Mare Schumacher

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

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

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

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

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

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

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

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

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

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

Notes from the Field: Fatal Pneumonic Tularemia Associated with Dog Exposure — Arizona, June 2016

On June 15, 2016, Arizona public health officials were notified of a presumptive positive Francisella tularensis blood culture result from a woman aged 73 years with pulmonary sarcoidosis who had recently died from respiratory failure. She had been taking amoxicillin for a dental infection. She was evaluated on June 6 for 4 days of fever, myalgia, anorexia, and diarrhea. Because of suspected colitis she was advised to discontinue amoxicillin; she declined hospital admission. Two days later, she was hospitalized for shortness of breath and confusion. Chest radiography revealed a right lower lobe pneumonia and an effusion. This was treated with cefepime and intravenous doxycycline. On June 8, her stool tested positive for Clostridium difficile toxin A/B by polymerase chain reaction, requiring treatment with metronidazole and vancomycin. Her condition deteriorated, and she died on June 11. Tularemia was not suspected as cause of illness until June 17 when a blood culture collected on June 6 was confirmed as F. tularensis, a Tier 1 select agent; no laboratory exposures occurred. The patient lived in a semirural area of northern Arizona, did not engage in outdoor activities, and had no known history of insect bites, exposure to animal carcasses or untreated water. She traveled to Hawaii May 16–26, returning approximately 11 days before illness onset. Postmortem exam revealed no bites, abscesses, or lymphadenopathy. The patient’s dog was noted to be lethargic and anorexic in late May, 3 days after being found with a rabbit carcass in its mouth. The patient and dog had frequent close contact. Serum from the dog, obtained approximately 3 weeks after its illness and the patient’s death, had a F. tularensis-specific titer of 1:256. An assessment of the property on June 23 revealed numerous rabbits and one squirrel carcass with F. tularensis DNA detected in its liver and spleen. Genotyping of F. tularensis from squirrel and human samples showed both infections were attributable to an A.II strain. Approximately 125 human tularemia cases are reported in the United States annually. Humans are infected through arthropod bites, contact with infectious tissues, inhalation, or ingestion (1). Symptoms commonly begin 3–5 days after exposure and can include fever, skin lesions, lymphadenopathy, difficulty breathing, and diarrhea (1). Two F. tularensis subspecies, tularensis (Type A) and holarctica (Type B), cause human tularemia (1,2). Distinct clades within Type A (A.I and A.II) are associated with different virulence in humans and laboratory animals (2,3). A.II strains are localized to the western United States and associated with milder illness than are A.I strains (2,3). Based on the patient’s respiratory symptoms, radiographic findings, and lack of alternative exposure history, exposure likely occurred at her property through inhalation of F. tularensis, potentially via close contact with her dog. The dog might have transmitted infectious material through oral secretions after mouthing an infected carcass or brought infectious material on its fur into contact with the patient. Human illness linked to dogs has been documented (3). The role of pulmonary sarcoidosis in this patient’s illness is unclear, but it might have contributed to the severe outcome of infection with an A.II strain (4). Concurrent infection with C. difficile might also have exacerbated the clinical course of tularemia. Diagnosis of tularemia is challenging because symptoms are nonspecific and exposure history is often unclear. Thorough ascertainment of animal exposures, including nature of contact, might refine clinical suspicion for specific zoonoses. Preventing exposure and implementing early, appropriate therapy can reduce morbidity and mortality. Additional information is available at https://www.cdc.gov/tularemia.