Exposure Characteristics of Hantavirus Pulmonary Syndrome Patients, United States, 1993-2015.

Those at highest risk are persons in occupations with potential for rodent exposure and American Indian women 40--64 years of age.

Hypervirulent emm59 Clone in Invasive Group A Streptococcus Outbreak, Southwestern United States.

The hyper-virulent emm59 genotype of invasive group A Streptococcus was identified in northern Arizona in 2015. Eighteen isolates belonging to a genomic cluster grouped most closely with recently identified isolates in New Mexico. The continued transmission of emm59 in the southwestern United States poses a public health concern.

Where Are the Ticks? Solving the Mystery of a Tickborne Relapsing Fever Outbreak at a Youth Camp.

During the summer of 2014 an outbreak of tickborne relapsing fever (TBRF) occurred in a group of high school students and staff at a youth camp, which was reported to Coconino County Public Health Services District. Six confirmed and five probable cases of TBRF occurred. During the environmental investigation two rodents tested positive for TBRF, but the vector, soft ticks, could not be found in their "normal" habitat. Ticks were finally located in areas not typical for soft ticks.

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.

Factors associated with receipt of 2009 pandemic influenza A (H1N1) monovalent and seasonal influenza vaccination among school-aged children: Maricopa County, Arizona, 2009-2010 influenza season.

CONTEXT: To target school-aged children (SAC), who were identified as a priority for pandemic 2009 Influenza A (pH1N1) vaccination, Maricopa County (MC) initiated school-based influenza vaccination in 69% of its 706 schools during the 2009-2010 influenza season. OBJECTIVE: To determine factors associated with receipt of pH1N1 monovalent and 2009-2010 seasonal influenza vaccination among SAC and evaluate the association of school-based vaccination with vaccination status of SAC. DESIGN: Random-digit dialing was used to survey 600 MC households with willing adult participants and children grades K-12. Logistic regression was used to identify factors associated with pH1N1 and seasonal vaccine receipt. SETTING: Arizona. PARTICIPANTS: Household adults with children grades K-12. MAIN OUTCOME MEASURE: Characteristics of children, parents, and households were obtained. RESULTS: Among 909 SAC, 402 (44%) received pH1N1 and 436 (48%) received seasonal vaccination. Factors associated with pH1N1 vaccination included vaccine availability at school (adjusted odds ratio [AOR]: 1.6; 95% confidence interval [CI]: 1.0-2.7), high-risk medical condition in child (AOR: 2.4; 95% CI: 1.4-4.0), elementary versus high school attendance (AOR: 1.6; 95% CI: 1.0-2.7), and seasonal influenza vaccination (AOR: 10.0; 95% CI: 6.4-15.6). Factors associated with seasonal vaccination included Hispanic ethnicity (AOR: 2.2; 95% CI: 1.1-4.2), health insurance coverage (AOR: 4.8; 95% CI: 1.7-13.7), elementary versus high school attendance (AOR: 1.5; 95% CI: 1.0-2.5), and pH1N1 vaccination (AOR: 10.5; 95% CI: 6.7-16.6). CONCLUSIONS: Availability of pH1N1 vaccine at school was independently associated with pH1N1 vaccination of MC school-aged children. School-based influenza vaccination campaigns should be considered to increase vaccination among this population.

A prolonged outbreak of Salmonella Montevideo infections associated with multiple locations of a restaurant chain in Phoenix, Arizona, 2008.

An outbreak of Salmonella serotype Montevideo infections associated with multiple locations of restaurant chain A in Phoenix, AZ, was identified in July 2008. One infected individual reported eating at a chain A catered luncheon where others fell ill; we conducted a cohort study among attendees to identify the vehicle. Food and environmental samples collected at six chain A locations were cultured for Salmonella. Restaurant inspection results were compared among 18 chain A locations. Routine surveillance identified 58 Arizona residents infected with the outbreak strain. Three chain A locations, one of which catered the luncheon, were named by two or more case patients as a meal source in the week prior to illness onset. In the cohort study of luncheon attendees, 30 reported illness, 10 of which were later culture confirmed. Illness was reported by 30 (61%) of 49 attendees who ate chicken and by 0 of 7 who did not. The outbreak strain was isolated from two of these three locations from uncooked chicken in marinade, chopped cilantro, and a cutting board dedicated to cutting cooked chicken. Raw chicken, contaminated before arrival at the restaurant, was the apparent source of this outbreak. The three locations where two or more case patients ate had critical violations upon routine inspection, while 15 other locations received none. Poor hygiene likely led to cross-contamination of food and work areas. This outbreak supports the potential use of inspections in identifying restaurants at high risk of outbreaks and the need to reduce contamination of raw products at the source and prevent cross-contamination at the point of service.

Tick-Borne Relapsing Fever Outbreak Among a High School Football Team at an Outdoor Education Camping Trip, Arizona, 2014.

During August 2014, five high school students who had attended an outdoor education camp were hospitalized with a febrile illness, prompting further investigation. Ten total cases of tick-borne relapsing fever (TBRF) were identified-six cases confirmed by culture or visualization of spirochetes on blood smear and four probable cases with compatible symptoms (attack rate: 23%). All patients had slept in the campsite's only cabin. Before the camp, a professional pest control company had rodent proofed the cabin, but no acaricides had been applied. Cabin inspection after the camp found rodents and Ornithodoros ticks, the vector of TBRF. Blood samples from a chipmunk trapped near the cabin and from patients contained Borrelia hermsii with identical gene sequences (100% over 630 base pairs). Health departments in TBRF endemic areas should consider educating cabin owners and pest control companies to apply acaricides during or following rodent proofing, because ticks that lack rodents for a blood meal might feed on humans.

The validity of chief complaint and discharge diagnosis in emergency department-based syndromic surveillance.

OBJECTIVE: Emergency department (ED)-based syndromic surveillance systems are being used by public health departments to monitor for outbreaks of infectious diseases, including bioterrorism; however, few systems have been validated. The authors evaluated a "drop-in" syndromic surveillance system by comparing syndrome categorization in the ED with chief complaints and ED discharge diagnoses from medical record review. METHODS: A surveillance form was completed for each ED visit at 15 participating Arizona hospitals between October 27 and November 18, 2001. Each patient visit was assigned one of ten clinical syndromes or "none." For six of 15 EDs, kappa statistics were used to compare syndrome agreement between surveillance forms and syndrome categorization with chief complaint and ED discharge diagnosis from medical record review. RESULTS: Overall, agreement between surveillance forms and ED discharge diagnoses (kappa = 0.55; 95% confidence interval [CI] = 0.52 to 0.59) was significantly higher than between surveillance forms and chief complaints (kappa = 0.48; 95% CI = 0.44 to 0.52). Agreement between chief complaints and ED discharge diagnoses was poor for respiratory tract infection with fever (kappa = 0.33; 95% CI = 0.27 to 0.39). Furthermore, pediatric chief complaints showed lower agreement for respiratory tract infection with fever when compared with adults (kappa = 0.34 [95% CI = 0.20 to 0.47] vs. kappa = 0.44 [95% CI = 0.28 to 0.59], respectively). CONCLUSIONS: In general, this syndromic surveillance system classified patients into appropriate syndrome categories with fair to good agreement compared with chief complaints and discharge diagnoses. The present findings suggest that use of ED discharge diagnoses, in addition to or instead of chief complaints, may increase surveillance validity for both automated and drop-in syndromic surveillance systems.