Borrelia hermsii spirochetes transmitted by Ornithodoros hermsii ticks. Once infected, these soft ticks are infectious for life and transmit the spirochete to sleeping humans quickly (possibly within 30 seconds) during short feeds (15-90 minutes). On August 10, 2014, the Coconino County Public Health Services District in Arizona was notified by a local hospital that five high school students who attended the same outdoor education camp had been hospitalized with fever, headache, and myalgias. Hantavirus infection initially was suspected because of reported exposure to rodent droppings, but after detecting spirochetes on peripheral blood smears from all five hospitalized students, TBRF was diagnosed. The camp was instructed to close immediately, and the health department, in collaboration with local university experts, investigated to identify additional cases, determine the cause, and prevent further infections. A total of 11 cases (six confirmed and five probable) were identified.

Tickborne relapsing fever - United States, 1990-2011.

Tickborne relapsing fever (TBRF) is a zoonosis caused by spirochetes of the genus Borrelia and transmitted to humans by ticks of the genus Ornithodoros. TBRF is endemic in the western United States, predominately in mountainous regions. Clinical illness is characterized by recurrent bouts of fever, headache, and malaise. Although TBRF is usually a mild illness, severe sequelae and death can occur. This report summarizes the epidemiology of 504 TBRF cases reported from 12 western states during 1990-2011. Cases occurred most commonly among males and among persons aged 10‒14 and 40‒44 years. Most reported infections occurred among nonresident visitors to areas where TBRF is endemic. Clinicians and public health practitioners need to be familiar with current epidemiology and features of TBRF to adequately diagnose and treat patients and recognize that any TBRF case might indicate an ongoing source of potential exposure that needs to be investigated and eliminated.

Serologic survey for exposure following fatal Balamuthia mandrillaris infection.

Granulomatous amebic encephalitis (GAE) from Balamuthia mandrillaris, a free-living ameba, has a case fatality rate exceeding 90% among recognized cases in the USA. In August 2010, a GAE cluster occurred following transplantation of infected organs from a previously healthy landscaper in Tucson, AZ, USA, who died from a suspected stroke. As B. mandrillaris is thought to be transmitted through soil, a serologic survey of landscapers and a comparison group of blood donors in southern Arizona was performed. Three (3.6%) of 83 serum samples from landscapers and 11 (2.5%) of 441 serum samples from blood donors were seropositive (p = 0.47). On multivariable analysis, county of residence was associated with seropositivity, whereas age, sex, and ethnicity were not. Exposure to B. mandrillaris, previously unexamined in North America, appears to be far more common than GAE in Southern Arizona. Risk factors for disease progression and the ameba's geographic range should be examined.

Association between Precipitation Events, Drought, and Animal Operations with Campylobacter Infections in the Southwest United States, 2009-2021.

BACKGROUND: Weather variability is associated with enteric infections in people through a complex interaction of human, animal, and environmental factors. Although Campylobacter infections have been previously associated with precipitation and temperature, the association between precipitation and drought on campylobacteriosis has not been studied. OBJECTIVE: Using data from Arizona, Colorado, New Mexico, and counties in Utah, this ecological study aimed to assess the association between precipitation and the incidence of campylobacteriosis by county from 2009 to 2021 and to determine how this association is modified by prior drought level and animal operations. METHODS: We merged 38,782 cases of campylobacteriosis reported in 127 counties with total precipitation (in inches), temperature (in average degrees Fahrenheit), Palmer Drought Severity Index (PDSI, category), and animal census data (presence, density per square mile) by week from 2009 to 2021. Negative binomial generalized estimating equations adjusted for temperature with a 3-wk lag were used to explore the association between precipitation on campylobacteriosis with resulting incidence rate ratios (IRRs). Stratified analyses explored the association with precipitation following antecedent drought, presence of farm operations, and animal density. RESULTS: A 1-in (25.4 mm) increase in precipitation was associated with a 3% increase in campylobacteriosis reported 3 wks later (IRR=1.03; 95% CI: 1.02, 1.04) after adjusting for average temperature and PDSI. Compared with normal conditions, there were significantly more cases when precipitation followed antecedent extremely wet (IRR=1.15; 95% CI: 1.04, 1.26), very wet (IRR=1.09; 95% CI: 1.01, 1.18), moderately wet (IRR=1.06; 95% CI: 1.01, 1.12), moderate drought (IRR=1.11; 95% CI: 1.07, 1.16), and severe drought (IRR=1.06; 95% CI: 1.02, 1.11) conditions, whereas there were significantly fewer cases (IRR=0.89; 95% CI: 0.85, 0.94) for antecedent extreme drought. Compared to counties with no animal operations, counties with animal operations had significantly more cases following precipitation for every PDSI category except extreme drought. Counties with a higher density of beef cattle, goats for meat, chicken broilers, and chicken layers had significantly higher rates of campylobacteriosis following precipitation than those with no such operations, whereas those with dairy cattle and goats for milk, did not. DISCUSSION: In this majority arid and semiarid environment, precipitation following prior wet conditions and moderate and severe drought were significantly associated with increased rates of campylobacteriosis, and only in prior extreme drought did rates decrease. Where the precipitation fell made a difference; after precipitation, counties with farm operations had significantly more cases compared to counties without farm operations. Further work should assess individual-level risk factors within environmental exposure pathways for Campylobacter. https://doi.org/10.1289/EHP14693.

A framework for integrating wastewater-based epidemiology and public health.

Wastewater-based epidemiology (WBE) is an environmental approach to monitor community health through the analysis of sewage. The COVID-19 pandemic catalyzed scientists and public health professionals to revisit WBE as a tool to optimize resource allocation to mitigate disease spread and prevent outbreaks. Some studies have highlighted the value of WBE programs that coordinate with public health professionals; however, the details necessary for implementation are not well-characterized. To respond to this knowledge gap, this article documents the framework of a successful WBE program in Arizona, titled Wastewater Analysis for Tactical Epidemiological Response Systems (WATERS), detailing the developed structure and methods of communication that enabled public health preparedness and response actions. This communication illustrates how program operations were employed to reduce outbreak severity. The structure outlined here is customizable and may guide other programs in the implementation of WBE as a public health tool.

Pan-Enterovirus Characterization Reveals Cryptic Circulation of Clinically Relevant Subtypes in Arizona Wastewater.

Background: Most seasonally circulating enteroviruses result in asymptomatic or mildly symptomatic infections. In rare cases, however, infection with some subtypes can result in paralysis or death. Of the 300 subtypes known, only poliovirus is reportable, limiting our understanding of the distribution of other enteroviruses that can cause clinical disease. Objective: The overarching objectives of this study were to: 1) describe the distribution of enteroviruses in Arizona during the late summer and fall of 2022, the time of year when they are thought to be most abundant, and 2) demonstrate the utility of viral pan-assay approaches for semi-agnostic discovery that can be followed up by more targeted assays and phylogenomics. Methods: This study utilizes pooled nasal samples collected from school-aged children and long-term care facility residents, and wastewater from multiple locations in Arizona during July-October of 2022. We used PCR to amplify and sequence a region common to all enteroviruses, followed by species-level bioinformatic characterization using the QIIME 2 platform. For Enterovirus-D68 (EV-D68), detection was carried out using RT-qPCR, followed by confirmation using near-complete whole EV-D68 genome sequencing using a newly designed tiled amplicon approach. Results: In the late summer and early fall of 2022, multiple enterovirus species were identified in Arizona wastewater, with Coxsackievirus A6, EV-D68, and Coxsackievirus A19 composing 86% of the characterized reads sequenced. While EV-D68 was not identified in pooled human nasal samples, and the only reported acute flaccid myelitis case in Arizona did not test positive for the virus, an in-depth analysis of EV-D68 in wastewater revealed that the virus was circulating from August through mid-October. A phylogenetic analysis on this relatively limited dataset revealed just a few importations into the state, with a single clade indicating local circulation. Significance: This study further supports the utility of wastewater-based epidemiology to identify potential public health threats. Our further investigations into EV-D68 shows how these data might help inform healthcare diagnoses for children presenting with concerning neurological symptoms.

Barriers to stool specimen collection during foodborne and enteric illness outbreak investigations in Arizona and Colorado.

Stool specimen collection during a foodborne or enteric illness outbreak investigation is essential for determining the outbreak etiology and for advancing the epidemiologic understanding of the pathogens and food vehicles causing illness. However, public health professionals face multifaceted barriers when trying to collect stool specimens from ill person during an outbreak investigation. The Colorado Integrated Food Safety Center of Excellence (Colorado IFS CoE) and the Arizona Department of Health Services surveyed local public health agencies (LPHAs) to identify barriers to collecting ≥2 clinical specimens in foodborne and enteric illness outbreaks. The most commonly selected patient-related barrier was that the patient did not think it is important to provide a stool sample because they are well by the time the LPHA follows-up (61%). The most frequently selected outbreak-related barrier was the LPHA did not learn about the outbreak until after symptoms had resolved (61%). Time/personnel not being available for stool collection was the most frequently chosen health department-related barrier (51%). Timing of the outbreak (e.g., on a weekend or holiday) was the most frequently selected transportation-related barrier (51%) to collecting ≥2 stool specimens. Many of the frequently cited barriers in this survey were similar to those previously reported, such as workforce capacity and patient privacy concerns, indicating that these barriers are ongoing. Reducing barriers to stool collection during outbreaks will require efforts led at the national and state levels, such as increased enteric illness program funding, educating public health staff on the importance of specimen collection during every enteric illness outbreak, and providing specimen collection resources to LPHA staff.