Cost Analysis of 3 Concurrent Public Health Response Events: Financial Impact of Measles Outbreak, Super Bowl Surveillance, and Ebola Surveillance in Maricopa County.

OBJECTIVE: To generate estimates of the direct costs of mounting simultaneous emergency preparedness and response activities to respond to 3 major public health events. DESIGN: A cost analysis was performed from the perspective of the public health department using real-time activity diaries and retrospective time and activity self-reporting, wage and fringe benefit data, and financial records to track costs. SETTING: Maricopa County Department of Public Health (MCDPH) in Arizona. The nation's third largest local public health jurisdiction, MCDPH is the only local health agency serving Maricopa's more than 4 000 000 residents. Responses analyzed included activities related to a measles outbreak with 2 confirmed cases, enhanced surveillance activities surrounding Super Bowl XLIX, and ongoing Ebola monitoring, all between January 22, 2015, and March 4, 2015. PARTICIPANTS: Time data were sought from all MCDPH staff who participated in activities related to any of the 3 relevant responses. In addition, time data were sought from partners at the state health department and a community hospital involved in response activities. Time estimates were received from 128 individuals (response rate 88%). MAIN OUTCOME MEASURE: Time and cost to MCDPH for each response and overall. RESULTS: Total MCDPH costs for measles-, Super Bowl-, and Ebola-related activities from January 22, 2015, through March 4, 2015, were $224 484 (>5800 hours). The majority was for personnel ($203 743) and the costliest response was measles ($122 626 in personnel costs). In addition, partners reported working more than 700 hours for these 3 responses during this period. CONCLUSIONS: Funding for public health departments remains limited, yet public health responses can be cost- and time-intensive. To effectively plan for future public health responses, it may be necessary to share experiences and financial lessons learned from similar public health responses. External partnerships represent a key contribution for responses such as those examined. It can be expensive for local public health departments to mount effective responses, especially when multiple responses occur simultaneously.

St. Louis encephalitis virus possibly transmitted through blood transfusion-Arizona, 2015.

BACKGROUND: St. Louis encephalitis virus is a mosquito-borne flavivirus that infrequently causes epidemic central nervous system infections. In the United States, blood donors are not screened for St. Louis encephalitis virus infection, and transmission through blood transfusion has not been reported. During September 2015, St. Louis encephalitis virus infection was confirmed in an Arizona kidney transplant recipient. An investigation was initiated to determine the infection source. STUDY DESIGN AND METHODS: The patient was interviewed, and medical records were reviewed. To determine the likelihood of mosquito-borne infection, mosquito surveillance data collected at patient and blood donor residences in timeframes consistent with their possible exposure periods were reviewed. To investigate other routes of exposure, organ and blood donor and recipient specimens were obtained and tested for evidence of St. Louis encephalitis virus infection. RESULTS: The patient presented with symptoms of central nervous system infection. Recent St. Louis encephalitis virus infection was serologically confirmed. The organ donor and three other organ recipients showed no laboratory or clinical evidence of St. Louis encephalitis virus infection. Among four donors of blood products received by the patient via transfusion, one donor had a serologically confirmed, recent St. Louis encephalitis virus infection. Exposure to an infected mosquito was unlikely based on the patient's minimal outdoor exposure. In addition, no St. Louis encephalitis virus-infected mosquito pools were identified around the patient's residence. CONCLUSION: This investigation provides evidence of the first reported possible case of St. Louis encephalitis virus transmission through blood product transfusion. Health care providers and public health professionals should maintain heightened awareness for St. Louis encephalitis virus transmission through blood transfusion in settings where outbreaks are identified.

Notes from the field: outbreak of skin lesions among high school wrestlers--Arizona, 2014.

Skin infections are a common problem among athletes at all levels of competition; among wrestlers, 8.5% of all adverse events are caused by skin infections. Wrestlers are at risk because of the constant skin-to-skin contact required during practice and competition. The most common infections transmitted among high school wrestlers include fungal infections (e.g., ringworm), the viral infection herpes gladiatorum caused by herpes simplex virus-1 (HSV-1), and bacterial infections (e.g., impetigo) caused by Staphylococcus or Streptococcus species, including methicillin-resistant Staphylococcal aureus (MRSA). On February 7, 2014, the Maricopa County Department of Public Health was notified of multiple wrestlers who reported skin lesions 2 weeks after participating in a wrestling tournament at school A. The tournament was held on January 24-25 and included 168 wrestlers representing 24 schools. The county health department initiated an investigation to identify cases of skin lesion, determine lesion etiology, identify risks associated with lesion development, and provide guidance for preventing additional cases.

Concurrent Outbreaks of St. Louis Encephalitis Virus and West Nile Virus Disease - Arizona, 2015.

St. Louis encephalitis virus (SLEV) and West Nile virus (WNV) are closely related mosquito-borne flaviviruses that can cause outbreaks of acute febrile illness and neurologic disease. Both viruses are endemic throughout much of the United States and have the same Culex species mosquito vectors and avian hosts (1); however, since WNV was first identified in the United States in 1999, SLEV disease incidence has been substantially lower than WNV disease incidence, and no outbreaks involving the two viruses circulating in the same location at the same time have been identified. Currently, there is a commercially available laboratory test for diagnosis of acute WNV infection, but there is no commercially available SLEV test, and all SLEV testing must be performed at public health laboratories. In addition, because antibodies against SLEV and WNV can cross-react on standard diagnostic tests, confirmatory neutralizing antibody testing at public health laboratories is usually required to determine the flavivirus species (2). This report describes the first known concurrent outbreaks of SLEV and WNV disease in the United States.

Lack of Measles Transmission to Susceptible Contacts from a Health Care Worker with Probable Secondary Vaccine Failure - Maricopa County, Arizona, 2015.

On January 23, 2015, the Maricopa County Department of Public Health (MCDPH) was notified of a suspected measles case in a nurse, a woman aged 48 years. On January 11, the nurse had contact with a patient with laboratory-confirmed measles associated with the Disneyland theme park-related outbreak in California. On January 21, she developed a fever (103°F [39.4°C]), on January 23 she experienced cough and coryza, and on January 24, she developed a rash. The patient was instructed to isolate herself at home. On January 26, serum, a nasopharyngeal swab, and a urine specimen were collected. The following day, measles infection was diagnosed by real time reverse transcription polymerase chain reaction testing of the nasopharyngeal swab and urine specimen and by detection of measles-specific immunoglobulin (Ig)M and IgG in serum by enzyme-linked immunosorbent assay. Because of her symptoms and laboratory results, the patient was considered to be infectious.

Clinical, diagnostic, and epidemiological features of a community-wide outbreak of canine leptospirosis in a low-prevalence region (Maricopa County, Arizona).

OBJECTIVE: To describe clinical, diagnostic, and epidemiological features of an outbreak of leptospirosis in dogs in Maricopa County, Ariz, from January 2016 through June 2017. ANIMALS: 71 case and 281 control dogs. PROCEDURES: Cases were classified as confirmed, probable, suspect, or not a case on the basis of medical record data that fulfilled clinical, diagnostic, and epidemiological criteria. Potential exposures were assessed by owner survey. For the case-control investigation, control dogs were recruited through owner completion of a July 2017 survey. Summary statistics and ORs for case dog lifestyle factors were reported. RESULTS: 54 dogs were classified as confirmed and 17 as probable cases. For 4 dogs of a household cluster (5 confirmed and 3 probable), the highest microscopic agglutination titer was for serovar Djasiman (Leptospira kirschneri detected by PCR assay), and for 13 dogs of a community outbreak (49 confirmed and 14 probable cases), the highest titer was for serovar Canicola (Leptospira interrogans detected by PCR assay). The 44 case dogs included in the case-control investigation were 7.7 (95% CI, 3.5 to 16.7) and 2.9 times (95% CI, 1.3 to 6.6) as likely as control dogs to have visited dog daycare or to have been kenneled overnight at a boarding facility, respectively, 30 days prior to the onset of clinical signs or diagnosis. CONCLUSIONS AND CLINICAL RELEVANCE: Diagnostic and epidemiological findings indicated 2 outbreaks. Transmission where dogs congregated likely propagated the community outbreak. Outbreaks of leptospiral infections can occur in regions of low prevalence, and a dog's exposure to areas where dogs congregate should be considered when making Leptospira vaccination recommendations.

Comparison of Characteristics of Patients with West Nile Virus or St. Louis Encephalitis Virus Neuroinvasive Disease During Concurrent Outbreaks, Maricopa County, Arizona, 2015.

West Nile virus (WNV) and St. Louis encephalitis virus (SLEV) are closely related mosquito-borne flaviviruses that can cause neuroinvasive disease. No concurrent WNV and SLEV disease outbreaks have previously been identified. When concurrent outbreaks occurred in 2015 in Maricopa County, Arizona, we collected data to describe the epidemiology, and to compare features of patients with WNV and SLEV neuroinvasive disease. We performed enhanced case finding, and gathered information from medical records and patient interviews. A case was defined as a clinically compatible illness and laboratory evidence of WNV, SLEV, or unspecified flavivirus infection in a person residing in Maricopa County in 2015. We compared demographic and clinical features of WNV and SLEV neuroinvasive cases; for this analysis, a case was defined as physician-documented encephalitis or meningitis and a white blood cell count >5 cells/mm3 in cerebrospinal fluid. In total, we identified 82 cases, including 39 WNV, 21 SLEV, and 22 unspecified flavivirus cases. The comparative analysis included 21 WNV and 14 SLEV neuroinvasive cases. Among neuroinvasive cases, the median age of patients with SLEV (63 years) was higher than WNV (52 years). Patients had similar symptoms; rash was identified more frequently in WNV (33%) neuroinvasive cases than in SLEV (7%) cases, but this difference was not statistically significant (p = 0.11). In summary, during the first known concurrent WNV and SLEV disease outbreaks, no specific clinical features were identified that could differentiate between WNV and SLEV neuroinvasive cases. Health care providers should consider both infections in patients with aseptic meningitis or encephalitis.

Human Rabies Postexposure Prophylaxis Knowledge and Retention Among Health Professionals by Using an Online Continuing Education Module: Arizona, 2012 to 2015.

Rabies postexposure prophylaxis (PEP) is administered for rabies prevention after a human exposure to a potentially rabid animal, such as a bite. Previous studies have reported that rabies PEP is often inappropriately administered. Health professional education was proposed as one potential solution to address inappropriate PEP use. We assessed baseline knowledge, knowledge gain, and knowledge retention among health professionals in Arizona of rabies epidemiology and appropriate PEP administration. Maricopa County Department of Public Health created an online rabies PEP continuing education module and measured knowledge before and after module completion using a 10-question test. The same test was administered three times (pretest, posttest, and retention test at ≥3 months). To assess knowledge gain and retention, we compared median scores using nonparametric methods. A total of 302 respondents completed the pretest (median score, 60%) and posttest (median score, 90%; p < .001); 98 respondents completed all three tests with median scores 60% (pretest), 90% (posttest, p < .01), and 80% (retention test and compared with pretest, p < .01). Sixty-nine (70%) respondents improved their pretest to retention test score by a mean of 2.4 points out of a total 10 points (median: 2 points; range: -5 to 7 points). Only 48% of pretest respondents correctly answered that PEP should not be administered immediately to anyone bitten by a healthy dog. However, 81% and 70% answered correctly on the posttest (p < .0001) and retention test (p = .002), respectively. Respondents demonstrated rabies epidemiology and PEP knowledge gain and ≥3-month knowledge retention after completing the online continuing education module.

Despite high-risk exposures, no evidence of zoonotic transmission during a canine outbreak of leptospirosis.

Leptospirosis is a bacterial zoonosis that affects many mammals, including humans and dogs; dogs can transmit the bacteria to humans, but the frequency of transmission and highest risk exposures are poorly understood. During 2016-2017, the Maricopa County Department of Public Health, Arizona Department of Health Services and Centers for Disease Control and Prevention investigated the zoonotic potential of a canine leptospirosis outbreak in the Phoenix metro area. We identified symptomatic persons exposed to canine leptospirosis cases by conducting active and passive surveillance. We tested dog owners (n = 9) and animal care providers (n = 109) for serological evidence of Leptospira spp. infection (via the microscopic agglutination test [MAT]) and interviewed these persons about their specific exposures to canine cases and general exposures to canine blood and urine. Through surveillance, seven symptomatic persons were identified; six were tested and all were negative by MAT, and of these six, four persons were negative by PCR (two did not have PCR testing). All serosurvey participants (n = 118) were also seronegative. Among animal care providers, bare skin contact with urine/blood from a canine case was reported by 23.2%; two persons reported dog urine splashing in their face. Veterinary technicians were more likely to have bare skin contact with blood from a canine case compared to veterinarians and boarding facility staff (p < 0.001). Infection control practices were inconsistent; when working with specimens from a canine leptospirosis case, 44.6% of participants reported always wearing gloves when working with urine (i.e., collecting specimens), and 54.5% always wore gloves when working with blood. Veterinary technicians were also most likely to engage in all activities involving potential urine/blood contact, such as conducting laboratory tests (p < 0.01). We therefore recommend that veterinary technicians specifically receive targeted education about infection control practices. Our results suggest that dog-to-human transmission of leptospirosis is uncommon.

Genomic Analyses of Acute Flaccid Myelitis Cases among a Cluster in Arizona Provide Further Evidence of Enterovirus D68 Role.

Enteroviruses are a common cause of respiratory and gastrointestinal illness, and multiple subtypes, including poliovirus, can cause neurologic disease. In recent years, enterovirus D68 (EV-D68) has been associated with serious neurologic illnesses, including acute flaccid myelitis (AFM), frequently preceded by respiratory disease. A cluster of 11 suspect cases of pediatric AFM was identified in September 2016 in Phoenix, AZ. To determine if these cases were associated with EV-D68, we performed multiple genomic analyses of nasopharyngeal (NP) swabs and cerebrospinal fluid (CSF) material from the patients, including real-time PCR and amplicon sequencing targeting the EV-D68 VP1 gene and unbiased microbiome and metagenomic sequencing. Four of the 11 patients were classified as confirmed cases of AFM, and an additional case was classified as probable AFM. Real-time PCR and amplicon sequencing detected EV-D68 virus RNA in the three AFM patients from which NP swabs were collected, as well as in a fourth patient diagnosed with acute disseminated encephalomyelitis, a disease that commonly follows bacterial or viral infections, including enterovirus. No other obvious etiological causes for AFM were identified by 16S or RNA and DNA metagenomic sequencing in these cases, strengthening the likelihood that EV-D68 is an etiological factor. Herpes simplex viral DNA was detected in the CSF of the fourth case of AFM and in one additional suspect case from the cluster. Multiple genomic techniques, such as those described here, can be used to diagnose patients with suspected EV-D68 respiratory illness, to aid in AFM diagnosis, and for future EV-D68 surveillance and epidemiology.IMPORTANCE Enteroviruses frequently result in respiratory and gastrointestinal illness; however, multiple subtypes, including poliovirus, can cause severe neurologic disease. Recent biennial increases (i.e., 2014, 2016, and 2018) in cases of non-polio acute flaccid paralysis have led to speculations that other enteroviruses, specifically enterovirus D68 (EV-D68), are emerging to fill the niche that was left from poliovirus eradication. A cluster of 11 suspect cases of pediatric acute flaccid myelitis (AFM) was identified in 2016 in Phoenix, AZ. Multiple genomic analyses identified the presence of EV-D68 in the majority of clinical AFM cases. Beyond limited detection of herpesvirus, no other likely etiologies were found in the cluster. These findings strengthen the likelihood that EV-D68 is a cause of AFM and show that the rapid molecular assays developed for this study are useful for investigations of AFM and EV-D68.

Healthcare-Associated Pertussis Outbreak in Arizona: Challenges and Economic Impact, 2011.

An outbreak investigation identified 15 pertussis cases among 5 infants and 10 healthcare professionals at 1 hospital's neonatal intensive care unit (NICU). The cost of the outbreak to this hospital was $97 745. Heightened awareness of pertussis in NICUs is key to preventing healthcare-associated spread and minimizing outbreak-control-related costs. Bordetella pertussis is a highly communicable bacterial pathogen that causes a prolonged cough illness and is spread by respiratory droplet transmission. Infants aged ≤6 months are most susceptible to B pertussis infection and pertussis-associated complications, including pneumonia, encephalopathy, and death, and are commonly hospitalized for treatment [ 1]. Despite a universal pertussis vaccination program, 27 550 pertussis cases were reported in the United States during 2010 [ 2]. Pertussis outbreaks in healthcare settings can be challenging and costly to control [3]. On September 13, 2011 and September 15, 2011, 3 pertussis cases, including 2 confirmed by B pertussis isolation, among preterm infants discharged ≤30 days previously from a 71-bed NICU of a general hospital (NICU A) were reported by Hospital B, a large pediatric facility, to Maricopa County Department of Public Health. This report describes the outbreak, examines outbreak-associated costs and risk factors that might have contributed to healthcare-associated transmission, and provides guidance to prevent outbreaks in healthcare settings.

Chryseobacterium indologenes in a woman with metastatic breast cancer in the United States of America: a case report.

INTRODUCTION: We report the seventh case of Chryseobacterium indologenes occurring in the United States of America. C. indologenes is seldom isolated from clinical specimens but has caused hospital-acquired infections in Taiwan and rarely elsewhere. CASE PRESENTATION: A 32-year-old Caucasian woman with metastatic breast cancer presented to a hospital emergency department with bilateral radiation-induced pleural effusions and respiratory failure. The patient was hospitalized and ventilated for 26 days; tracheal aspirates collected on ventilation days 24 and 26 grew C. indologenes. The patient subsequently died as a result of worsening ventilator-associated pneumonia and stage IV breast cancer. CONCLUSIONS: C. indologenes infection should be considered for hospitalized patients with a history of malignancy, especially those with indwelling devices and antibiotic use for >14 days.

Modifiable risk factors for West Nile virus infection during an outbreak--Arizona, 2010.

West Nile virus (WNV) is the leading cause of mosquito-borne disease in the United States; however, risk factors for infection are poorly defined. We performed a case-control study to identify modifiable risk factors for WNV infection. Case-patients (N = 49) had laboratory evidence of recent WNV infection, whereas control-subjects (N = 74) had negative WNV serology. We interviewed participants, surveyed households, and assessed environmental data. WNV infection was associated with living in or near Water District X within Gilbert Township (adjusted odds ratio [aOR] 5.2; 95% confidence interval [95% CI] = 1.5-18.1), having water-holding containers in their yard (aOR 5.0; 95% CI = 1.5-17.3), and not working or attending school outside the home (aOR 2.4; 95% CI = 1.1-5.5). During this outbreak, WNV infection was likely primarily acquired peri-domestically with increased risk associated with potential mosquito larval habitats around the home and neighborhood.

Francisella tularensis subsp. novicida isolated from a human in Arizona.

BACKGROUND: Francisella tularensis is the etiologic agent of tularemia and is classified as a select agent by the Centers for Disease Control and Prevention. Currently four known subspecies of F. tularensis that differ in virulence and geographical distribution are recognized:tularensis (type A), holarctica (type B), mediasiatica, and novicida. Because of the Select Agent status and differences in virulence and geographical location, the molecular analysis of any clinical case of tularemia is of particular interest. We analyzed an unusual Francisella clinical isolate from a human infection in Arizona using multiple DNA-based approaches. FINDINGS: We report that the isolate is F. tularensis subsp. novicida, a subspecies that is rarely isolated. CONCLUSION: The rarity of this novicida subspecies in clinical settings makes each case study important for our understanding of its role in disease and its genetic relationship with other F. tularensis subspecies.