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.

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.

Tropical splenomegaly is often associated with malaria and schistosomiasis. In 2014 and 2015, 145 Congolese refugees in western Uganda diagnosed with splenomegaly during predeparture medical examinations underwent enhanced screening for various etiologies. After anecdotal reports of unresolved splenomegaly and complications after U.S. arrival, patients were reassessed to describe long-term clinical progression after arrival in the United States. Post-arrival medical information was obtained through medical chart abstraction in collaboration with state health partners in nine participating states. We evaluated observed splenomegaly duration and associated clinical sequelae between 130 case patients from eastern Congo and 102 controls through adjusted hierarchical Poisson models, accounting for familial clustering. Of the 130 case patients, 95 (73.1%) had detectable splenomegaly after arrival. Of the 85 patients with records beyond 6 months, 45 (52.9%) had persistent splenomegaly, with a median persistence of 14.7 months (range 6.0-27.9 months). Of the 112 patients with available results, 65 (58.0%) patients had evidence of malaria infection, and the mean splenomegaly duration did not differ by Plasmodium species. Refugees with splenomegaly on arrival were 43% more likely to have anemia (adjusted relative risk [aRR]: 1.43, 95% CI: 1.04-1.97). Those with persistent splenomegaly were 60% more likely (adjusted relative risk [aRR]: 1.60, 95% CI: 1.15-2.23) to have a hematologic abnormality, particularly thrombocytopenia (aRR: 5.53, 95% CI: 1.73-17.62), and elevated alkaline phosphatase (aRR: 1.57, 95% CI: 1.03-2.40). Many patients experienced persistent splenomegaly, contradicting literature describing resolution after treatment and removal from an endemic setting. Other possible etiologies should be investigated and effective treatment, beyond treatment for malaria and schistosomiasis, explored.

Leptospirosis, caused by Leptospira spp., is a zoonotic bacterial disease important to both human and animal health. Six pathogenic serovars are currently known to commonly infect and cause disease in dogs in the United States. While canine leptospirosis infection is historically rare in Arizona (</=5 cases reported annually) (ADHS unpublished data) several clusters were reported in Maricopa County (MC) during February 2016-January 2017. Public health initiated an outbreak response and developed a knowledge, attitudes, and practices survey for veterinarians. The goals were to determine awareness and general attitudes about canine leptospirosis and to identify gaps in veterinarians' knowledge in treatment and prevention. We distributed a 40-question self-administered online survey to 1058 Arizona Veterinary Medical Association members, made available during February 9-May 15, 2017. We analyzed the results using Pearson's Chi-squared or Fisher's exact test; a P-value <0.05 was considered statistically significant. We analyzed 202 complete responses. Veterinarians from 10 (66%) of 15 Arizona counties were represented. MC practices were more likely to stock leptospirosis vaccine (80%) than other counties combined (58%) (P=0.004). The average composite knowledge score was 24.4 out of 38 (range 12-37, median 24); 49% of respondents demonstrated higher knowledge as defined by authors, largely in identification of leptospirosis risk factors (86%) and routes of exposure (73%). Fewer than half (45%) of respondents correctly identified the length of time bacteria can be shed in dogs' urine. Eighty-one percent of respondents demonstrated lower knowledge about clinical signs associated with leptospirosis; only 47% of respondents identified eight clinical signs commonly associated with leptospirosis. Sixty-one percent of MC respondents agreed that leptospirosis is an important canine disease in their geographic area, while only 40% of other county respondents agreed (P=0.03). Seventy percent of respondents identified diagnostic testing options. The majority correctly selected infection-control practices in line with recommendations from 2 national clinical guidelines. More respondents would recommend leptospirosis vaccination if dogs traveled or lived in rural areas (87-96%) than if dogs attended day care or were boarded (63%). We identified opportunities for education, including the local epidemiology of leptospirosis, transmission prevention strategies, vaccine safety, testing, clinical identification, and emerging risk factors. Our findings will help guide the design of educational materials for small animal veterinarians in Arizona regarding recommendations for prevention of animal and human leptospirosis infections; these efforts could also shift the culture of reporting companion animal diseases to improve future One Health collaborations.

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.

We describe a 2016 community-wide recreational water-associated cryptosporidiosis outbreak investigation and response in Maricopa County, Arizona. Persons with a laboratory-confirmed illness were interviewed using a standardized questionnaire that assessed exposures 2 weeks before symptom onset. A convenience sample of managers and operators of chlorine-treated public aquatic facilities was surveyed regarding permanent supplemental treatment systems for Cryptosporidium. Among 437 cases identified (median age 12, range <1-75 years), 260 persons were interviewed. Public-treated recreational water was the most frequently reported exposure (177, 68%) of interviewed persons; almost 1 in 5 (43, 17%) swam when diarrhea was ongoing. After the 2016 outbreak, managers of some facilities expressed intentions to install supplementary water treatment systems, and by May 2017, at least one large facility installed an ultraviolet light system. Strategies to prevent additional illness included community messaging, education, and targeted remediation of affected facilities on the basis of interviews. Challenges to remediation during a cryptosporidiosis outbreak in a large jurisdiction with primarily outdoor pools underscore the importance of promoting healthy swimming practices that help prevent contamination from occurring.

In 2016, CDC saw an increase in cases of acute flaccid myelitis (AFM); 144 persons in 37 states and the District of Columbia were confirmed to have AFM. After investigations in California (1) and Colorado (2) in 2014, CDC characterized AFM as an acute flaccid paralysis (AFP) distinguishable by magnetic resonance imaging (MRI) abnormalities of the gray matter of the anterior and posterior spinal cord segments, involving one or more spinal segments (3). Although certain viruses (e.g., nonpoliovirus enteroviruses, adenoviruses, and West Nile virus) can cause rare cases of AFP, and findings from the 2014 outbreak investigations indicated that enterovirus D68 (EV-D68) was temporally associated with AFM, no viral etiology for AFM has been definitively established (3). In September 2016, an acute care hospital in Arizona notified the Maricopa County Department of Public Health (MCDPH) of a suspected case of AFM and subsequent cluster of 11 children who were evaluated with similar neurologic deficits; differential diagnoses included transverse myelitis and AFM. The Maricopa County Department of Public Health, in cooperation with the Arizona Department of Health Services, CDC, the Translational Genomics Research Institute (TGen, Flagstaff, Arizona), and the acute care hospital, initiated an investigation to confirm AFM cases and identify an etiology. | The 2015 Council of State and Territorial Epidemiologists and CDC case definition for probable AFM requires acute onset of flaccid limb weakness and cerebrospinal fluid (CSF) pleocytosis (CSF white blood cell [WBC] count >5/mm3 when corrected for red blood cells). A confirmed case must have an MRI demonstrating lesions restricted primarily to the gray matter of the spinal cord, in addition to acute onset of flaccid limb weakness (4). Based on medical chart abstraction and review of the MRI images, a CDC neurology subject matter expert verified four confirmed cases of AFM and one probable case. Among the six patients whose cases did not meet the AFM confirmed or probable case definition, two had focal limb weakness and pleocytosis (CSF WBC = 7/mm3 and 22/mm3, respectively), but MRI results indicated alternative etiologies (acute disseminated encephalomyelitis and neuromyelitis optica, respectively). The case that met the probable case definition had pleocytosis (CSF WBC = 7/mm3), but MRI findings were inconsistent with AFM, and no other plausible diagnosis was identified.

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).

TO THE EDITOR: An outbreak of Cryptococcus gattii cryptococcosis has been ongoing in the US Pacific Northwest (PNW) since 1999. In contrast to C. neoformans infections, which typically cause meningitis in HIV-infected persons, outbreak-associated C. gattii infections occur primarily in persons without HIV and often cause pneumonia. Sporadic, nonoutbreak-associated C. gattii infections often cause meningitis and have been reported outside the PNW. The prevalence of both types of C. gattii infection in the United States is unknown because diagnostic practices and awareness vary among physicians.