Laura M. Erhart

The Public Health Impact of Coccidioidomycosis in Arizona and California

The numbers of reported cases of coccidioidomycosis in Arizona and California have risen dramatically over the past decade, with a 97.8% and 91.1% increase in incidence rates from 2001 to 2006 in the two states, respectively. Of those cases with reported race/ethnicity information, Black/African Americans in Arizona and Hispanics and African/Americans in California experienced a disproportionately higher frequency of disease compared to other racial/ethnic groups. Lack of early diagnosis continues to be a problem, particularly in suspect community-acquired pneumonia, underscoring the need for more rapid and sensitive tests. Similarly, the inability of currently available therapeutics to reduce the duration and morbidity of this disease underscores the need for improved therapeutics and a preventive vaccine.

Enhanced surveillance of coccidioidomycosis, Arizona, USA, 2007-2008.

Additional public and provider education are needed to reduce delays in diagnosis.

Effect of school closure on the incidence of influenza among school-age children in Arizona

Objective. We assessed the impact of school closures as a viable intervention in the event of an influenza pandemic. Methods. We evaluated the effect of scheduled, two-week winter break school closures during the 2004–2008 school years on the occurrence of influenza among children aged 5–17 years in Arizona. Results. We found a consistent pattern of benefit to school-age children during winter school closures when non-school-age children and adults experienced significant increases in influenza incidence, an increase not seen among school-age children. Quantitative analysis showed that school closures may prevent or delay as much as 42% of potential influenza cases among school-age children. In addition, the ratio of illness in school-age children as compared with adults and non-school-age children decreased significantly from before to during the same school closure periods. Conclusion. This analysis provides evidence to suggest that school-age children may experience a slowing of influenza transmission during winter school closures compared with those not of school age. Federal, state, and local policy makers may consider these findings in their pandemic influenza and public health emergency preparedness planning efforts.

The changing epidemiology of hepatitis A in Arizona following intensive immunization programs (1988-2007)

INTRODUCTION Arizona had the highest hepatitis A incidence of any U.S. state during 1987-1997. In 1995, the first hepatitis A vaccines became available in the U.S. A series of hepatitis A vaccination policies and recommendations were implemented in 1996-2006. Our objective was to examine the shifting epidemiologic patterns in hepatitis A in Arizona from 1988 to 2007. METHODS Passive surveillance reports to the Arizona Department of Health Services were used to compare hepatitis A rates by age, race/ethnicity and geographic area, before and after widespread vaccination. Reported risk factors and possible sources of infection were compared for two time periods. Age-adjusted incidence during three periods was mapped. RESULTS Overall hepatitis A incidence in Arizona fell from 58 cases per 100,000 in 1988 to 2 per 100,000 in 2007. The proportion of reported cases among children dropped from 62% in 1994-1995 to 32% in 2006-2007. Racial/ethnic disparities between American Indians and non-Hispanic White populations have been eliminated. The geographic distribution of cases within the state has shifted. Earlier cases were likely to report contact with another hepatitis A case or childcare facilities, while later cases indicated recent international travel. CONCLUSION A major shift in the overall burden of hepatitis A and hepatitis A transmission has occurred in Arizona since the widespread implementation of immunization policies and the concomitant rise in vaccination rates in the state. Current transmission has shifted to older age groups and disparities by race/ethnicity are now highest in Hispanic populations. Future strategies to further reduce hepatitis A transmission may require broadening recommendations to include general adult populations without previous vaccination history.

Surveillance for severe acute respiratory infections in Southern Arizona, 2010–2014

The Binational Border Infectious Disease Surveillance program began surveillance for severe acute respiratory infections (SARI) on the US–Mexico border in 2009. Here, we describe patients in Southern Arizona.

The Effect of Policy Changes on Hepatitis A Vaccine Uptake in Arizona Children, 1995-2008

Objective. In 1995, the first hepatitis A vaccines became available for use. At that time, Arizona had the highest hepatitis A incidence of all 50 states. During that same time period, the Arizona State Immunization Information System (ASIIS) was created to collect information on all immunizations given in the state. Four state-level hepatitis A vaccination policies were enacted according to Centers for Disease Control and Prevention recommendations and local initiatives from 1996 to 2005. Our primary objective was to assess the impact of these policies on vaccine uptake in children. Methods. Immunization records from ASIIS were used to calculate yearly coverage of children with at least one reported hepatitis A vaccination between 1995 and 2008. Proportions vaccinated were calculated by age group (12–23 months, 24–59 months, 5–9 years, 10–14 years, and 15–19 years) for three regions: Maricopa County; Apache and Navajo counties; and the remaining 12 Arizona counties, which were grouped as one to reflect different target groups for the four policies examined. We calculated percent changes from before and after each policy implementation. Results. Significantly different percent changes were detected among the three regions that related to the four policies implemented. Percent change in uptake was consistently higher in the regions that were targeted for that specific policy. Conclusions. Analysis of ASIIS data revealed a major effect of hepatitis A policy recommendations on vaccine uptake in Arizona. Targeting high-risk populations through vaccine recommendations and child care entry requirements was highly successful in achieving higher vaccination coverage.

Variations in positive predictive values for rapid influenza tests for 2009 pandemic influenza a (pH1N1)--Arizona, April-October 2009.

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 hospitals 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.

The role of ethnicity and travel on Hepatitis A vaccination coverage and disease incidence in Arizona at the United States-Mexico Border.

Background: Hepatitis A (HAV) incidence has decreased in the United States, yet regional disparities persist. The role of international travel has become increasingly important in HAV transmission. We compared the relative burden of HAV in border and non-border regions in Arizona and examined the role of travel in sustaining HAV transmission. Methods: HAV vaccination coverage was calculated by age and region, using Arizona State Immunization Information System data. Incidence, demographics, and risk factors of cases reported through Arizona’s infectious disease surveillance system between 2006 and 2011 were analyzed. Results: Hepatitis A incidence was higher in the border region of Arizona. Compared with the rest of Arizona, one-dose coverage in children <15 years was lower in the border region until 2008. Second dose coverage was lower in the border region, particularly among Spanish speakers. International travel among cases was generally high; however, in the border region cases were more likely to visit Mexico or South/Central America (94% vs. 80%, P value = 0.01) and be Hispanic (68% vs. 42%, P value = 0.0003). Conclusions: Rates of HAV continue to be higher in the Arizona border region; the risk appears particularly high among Hispanics with recent travel in the Americas. Border surveillance should be emphasized, along with vaccination of all travelers, to continue to decrease and control HAV.