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The article describes the results of a blood donor screening conducted by the American Red Cross during August 2006-January 2007 to identify chagas disease caused by the bloodborne parasite Trypanosoma cruzi. Information on the stages of chagas disease is offered. Background of vector-borne transmission of Chagas disease in the U.S. is also presented.

We describe an incidental Burkholderia pseudomallei laboratory exposure in Arizona, USA. Because melioidosis cases are increasing in the United States and B. pseudomallei reservoirs have been discovered in the Gulf Coast Region, US laboratory staff could be at increased risk for B. pseudomallei exposure.

Background: Short-term rehabilitation units present unique infection control challenges because of high turnover and medically complex residents. In June 2021, the Maricopa County Department of Public Health was notified of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta outbreak in a skilled nursing facility short-term rehabilitation unit. We describe the outbreak and assess vaccine effectiveness (VE)., Methods: Facility electronic medical records were reviewed for residents who spent > 1 night on the affected unit between June 10 and July 23, 2021, to collect demographics, SARS-CoV-2 test results, underlying medical conditions, vaccination status, and clinical outcomes. Coronavirus disease 2019 VE estimates using Cox proportional hazards models were calculated., Results: Forty (37%) of 109 short-stay rehabilitation unit residents who met inclusion criteria tested positive for SARS-CoV-2. SARS-CoV-2-positive case-patients were mostly male (58%) and White (78%) with a median age of 65 (range, 27-92) years; 11 (27%) were immunocompromised. Of residents, 39% (10 cases, 32 noncases) received 2 doses and 9% (4 cases, 6 noncases) received 1 dose of messenger RNA (mRNA) vaccine. Among nonimmunocompromised residents, adjusted 2-dose primary-series mRNA VE against symptomatic infection was 80% (95% confidence interval, 15-95). More cases were hospitalized (33%) or died (38%) than noncases (10% hospitalized; 16% died)., Conclusions: In this large SARS-CoV-2 Delta outbreak in a high-turnover short-term rehabilitation unit, a low vaccination rate and medically complex resident population were noted alongside severe outcomes. VE of 2-dose primary-series mRNA vaccine against symptomatic infection was the highest in nonimmunocompromised residents. Health departments can use vaccine coverage data to prioritize facilities for assistance in preventing outbreaks., (Published by Oxford University Press for the Infectious Diseases Society of America 2022.)

The Maricopa County Department of Public Health in Arizona investigated three COVID-19 outbreaks associated with club sports, two in tournaments and one in a hockey league. During September through November 2020, 195 team-associated and 69 secondary household contact cases were identified among 2093 athletes, coaches, and staff members; the team attack rate ranged from 6% to 72%. Outbreaks occurred during high community transmission periods in Maricopa County. Identification of contacts and characterization of prevention strategies were challenging because of limited cooperation from athletes, families, and staff. ( Am J Public Health . 2022;112(2):216-219. https://doi.org/10.2105/AJPH.2021.306579).

We conducted a community seroprevalence survey in Arizona, from September 12 to October 1, 2020, to determine the presence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We used the seroprevalence estimate to predict SARS-CoV-2 infections in the jurisdiction by applying the adjusted seroprevalence to the county's population. The estimated community seroprevalence of SARS-CoV-2 infections was 4.3 times greater (95% confidence interval = 2.2, 7.5) than the number of reported cases. Field surveys with representative sampling provide data that may help fill in gaps in traditional public health reporting. ( Am J Public Health . 2022;112(1):38-42. https://doi.org/10.2105/AJPH.2021.306568).

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.

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

School nurses often play large roles in implementation of school vaccination requirements aimed at controlling the spread of communicable disease. We analyzed the association between the presence of a school nurse and school-level vaccination rates in Arizona. Using school-level data from Arizona sixth-grade schools ( n = 749), we regressed average sixth-grade school-level immunization rates on presence of a school nurse (registered nurse [RN] or licensed practical nurse [LPN]) and school-level socioeconomic status (SES), controlling for other school- and district-level characteristics. Schools with a nurse had higher overall vaccination rates than those without a nurse (96.1% vs. 95.0%, p < .01). For schools in the lowest SES quartile, the presence of a school nurse was associated with approximately 2 percentage point higher immunization rates. These findings add to the growing literature that defines the impact of school nurses on student health status and outcomes, emphasizing the value of school nurses, especially in lower SES schools.

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. In response to the first cases identified in the United States, close contacts of confirmed COVID-19 cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. Close contacts of nine early travel-related cases in the United States were identified and monitored daily for development of symptoms (active monitoring). Selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction at the Centers for Disease Control and Prevention. Four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. Three hundred thirty-eight of the 404 close contacts provided at least basic exposure information, of whom 159 close contacts had ≥1 set of respiratory samples collected and tested. Across all actively monitored close contacts, two additional symptomatic COVID-19 cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. When considering only household members, all of whom had ≥1 respiratory sample tested for SARS-CoV-2, the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was 13% (95% CI: 4-38%). The results from these contact tracing investigations suggest that household members, especially significant others, of COVID-19 cases are at highest risk of becoming infected. The importance of personal protective equipment for healthcare workers is also underlined. Isolation of persons with COVID-19, in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of COVID-19., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Maricopa County, Arizona (2017 population about 4.3 million), is located in the Sonoran Desert. In 2005, the Maricopa County Department of Public Health (MCDPH) established a heat-associated mortality surveillance system that captures data on circumstances of death for Maricopa County residents and visitors. We analyzed 2006-2016 surveillance system data to understand the characteristics and circumstances of heat-associated deaths., Methods: We classified heat-associated deaths based on International Classification of Diseases, Tenth Revision codes (X30, T67.X, and P81.0) and phrases (heat exposure, environ, exhaustion, sun, heat stress, heat stroke, or hyperthermia) in part I or part II of the death certificate. We summarized data on decedents' demographic characteristics, years lived in Arizona, location of death (indoors vs outdoors), presence and functionality of air conditioning, and whether the decedent had been homeless. We examined significant associations between variables by using the Pearson χ 2 tests and logistic regression., Results: During 2006-2016, MCDPH recorded data on 920 heat-associated deaths, 912 of which included location of injury. Of 565 (62%) heat-associated deaths that occurred outdoors, 458 (81%) were among male decedents and 243 (43%) were among decedents aged 20-49. Of 347 (38%) heat-associated deaths that occurred indoors, 201 (58%) were among decedents aged ≥65. Non-Arizona residents were 5 times as likely as Arizona residents to have a heat-associated death outdoors ( P < .001). Of 727 decedents with data on duration of Arizona residency, 438 (60%) had resided in Arizona ≥20 years., Conclusions: Ongoing evaluation of interventions that target populations at risk for both outdoor and indoor heat-associated deaths can further inform refinement of the surveillance system and identify best practices to prevent heat-associated deaths.

West Nile virus (WNV) and St. Louis encephalitis virus (SLEV) are closely related mosquito-borne flaviviruses that cause clinical disease ranging from febrile illness to encephalitis. The standard for serological diagnosis is immunoglobulin M (IgM) testing followed by confirmatory plaque reduction neutralization test (PRNT) to differentiate the infecting virus. However, the PRNT is time-consuming and requires manipulation of live virus. During concurrent WNV and SLEV outbreaks in Arizona in 2015, we assessed use of a diagnostic algorithm to simplify testing. It incorporated WNV and SLEV ratios based on positive-to-negative (P/N) values derived from the IgM antibody-capture enzyme-linked immunosorbent assay. We compared each sample's ratio-based result with the confirmed WNV or SLEV sample result indicated by PRNT or PCR testing. We analyzed data from 70 patients with 77 serum and cerebrospinal fluid samples, including 53 patients with confirmed WNV infection and 17 patients with confirmed SLEV infection. Both WNV and SLEV ratios had specificity ≥95%, indicating a high likelihood that each ratio was correctly identifying the infecting virus. The SLEV ratio sensitivity of 30% was much lower than the WNV ratio sensitivity of 91%, likely because of higher cross-reactivity of SLEV antibodies and generation of lower P/N values. The standard for serological diagnosis of WNV and SLEV infections remains IgM testing followed by PRNT. However, these results suggest the ratios could potentially be used as part of a diagnostic algorithm in outbreaks to substantially reduce the need for PRNTs.

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/mm 3 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.

Background: Coronavirus disease 2019 (COVID-19) causes a range of illness severity. Mild illness has been reported, but whether illness severity correlates with infectivity is unknown. We describe the public health investigation of a mildly ill, nonhospitalized COVID-19 case who traveled to China., Methods: The case was a Maricopa County resident with multiple severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive specimens collected on 22 January 2020. Contacts were persons exposed to the case on or after the day before case diagnostic specimen collection. Contacts were monitored for 14 days after last known exposure. High-risk contacts had close, prolonged case contact (≥ 10 minutes within 2 m). Medium-risk contacts wore all US Centers for Disease Control and Prevention-recommended personal protective equipment during interactions. Nasopharyngeal and oropharyngeal (NP/OP) specimens were collected from the case and high-risk contacts and tested for SARS-CoV-2., Results: Paired case NP/OP specimens were collected for SARS-CoV-2 testing at 11 time points. In 8 pairs (73%), ≥ 1 specimen tested positive or indeterminate, and in 3 pairs (27%) both tested negative. Specimens collected 18 days after diagnosis tested positive. Sixteen contacts were identified; 11 (69%) had high-risk exposure, including 1 intimate contact, and 5 (31%) had medium-risk exposure. In total, 35 high-risk contact NP/OP specimens were collected for SARS-CoV-2 testing; all 35 pairs (100%) tested negative., Conclusions: This report demonstrates that SARS-CoV-2 infection can cause mild illness and result in positive tests for up to 18 days after diagnosis, without evidence of transmission to close contacts. These data might inform public health strategies to manage individuals with asymptomatic infection or mild illness., (Published by Oxford University Press for the Infectious Diseases Society of America 2020.)

Coccidioidomycosis is a debilitating fungal disease caused by inhalation of arthroconidia. We developed a novel approach for detection of airborne Coccidioides and used it to investigate the distribution of arthroconidia across the Phoenix, Arizona, metropolitan area. Air filters were collected daily from 21 stationary air-sampling units across the area: the first set collected before, during and after a large dust storm on August 25, 2015, and the second over the 45-day period September 25-November 8, 2016. Analysis of DNA extracted from the filters demonstrated that the day of the dust storm was not associated with increase of Coccidioides in air samples, although evidence of the low-level polymerase chain reaction (PCR) inhibition was observed in DNA extracted from samples collected on the day of the dust storm. Testing over 45 days identified uneven geographic distribution suggesting Coccidioides hot spots. In 2016, highest daily concentration of arthroconidia was observed between September 25-October 20, and only sporadic low levels were detected after that. These results provide evidence of seasonality and uneven spatial distribution of Coccidioides in the air. Our results demonstrate that routine air monitoring for arthroconidia is possible and provides an important tool for Coccidioides surveillance, which can address important questions about environmental exposure and human infection., (Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology 2019.)

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

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., Competing Interests: Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., (© 2019 Blackwell Verlag GmbH.)

The incidence of reported coccidioidomycosis in the past two decades has increased greatly; monitoring its changing epidemiology is essential for understanding its burden on patients and the healthcare system and for identifying opportunities for prevention and education. We provide an update on recent coccidioidomycosis trends and public health efforts nationally and in Arizona, California, and Washington State. In Arizona, enhanced surveillance shows that coccidioidomycosis continues to be associated with substantial morbidity. California reported its highest yearly number of cases ever in 2016 and has implemented interventions to reduce coccidioidomycosis in the prison population by excluding certain inmates from residing in prisons in high-risk areas. Coccidioidomycosis is emerging in Washington State, where phylogenetic analyses confirm the existence of a unique Coccidioides clade. Additional studies of the molecular epidemiology of Coccidioides will improve understanding its expanding endemic range. Ongoing public health collaborations and future research priorities are focused on characterizing geographic risk, particularly in the context of environmental change; identifying further risk reduction strategies for high-risk groups; and improving reporting of cases to public health agencies.

Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

On 10 August 2016, the Maricopa County Department of Public Health identified culture-confirmed Salmonella enterica serotype Javiana isolates from two persons who reported eating at a seafood restaurant; seven additional cases were reported by 15 August. We investigated to identify a source and prevent further illness. We interviewed persons with laboratory-reported Salmonella Javiana infection. Pulsed-field gel electrophoresis (PFGE) and whole genome sequencing of isolates were performed. A case was defined as diarrheal illness in a person during July to September 2016; confirmed cases had Salmonella Javiana isolate yielding outbreak-related PFGE patterns; probable cases had diarrheal illness and an epidemiologic link to a confirmed case. Case finding was performed (passive surveillance and identification of ill meal companions). A case-control study assessed risk factors for Salmonella Javiana infection among restaurant diners; control subjects were chosen among meal companions. No restaurant workers reported illness. Foods were reportedly cooked according to the Food Code. Food and environmental samples were collected and cultured; Salmonella Javiana with an indistinguishable PFGE pattern was isolated from portioned repackaged raw shrimp, halibut, and a freezer door handle. We identified 50 Salmonella Javiana cases (40 confirmed and 10 probable); illness onset range was from 22 July to 17 September 2016. Isolates from 40 patients had highly related PFGE patterns. Thirty-three (73%) of 45 patients interviewed reported eating at the restaurant. Among 21 case patients and 31 control subjects, unfried cooked shrimp was associated with illness (odds ratio, 6.7; 95% confidence interval, 1.8 to 24.9; P = 0.004). Among restaurant diners, laboratory and case-control evidence indicated shrimp as the possible outbreak source; poor thermal inactivation of Salmonella on shrimp is theorized as a possible cause. Cross-contamination might have prolonged this outbreak; however, the source was not identified and highlights limitations that can arise during these types of investigations.

In Arizona during 1997-2013, coccidioidomycosis increased from 21 to 90 cases/100,000 population, but coccidioidomycosis-associated deaths remained stable at 3-6 deaths/million population. We used the capture-recapture method by using death certificates and hospital discharge data to more fully estimate the total number of coccidioidomycosis-attributable deaths and compared this with published estimates. Death certificates were included if any cause of death included coccidioidomycosis; hospital discharge data deaths were included if any discharge diagnosis included coccidioidomycosis and laboratory confirmation. Among deaths during 2008-2013, we identified 529 coccidioidomycosis-attributable deaths from death certificates and 560 from hospital discharge data, with 251 deaths identified in both databases. Capture-recapture estimated 1,178 total coccidioidomycosis-attributable deaths, compared with 164 deaths (underlying cause of death) or 529 deaths (any cause of death) on death certificates. Coccidioidomycosis-attributable deaths are underreported from two- to sevenfold on Arizona death certificates, demonstrating an education need for death certifiers to document coccidioidomycosis mortality., (Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology 2017.)

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., (© 2017 AABB.)

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).

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

During July to November 2012, two botulism outbreaks (12 cases total) occurred in one all-male prison; both were associated with illicitly brewed alcohol (pruno) consumption. Inmate surveys were conducted to evaluate and develop prevention and education strategies. Qualitative surveys with open-ended questions were performed among inmates from rooms where outbreaks occurred to learn about pruno consumption. Quantitative surveys assessed knowledge gained after the outbreaks and preferred information sources. For the quantitative surveys, 250 inmates were randomly selected by bed from across the correctional facility and 164 inmates were interviewed. Only 24% of inmates reported any botulism knowledge before the outbreaks and education outreach, whereas 73% reported knowledge after the outbreaks (p < .01). Preferred information sources included handouts/fliers (52%) and the prison television channel (32%)., (© The Author(s) 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.

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.

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., (Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society 2013. This work is written by US Government employees and is in the public domain in the US.)

Context: An outbreak of gastrointestinal (GI) illness among retirement community residents was reported to the Maricopa County Department of Public Health. Online surveys can be useful for rapid investigation of disease outbreaks, especially when local health departments lack time and resources to perform telephone interviews. Online survey utility among older populations, which may lack computer access or literacy, has not been defined., Objective: To investigate and implement prevention measures for a GI outbreak and assess the utility of an online survey among retirement community residents., Design: A retrospective cohort investigation was conducted using an online survey distributed through the retirement community e-mail listserv; a follow-up telephone survey was conducted to assess computer literacy and Internet access. A case was defined as any GI illness occurring among residents during March 1-14, 2012., Setting: A barbecue in a retirement community of 3000 residents., Participants: Retirement community residents., Intervention: Residents were directed to discard leftover food and seek health care for symptoms. A telephone survey was conducted to assess the utility of online surveys in this population., Main Outcome Measures: Computer literacy and Internet access of retirement community residents., Results: Of 1000 residents on the listserv, 370 (37%) completed the online survey (mean age, 69.7 years; 60.6% women); 66 residents (17.8%) reported a GI illness after the barbecue, 63 (95.5%) reported diarrhea, and 5 (7.6%) reported vomiting. Leftover beef from an attendee's refrigerator grew Clostridium perfringens. Of 552 residents contacted by telephone, 113 completed the telephone survey (mean age, 71.3 years; 63.3% women), 101 (89.4%) reported the ability to send e-mail, 82 (81.2%) checked e-mail daily, and 28 (27.7%) checked e-mail on a handheld device. The attack rate was 17.8% for online versus 2.7% for telephone respondents (P < .001)., Conclusions: This outbreak demonstrated the utility of an online survey to rapidly collect information and implement prevention measures among an older demographic.

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.

Flagstaff, Arizona, USA, experienced notable outbreaks of rabies caused by a bat rabies virus variant in carnivore species in 2001, 2004, 2005, 2008, and 2009. The most recent epizootic involved transmission among skunk and fox populations and human exposures. Multiple, wide-ranging control efforts and health communications outreach were instituted in 2009, including a household survey given to community members. Although the Flagstaff community is knowledgeable about rabies and the ongoing outbreaks in general, gaps in knowledge about routes of exposure and potential hosts remain. Future educational efforts should include messages on the dangers of animal translocation and a focus on veterinarians and physicians as valuable sources for outreach. These results will be useful to communities experiencing rabies outbreaks as well as those at current risk.

Context: Rapid influenza diagnostic tests (RIDTs) are used for influenza screening, clinical decision making, and influenza surveillance. In August 2009, a hospital reported increased false-positive RIDT results to the Arizona Department of Health Services. Because of reported RIDT low sensitivities (40%-62%) for 2009 pandemic influenza A (pH1N1), the hospital's report raised further concerns about the specificity and clinical utility of RIDTs., Objective: To determine the positive predictive value (PPV) of RIDTs compared with real-time reverse transcription-polymerase chain reaction assay (rRT-PCR) using Centers for Disease Control and Prevention (CDC) protocols and primers as a standard., Design: A standardized survey collected information including RIDT brand/lot number, training of personnel performing test, type of laboratory, swab and specimen type, time from collection to testing, sample storage, and viral transport medium., Setting: Arizona., Participants: Seven Arizona laboratories submitted positive RIDT clinical samples to Arizona State Public Health Laboratory (ASPHL) for confirmatory rRT-PCR testing., Main Outcome Measure: The PPV was calculated on the basis of rRT-PCR-positive results for April through October., Results: Results from 600 specimens using 1 of 4 RIDTs were available. Median pH1N1 PPV was 80% (range: 62%-91%) when calculated by RIDT brand. A significant difference in PPV was identified between the 2 largest facilities, which used the same RIDT brand, BinaxNOW Influenza A&B, (Laboratories A, 33% and B, 92%, [P < .01]). The facilities reported similar testing practices except lot numbers used and timing of testing. Laboratory A used lot 003684 and performed testing within 1 hour of collection; Laboratory B used multiple lots, excluding lot 003684, and performed testing within 24 hours. Laboratory A switched RIDT brands and noted a significant PPV increase from 33% to 91% (P < .01)., Conclusions: Wide PPV variability combined with documented low sensitivity among RIDTs for pH1N1 diagnosis increases concerns about their specificity and clinical and epidemiologic utility for influenza.

Melioidosis is caused by Burkholderia pseudomallei, a Gram-negative bacillus, primarily found in soils in Southeast Asia and northern Australia. A recent case of melioidosis in non-endemic Arizona was determined to be the result of locally acquired infection, as the patient had no travel history to endemic regions and no previous history of disease. Diagnosis of the case was confirmed through multiple microbiologic and molecular techniques. To enhance the epidemiological analysis, we conducted several molecular genotyping procedures, including multi-locus sequence typing, SNP-profiling, and whole genome sequence typing. Each technique has different molecular epidemiologic advantages, all of which provided evidence that the infecting strain was most similar to those found in Southeast Asia, possibly originating in, or around, Malaysia. Advancements in new typing technologies provide genotyping resolution not previously available to public health investigators, allowing for more accurate source identification.

Coccidioidomycosis presumably causes ≤ 33% of community-acquired pneumonias cases, although < 15% of the patients are tested for coccidioidomycosis. We assessed healthcare providers' knowledge, attitudes, and practices regarding coccidioidomycosis diagnosis and treatment in Arizona. A survey was mailed to 7,608 eligible healthcare providers licensed by the Arizona medical, osteopathic, and nursing boards in October and December 2007. We used weights to adjust for non-response and multivariate logistic regression models to identify predictors of ≥ 70% correct regarding knowledge and treatment practices. Of 1,823 (24%) respondents, 53% were physicians, 52% were male, and the mean age was 51 years. Approximately 50% reported confidence in their ability to treat coccidioidomycosis, and 21% correctly answered all four treatment questions. Predictors of ≥ 70% correct concerning knowledge and treatment practices included always counseling patients after diagnosis (adjusted odds ratio [AOR]=4.4; 95% confidence interval [CI]: 2.8-7.1); specializing in infectious diseases (AOR=2.4; 95% CI: 1.0-5.7); and having received coccidioidomycosis continuing medical education (CME) in the last year (AOR=1.8; 95% CI: 1.2-2.6). These findings demonstrate that coccidioidomycosis CME improves knowledge of disease diagnosis and management, underscoring the need for a comprehensive coccidioidomycosis education campaign for healthcare providers in Arizona., (© 2011 ISHAM)

Burkholderia pseudomallei is a bacterium endemic to Southeast Asia and northern Australia, but it has not been found to occur endemically in the United States. We report an ostensibly autochthonous case of melioidosis in the United States. Despite an extensive investigation, the source of exposure was not identified.

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.

Background: Primary pneumonic plague is a rare but often fatal form of Yersinia pestis infection that results from direct inhalation of bacteria and is potentially transmissible from person to person. We describe a case of primary pneumonic plague in a wildlife biologist who was found deceased in his residence 1 week after conducting a necropsy on a mountain lion., Methods: To determine cause of death, a postmortem examination was conducted, and friends and colleagues were interviewed. Physical evidence was reviewed, including specimens from the mountain lion and the biologist's medical chart, camera, and computer. Human and animal tissues were submitted for testing. Persons in close contact (within 2 meters) to the biologist after he had developed symptoms were identified and offered chemoprophylaxis., Results: The biologist conducted the necropsy in his garage without the use of personal protective equipment. Three days later, he developed fever and hemoptysis and died approximately 6 days after exposure. Gross examination showed consolidation and hemorrhagic fluid in the lungs; no buboes were noted. Plague was diagnosed presumptively by polymerase chain reaction and confirmed by culture. Tissues from the mountain lion tested positive for Y. pestis, and isolates from the biologist and mountain lion were indistinguishable by pulsed-field gel electrophoresis. Among 49 contacts who received chemoprophylaxis, none developed symptoms consistent with plague., Conclusions: The biologist likely acquired pneumonic plague through inhalation of aerosols generated during postmortem examination of an infected mountain lion. Enhanced awareness of zoonotic diseases and appropriate use of personal protective equipment are needed for biologists and others who handle wildlife.

Background: Because of increases in reported syphilis, we sought to identify factors associated with missed and delayed syphilis treatment and partner elicitation interview., Methods: We reviewed syphilis cases reported during June 1, 2006 to May 31, 2007 and conducted multivariate logistic regression analyses to determine demographic and clinical predictors of missed and delayed syphilis treatment and partner elicitation interview., Results: Of 638 syphilis cases, 38 (6%) were identified as untreated cases. Median time-to-treatment was 7 days (range: 0-380) and median time-to-partner elicitation interview was 14 days (range: 0-380 days) for all case-patients. Both intervals were shorter for patients among whom syphilis was diagnosed at the STD clinic versus non-STD facilities. In multivariate analysis, diagnosis at a non-STD clinic (AOR: 2.6; 95% CI, 1.0-6.9) and having a late infection of unknown duration (AOR: 2.1; 95% CI, 1.0-4.6) were significantly associated with untreated syphilis., Conclusion: Time-to-treatment and time-to-partner elicitation interview were shorter for patients among whom syphilis was diagnosed at the STD clinic. For non-STD settings in Maricopa County, improvements in quality of care (i.e., timely treatment) and expeditious public health interventions (i.e., partner elicitation interview) are needed.