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.

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.

Measles outbreak in an unvaccinated family and a possibly associated international traveler - Orange County, Florida, December 2012-January 2013.

The Florida Department of Health in Orange County (DOH-Orange) was notified by a child care facility on January 11, 2013, that a parent had reported that an attendee and three siblings were ill with measles. All four siblings were unvaccinated for measles and had no travel history outside of Orange County during the periods when they likely had been exposed. A fifth, possibly associated case was later reported in a Brazilian citizen who had become ill while vacationing in Florida. The outbreak investigation that was conducted at multiple community settings in Orange County, including at an Orlando-area theme park, identified no additional cases. The genotype sequence was identical for cases 2-5, and visits to the same theme park suggested an unknown, common exposure and link between the cases. Sources of measles exposure can be difficult to identify for every measles case. Measles should be considered in the differential diagnosis of febrile rash illness, especially in unvaccinated persons. Reporting a confirmed or suspected case immediately to public health authorities is critical to limit the spread of measles.

An intervention for enhancing public health crisis response willingness among local health department workers: a qualitative programmatic analysis.

OBJECTIVES: This study evaluated the impact of a novel multimethod curricular intervention using a train-the-trainer model: the Public Health Infrastructure Training (PHIT). PHIT was designed to 1) modify perceptions of self-efficacy, response efficacy, and threat related to specific hazards and 2) improve the willingness of local health department (LHD) workers to report to duty when called upon. METHODS: Between June 2009 and October 2010, eight clusters of US LHDs (n = 49) received PHIT. Two rounds of focus groups at each intervention site were used to evaluate PHIT. The first round of focus groups included separate sessions for trainers and trainees, 3 weeks after PHIT. The second round of focus groups combined trainers and trainees in a single group at each site 6 months following PHIT. During the second focus group round, participants were asked to self-assess their preparedness before and after PHIT implementation. SETTING: Focus groups were conducted at eight geographically representative clusters of LHDs. PARTICIPANTS: Focus group participants included PHIT trainers and PHIT trainees within each LHD cluster. MAIN OUTCOME MEASURE(S): Focus groups were used to assess attitudes toward the curricular intervention and modifications of willingness to respond (WTR) to an emergency; self-efficacy; and response efficacy. RESULTS: Participants reported that despite challenges in administering the training, PHIT was well designed and appropriate for multiple management levels and disciplines. Positive mean changes were observed for all nine self-rated preparedness factors (p < 0.001). The findings show PHIT's benefit in improving self-efficacy and WTR among participants. CONCLUSIONS: The PHIT has the potential to enhance emergency response willingness and related self-efficacy among LHD workers.

EPPM and willingness to respond: the role of risk and efficacy communication in strengthening public health emergency response systems.

This study examines the attitudinal impact of an Extended Parallel Process Model (EPPM)-based training curriculum on local public health department (LHD) workers' willingness to respond to representative public health emergency scenarios. Data are from 71 U.S. LHDs in urban and rural settings across nine states. The study explores changes in response willingness and EPPM threat and efficacy appraisals between randomly assigned control versus intervention health departments, at baseline and 1 week post curriculum, through an EPPM-based survey/resurvey design. Levels of response willingness and emergency response-related attitudes/beliefs are measured. Analyses focus on two scenario categories that have appeared on a U.S. government list of scenarios of significant concern: a weather-related emergency and a radiological "dirty" bomb event (U.S. Department of Homeland Security, 2007). The greatest impact from the training intervention on response willingness was observed among LHD workers who had low levels of EPPM-related threat and efficacy perceptions at baseline. Self-efficacy and response efficacy and response willingness increased in intervention LHDs for both scenarios, with greater response willingness increases observed for the radiological "dirty" bomb terrorism scenario. Findings indicate the importance of building efficacy versus enhancing threat perceptions as a path toward greater response willingness, and suggest the potential applicability of such curricular interventions for boosting emergency response willingness among other cadres of health providers.

Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: a cross-sectional survey.

BACKGROUND: The all-hazards willingness to respond (WTR) of local public health personnel is critical to emergency preparedness. This study applied a threat-and efficacy-centered framework to characterize these workers' scenario and jurisdictional response willingness patterns toward a range of naturally-occurring and terrorism-related emergency scenarios. METHODS: Eight geographically diverse local health department (LHD) clusters (four urban and four rural) across the U.S. were recruited and administered an online survey about response willingness and related attitudes/beliefs toward four different public health emergency scenarios between April 2009 and June 2010 (66% response rate). Responses were dichotomized and analyzed using generalized linear multilevel mixed model analyses that also account for within-cluster and within-LHD correlations. RESULTS: Comparisons of rural to urban LHD workers showed statistically significant odds ratios (ORs) for WTR context across scenarios ranging from 1.5 to 2.4. When employees over 40 years old were compared to their younger counterparts, the ORs of WTR ranged from 1.27 to 1.58, and when females were compared to males, the ORs of WTR ranged from 0.57 to 0.61. Across the eight clusters, the percentage of workers indicating they would be unwilling to respond regardless of severity ranged from 14-28% for a weather event; 9-27% for pandemic influenza; 30-56% for a radiological 'dirty' bomb event; and 22-48% for an inhalational anthrax bioterrorism event. Efficacy was consistently identified as an important independent predictor of WTR. CONCLUSIONS: Response willingness deficits in the local public health workforce pose a threat to all-hazards response capacity and health security. Local public health agencies and their stakeholders may incorporate key findings, including identified scenario-based willingness gaps and the importance of efficacy, as targets of preparedness curriculum development efforts and policies for enhancing response willingness. Reasons for an increased willingness in rural cohorts compared to urban cohorts should be further investigated in order to understand and develop methods for improving their overall response.

Cluster of serogroup W135 meningococci, southeastern Florida, 2008-2009.

Recently, 14 persons in southeastern Florida were identified with Neisseria meningitidis serogroup W135 invasive infections. All isolates tested had matching or near-matching pulsed-field gel electrophoresis patterns and belonged to the multilocus sequence type 11 clonal complex. The epidemiologic investigation suggested recent endemic transmission of this clonal complex in southeastern Florida.