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Background Antibiotic-resistant Acinetobacter species are a growing public health threat, yet are not nationally notifiable, and most states do not mandate reporting. Additionally, there are no standardized methods to detect Acinetobacter species colonization. Methods An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) was identified at a Utah ventilator unit in a skilled nursing facility. An investigation was conducted to identify transmission modes in order to control spread of CRAB. Culture-based methods were used to identify patient colonization and environmental contamination in the facility. Results Of the 47 patients screened, OXA-23-producing CRAB were detected in 10 patients (21%), with 7 patients (15%) having been transferred from out-of-state facilities. Of patients who screened positive, 60% did not exhibit any signs or symptoms of active infection by chart review. A total of 38 environmental samples were collected and CRAB was recovered from 37% of those samples. Whole genome sequencing analyses of patient and environmental isolates suggested repeated CRAB introduction into the facility and highlighted the role of shared equipment in transmission. Conclusions The investigation demonstrated this ventilated skilled nursing facility was an important reservoir for CRAB in the community and highlights the need for improved surveillance, strengthened infection control and inter-facility communication within and across states.

Objectives Among young people, dual use of marijuana and e-cigarette, or vaping, products (EVPs) is linked with using more inhalant substances and other substances, and poorer mental health. To understand antecedents and potential risks of dual use in adults, we analyzed a representative adult population in Utah. Methods We used data from the 2018 Utah Behavioral Risk Factor Surveillance System (n = 10 380) and multivariable logistic regression to evaluate differences in sociodemographic characteristics, comorbidities, and risk factors among adults aged ≥18 who reported currently using both EVPs (any substance) and marijuana (any intake mode), compared with a referent group of adults who used either or neither. Results Compared with the referent group, adults using EVPs and marijuana had greater odds of being aged 18-29 (adjusted odds ratio [aOR] = 12.44; 95% CI, 6.15-25.14) or 30-39 (aOR = 3.75; 95% CI, 1.73-8.12) versus ≥40, being male (aOR = 3.29; 95% CI, 1.82-5.96) versus female, reporting ≥14 days of poor mental health in previous 30 days (aOR = 2.30; 95% CI, 1.23-4.32) versus Conclusions Clinicians and health promotion specialists working with adults using both EVPs and marijuana should assess risk factors and comorbidities that could contribute to dual use or associated outcomes and tailor prevention messaging accordingly.

Coronavirus disease 2019 (COVID-19) has had a substantial impact on racial and ethnic minority populations and essential workers in the United States, but the role of geographic social and economic inequities (i.e., deprivation) in these disparities has not been examined (1,2). As of July 9, 2020, Utah had reported 27,356 confirmed COVID-19 cases. To better understand how area-level deprivation might reinforce ethnic, racial, and workplace-based COVID-19 inequities (3), the Utah Department of Health (UDOH) analyzed confirmed cases of infection with SARS-CoV-2 (the virus that causes COVID-19), COVID-19 hospitalizations, and SARS-CoV-2 testing rates in relation to deprivation as measured by Utah's Health Improvement Index (HII) (4). Age-weighted odds ratios (weighted ORs) were calculated by weighting rates for four age groups (≤24, 25-44, 45-64, and ≥65 years) to a 2000 U.S. Census age-standardized population. Odds of infection increased with level of deprivation and were two times greater in high-deprivation areas (weighted OR = 2.08; 95% confidence interval [CI] = 1.99-2.17) and three times greater (weighted OR = 3.11; 95% CI = 2.98-3.24) in very high-deprivation areas, compared with those in very low-deprivation areas. Odds of hospitalization and testing also increased with deprivation, but to a lesser extent. Local jurisdictions should use measures of deprivation and other social determinants of health to enhance transmission reduction strategies (e.g., increasing availability and accessibility of SARS-CoV-2 testing and distributing prevention guidance) to areas with greatest need. These strategies might include increasing availability and accessibility of SARS-CoV-2 testing, contact tracing, isolation options, preventive care, disease management, and prevention guidance to facilities (e.g., clinics, community centers, and businesses) in areas with high levels of deprivation.

Undetected infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) contributes to transmission in nursing homes, settings where large outbreaks with high resident mortality have occurred (1,2). Facility-wide testing of residents and health care personnel (HCP) can identify asymptomatic and presymptomatic infections and facilitate infection prevention and control interventions (3-5). Seven state or local health departments conducted initial facility-wide testing of residents and staff members in 288 nursing homes during March 24-June 14, 2020. Two of the seven health departments conducted testing in 195 nursing homes as part of facility-wide testing all nursing homes in their state, which were in low-incidence areas (i.e., the median preceding 14-day cumulative incidence in the surrounding county for each jurisdiction was 19 and 38 cases per 100,000 persons); 125 of the 195 nursing homes had not reported any COVID-19 cases before the testing. Ninety-five of 22,977 (0.4%) persons tested in 29 (23%) of these 125 facilities had positive SARS-CoV-2 test results. The other five health departments targeted facility-wide testing to 93 nursing homes, where 13,443 persons were tested, and 1,619 (12%) had positive SARS-CoV-2 test results. In regression analyses among 88 of these nursing homes with a documented case before facility-wide testing occurred, each additional day between identification of the first case and completion of facility-wide testing was associated with identification of 1.3 additional cases. Among 62 facilities that could differentiate results by resident and HCP status, an estimated 1.3 HCP cases were identified for every three resident cases. Performing facility-wide testing immediately after identification of a case commonly identifies additional unrecognized cases and, therefore, might maximize the benefits of infection prevention and control interventions. In contrast, facility-wide testing in low-incidence areas without a case has a lower proportion of test positivity; strategies are needed to further optimize testing in these settings.

In August 2019, the Utah Department of Health (UDOH) received reports from health care providers of several cases of lung injury in persons who reported use of electronic cigarette (e-cigarette), or vaping, products (1,2). To describe the characteristics of medical care, potentially related conditions, and exposures among 83 patients in Utah, detailed medical abstractions were completed for 79 (95%) patients. Among patients receiving chart abstractions, 70 (89%) were hospitalized, 39 (49%) required breathing assistance, and many reported preexisting respiratory and mental health conditions. Interviews were conducted by telephone or in person with 53 (64%) patients or their proxies, and product samples from eight (15%) of the interviewed patients or proxies were tested. Among 53 interviewed patients, all of whom reported using e-cigarette, or vaping, products within 3 months of acute lung injury, 49 (92%) reported using any products containing tetrohydrocannabinol (THC), the principal psychoactive component of cannabis; 35 (66%) reported using any nicotine-containing products, and 32 (60%) reported using both. As reported in Wisconsin and Illinois (1), most THC-containing products were acquired from informal sources such as friends or illicit in-person and online dealers. THC-containing products were most commonly used one to five times per day, whereas nicotine-containing products were most commonly used >25 times per day. Product sample testing at the Utah Public Health Laboratory (UPHL) showed evidence of vitamin E acetate in 17 of 20 (89%) THC-containing cartridges, which were provided by six of 53 interviewed patients. The cause or causes of this outbreak is currently unknown (2); however, the predominant use among patients of e-cigarette, or vaping, products with prefilled THC-containing cartridges suggests that the substances in these products or the way in which they are heated and aerosolized play an important role in the outbreak. At present, persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific cause or causes of lung injury are not yet known and while the investigation continues, persons should consider refraining from use of all e-cigarette, or vaping, products.

Suicidal thoughts and behaviors among youths are important public health concerns in Utah, where the suicide rate among youths consistently exceeds the national rate and has been increasing for nearly a decade (1). In March 2017, CDC was invited to assist the Utah Department of Health (UDOH) with an investigation to characterize the epidemiology of fatal and nonfatal suicidal behaviors and identify risk and protective factors associated with these behaviors, among youths aged 10-17 years. This report presents findings related to nonfatal suicidal behaviors among Utah youths. To examine the prevalence of suicidal ideation and attempts among Utah youths and evaluate risk and protective factors, data from the 2015 Utah Prevention Needs Assessment survey were analyzed. Among 27,329 respondents in grades 8, 10, and 12, 19.6% reported suicidal ideation and 8.2% reported suicide attempts in the preceding 12 months. Significant risk factors for suicidal ideation and attempts included being bullied, illegal substance or tobacco use in the previous month, and psychological distress. A significant protective factor for suicidal ideation and attempts was a supportive family environment. UDOH, local health departments, and other stakeholders are using these findings to develop tailored suicide prevention strategies that address multiple risk and protective factors for suicidal ideation and attempts. Resources such as CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices (2) can help states and communities identify strategies and approaches using the best available evidence to prevent suicide, which include tailored strategies for youths.

In 2016, Zika virus disease developed in a man (patient A) who had no known risk factors beyond caring for a relative who died of this disease (index patient). We investigated the source of infection for patient A by surveying other family contacts, healthcare personnel, and community members, and testing samples for Zika virus. We identified 19 family contacts who had similar exposures to the index patient; 86 healthcare personnel had contact with the index patient, including 57 (66%) who had contact with body fluids. Of 218 community members interviewed, 28 (13%) reported signs/symptoms and 132 (61%) provided a sample. Except for patient A, no other persons tested had laboratory evidence of recent Zika virus infection. Of 5,875 mosquitoes collected, none were known vectors of Zika virus and all were negative for Zika virus. The mechanism of transmission to patient A remains unknown but was likely person-to-person contact with the index patient.

In September 2015, a Wyoming woman was admitted to a local hospital with a 5-day history of progressive weakness, ataxia, dysarthria, and dysphagia. Because of respiratory failure, she was transferred to a referral hospital in Utah, where she developed progressive encephalitis. On day 8 of hospitalization, the patient's family told clinicians they recalled that, 1 month before admission, the woman had found a bat on her neck upon waking, but had not sought medical care. The patient's husband subsequently had contacted county invasive species authorities about the incident, but he was not advised to seek health care for evaluation of his wife's risk for rabies. On October 2, CDC confirmed the patient was infected with a rabies virus variant that was enzootic to the silver-haired bat (Lasionycteris noctivagans). The patient died on October 3. Public understanding of rabies risk from bat contact needs to be improved; cooperation among public health and other agencies can aid in referring persons with possible bat exposure for assessment of rabies risk.

In May 2014, the Utah Public Health Laboratory (UPHL) notified the Utah Department of Health (UDOH) of specimens from three patients infected with Campylobacter jejuni yielding indistinguishable pulsed-field gel electrophoresis (PFGE) patterns. All three patients had consumed raw (unpasteurized and nonhomogenized) milk from dairy A. In Utah, raw milk sales are legal from farm to consumer with a sales permit from the Utah Department of Agriculture and Food (UDAF). Raw milk dairies are required to submit monthly milk samples to UDAF for somatic cell and coliform counts, both of which are indicators of raw milk contamination. Before this cluster's identification, dairy A's routine test results were within acceptable levels (

During August 2017, two separate clusters of platelet transfusion-associated bacterial sepsis were reported in Utah and California. In Utah, two patients died after platelet transfusions from the same donation. Clostridium perfringens isolates from one patient's blood, the other patient's platelet bag, and donor skin swabs were highly related by whole genome sequencing (WGS). In California, one patient died after platelet transfusion; Klebsiella pneumoniae isolates from the patient's blood and platelet bag residuals and a nontransfused platelet unit were matched using WGS. Investigation revealed no deviations in blood supplier or hospital procedures. Findings in this report highlight that even when following current procedures, the risk for transfusion-related infection and fatality persists, making additional interventions necessary. Clinicians need to be vigilant in monitoring for platelet-transmitted bacterial infections and report adverse reactions to blood suppliers and hemovigilance systems. Blood suppliers and hospitals could consider additional evidence-based bacterial contamination risk mitigation strategies, including pathogen inactivation, rapid detection devices, and modified screening of bacterial culture protocols.

On June 26, 2017, a hospital in southern Utah notified the Utah Department of Health of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections in two children from a small community on the Arizona-Utah border. Both children developed hemolytic uremic syndrome, characterized by hemolytic anemia, acute kidney failure, and thrombocytopenia and died within a few days of illness onset. Over the next few days, several more STEC-associated illnesses were reported in residents of the community. A joint investigation by local and state health agencies from Arizona and Utah and CDC was initiated to identify the outbreak source and prevent additional cases; a total of 12 cases were identified, including the two children who died. Investigators initially explored multiple potential sources of illness; epidemiologic and environmental information revealed cow manure contact as the likely initial cause of the outbreak, which was followed by subsequent person-to-person transmission. One of the outbreak strains was isolated from bull and horse manure collected from a yard near a community household with two ill children. Local health agencies made recommendations to the public related to both animal contact and hand hygiene to reduce the risk for STEC transmission. Animal or animal manure contact should be considered a potential source of STEC O157:H7 during outbreaks in communities where ruminants are kept near the home.

Objective: To monitor opioid-related overdose in real-time using emergency department visit data and to develop an opioid overdose surveillance report for Utah Department of Health (UDOH) and its public health partners. Introduction: The current surveillance system for opioid-related overdoses at UDOH has been limited to mortality data provided by the Office of the Medical Examiner (OME). Timeliness is a major concern with OME data due to the considerable lag in its availability, often up to six months or more. To enhance opioid overdose surveillance, UDOH has implemented additional surveillance using timely syndromic data to monitor fatal and nonfatal opioid-related overdoses in Utah. Methods: As one of the agencies participating in the National Syndromic Surveillance Program (NSSP), UDOH submits de-identified data on emergency department visit from Utah’s hospitals and urgent care facilities in close to real-time to the NSSP platform. Emergency department visit data are available for analysis using the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) system provided by NSSP. ESSENCE provides UDOH with patient-level syndromic data for analysis and early detection of abnormal patterns in emergency visits. A total of 38 out of 48 acute care hospitals and multiple urgent care facilities are enrolled in the system in Utah. More than 90% of these hospitals report chief complaint data, and discharge data are available from about 15% of the facilities. Data were analyzed by querying key terms in the chief complaint field including: any entry of: ‘overdose’, drug and brand names for opioids, street names, ‘naloxone’, and miss-spellings. Exclusion terms included any mention of: ‘denies’, ‘quit’, ‘refill’, ‘withdraw’, ‘dependence’, etc. Data containing any ICD entry of: T40.0-T40.4, T40.60, and T40.69 were included in the analysis. Results: Between September 1, 2016 and August 31, 2017, Utah Department of Health identified 4,063 opioid-related overdose emergency department (ED) visits through the ESSENCE system using both chief complaint and discharge diagnosis queries. Of these visits, 3,865 (95%) were identified using chief complaints alone and 198 (5%) visits were added by searching the discharge diagnosis field. Opioid-related visits comprised approximately 0.3% of the total ED visits (1,267,244) reported during this time (Graph 1). More than half of the opioid-related emergency visits were reported from just five facilities. Rate of opioid-related visits ranging from 0 to 292 visits per 100,000 population per year (median: 108 visits per 100,000 population per year), with an overall rate for the state of 129 visits per100, 000 population per year. The highest rate of opioid-related visits occurred among patients aged 18 to 24 (219 visits per 100,000 population per year), and 59% of all opioid-related patients in Utah were female. Conclusions: The results presented are estimates of opioid-related overdoses reported using close to real-time data. These results would not include visits with incomplete or incorrectly coded chief complaints or discharge codes, or cases of opioid overdose who do not present to an emergency department or urgent care facility. The results from using syndromic data are consistent with existing surveillance findings using mortality data in Utah. This suggests that syndromic surveillance data are useful for rapidly capturing opioid events, which may allow for a timelier public health response. UDOH is currently evaluating syndromic surveillance data versus hospital discharge data for opioid-related emergency department visits, which may further optimize queries in ESSENCE, in order to provide improved opioid surveillance data to local public health partners. This analysis demonstrates that using syndromic surveillance data provides a more time-efficient alternative, enabling more rapid public health interventions, which improved opportunities to reduce opioid-related morbidity and mortality in Utah.

In 2015, suicide was the third leading cause of death among persons aged 10-17 years (1), and in Utah, the age-adjusted suicide rate was consistently higher than the national rate during the past decade (2). In January 2017, the Utah Department of Health (UDOH) invited CDC to assist with an epidemiologic investigation of suicides among youths aged 10-17 years during 2011-2015 to identify precipitating factors. CDC analyzed data from the Utah Violent Death Reporting System (UTVDRS), National Vital Statistics System, and additional information collected in the field. During 2011-2015 in Utah, 150 youths died by suicide. Approximately three fourths of decedents were male (77.4%) and aged 15-17 years (75.4%). During this period, the unadjusted suicide rate per 100,000 youths in Utah increased 136.2%, from 4.7 per 100,000 population (2011) to 11.1 (2015), whereas among youths nationwide, the rate increased 23.5%, from 3.4 to 4.1. Among suicide decedents with circumstances data available, more than two thirds (68.3%) had multiple precipitating circumstances, including mental health diagnosis (35.2%), depressed mood (31.0%), recent crisis (55.3%), and history of suicidal ideation or attempt (29.6%). CDC's technical package of policies, programs, and practices to prevent suicide supported by the best available evidence can be used as a suicide prevention resource (3).

Background Fragmented communication of patients’ infectious status across healthcare networks impact regional spread of multidrug-resistant organisms (MDRO). This study aimed to quantify gaps in communication of patient MDRO status across Utah healthcare facilities and to identify opportunities to improve. Methods This is a cross-sectional retrospective mixed-methods study of patient transfers from three purposively selected healthcare facilities: an acute care (ACF), long-term acute care (LTAC), and skilled-nursing facility (SNF). Patients with known MDRO transferred out of these facilities over the previous week were identified in bimonthly samples spanning 2 months. Infection preventionists and admission nurses from facilities receiving these patients were interviewed. Results Of 293 patients transferred to another facility, 13% (n = 38) had an active infection or colonization with an MDRO. These 38 patients were transferred to 26 healthcare facilities within the state (4 ACF, 3 LTAC, 19 SNF). Gram-negative organisms with resistance to a carbapenem accounted for 15.8% of those transferred with an MDRO. There was no documentation of the state infection control transfer form (ICTF) at the sending facility for 68.5% of MDRO patient transfers. Of 22 admitting nurses interviewed, 19 (86.4%) did not receive an ICTF, 6 (27.3%) received no communication regarding patients’ infectious status, and 11 (50%) had to contact the sending facility for additional information. Moreover, 18.2% of patients had not been put on appropriate precautions. Several nurses expressed confusion with MDRO definitions and lack of guidance regarding care of MDRO colonized patients. Among infection preventionists asked about general MDRO transfers (n = 26), 26.9% reported that communication on infectious status of MDRO patients was received in under 40% of incoming transfers. When asked about a planned statewide MDRO registry, 80.8% felt that such a system would be actively searched at their facility, and 96.2% felt that a system that pushes out alerts would be useful. Conclusion Given the widespread gaps in communication of infectious status of patients with MDROs transferred across the healthcare facilities sampled, efforts to standardize and improve MDRO communication in the region is warranted. Disclosures All authors: No reported disclosures.

On July 12, 2016, the Utah Department of Health (UDOH) was notified by a clinician caring for an adult (patient A) who was evaluated for fever, rash, and conjunctivitis that began on July 1. Patient A had not traveled to an area with ongoing Zika virus transmission; had not had sexual contact with a person who recently traveled; and had not received a blood transfusion, organ transplant, or mosquito bites (1). Patient A provided care over several days to an elderly male family contact (the index patient) who contracted Zika virus abroad. The index patient developed septic shock with multiple organ failure and died in the hospital on June 25, 2016. The index patient's blood specimen obtained 2 days before his death had a level of viremia approximately 100,000 times higher than the average level reported in persons infected with Zika virus (2). Zika virus infection was diagnosed in patient A by real-time reverse transcription-polymerase chain reaction (rRT-PCR) testing on a urine specimen collected 7 days after symptom onset. In addition, a serum specimen collected 11 days after symptom onset, after patient A's symptoms had resolved, was positive for antibodies to Zika virus by Zika immunoglobulin M (IgM) capture enzyme-linked immunosorbent assay (MAC-ELISA) and had neutralizing antibodies detected by plaque-reduction neutralization testing (PRNT). Working with Salt Lake and Davis County Health Departments, UDOH requested assistance from CDC with an investigation to determine patient A's exposures and determine a probable source of infection.

Gonorrhea (caused by infection with Neisseria gonorrhoeae) is the second most commonly reported notifiable disease in the United States (1). Left untreated, gonorrhea is associated with serious long-term adverse health effects, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Infection also facilitates transmission of human immunodeficiency virus (2,3). Effective gonorrhea control relies upon early detection and effective antimicrobial treatment. To assess gonorrhea rate trends in Utah, the Utah Department of Health (UDOH) analyzed Utah National Electronic Disease Surveillance System (UT-NEDSS) data for the state during 2009-2014. After declining during 2009-2011, the statewide gonorrhea rate increased fivefold to 49 cases per 100,000 population in 2014. During 2009-2014, the proportion of cases among women increased from 21% to 39% (decreasing among males from 79% to 61%). Among male patients, the proportion who identified as men who have sex with men (MSM) decreased from 67% to 42%. These demographic changes suggest that increased heterosexual transmission of gonorrhea in Utah might be occurring. Health departments need to work with providers to ensure populations at high risk are being screened and properly treated for gonorrhea. Clinicians need to be aware of increases in the risk for infection among women and non-MSM males when making screening and testing decisions and educate their patients regarding gonorrhea transmission and prevention practices.

An epidemiologic model is developed to describe the incidence, prevalence, and mortality of diabetes. Available data are reviewed, analyzed, and applied to the model. The model provides a framework for understanding diabetes on a population basis, and is useful inidentifying needs and facilitating health care planning.