Health professionals have a need to continually maintain their competencies and a range of knowledge as new research, techniques, information, or ideas are exchanged or discovered. There are several barriers to obtaining required continuing education (CE), which can include the time spent and/or travel expenses incurred to participate in traditional CE courses (Garrison, Schardt, & Kochi, 2000). However, distance-based education, which refers to the formal method of study where students and instructors do not meet in an instructional space but use the Internet or other electronic-mediated methods, is increasingly being used to 768329P HPXXX10.
BackgroundHepatitis A virus (HAV) outbreaks can occur in settings with poor sanitation and crowding, including homeless shelters. On March 29, the Maricopa County Department of Public Health identified three confirmed HAV cases among homeless persons using services at one campus. We sought to determine outbreak source and scope and prevent further spread.MethodsCases were defined as having symptoms of acute hepatitis and a positive IgM anti-HAV test in persons with a history of homelessness or exposure or epidemiologic link to the campus and onset in 2017. Case-finding included enhanced surveillance with outreach to campus staff and healthcare providers who serve homeless persons. In-person interviews were conducted with campus HAV vaccination clinic attendees on April 4 and 11. To assess factors associated with HAV infection, a case–control study was conducted; campus clients or staff without a HAV diagnosis were controls. An environmental inspection was conducted. CDC performed HAV molecular sequencing.ResultsTwelve cases were identified, one by facility reporting, three by healthcare reporting, and eight by enhanced surveillance. Illness onsets were February 15–April 27; mean age was 47 years; 50% were male. The patient with the earliest onset arrived ~February 5 from San Diego, California, an area with an ongoing HAV outbreak. No campus food safety concerns were identified; educational flyers, soap, and alcohol-based hand sanitizer were provided to the campus. HAV vaccine was administered to 221 (22%) of ~1,000 clients and 105 (42%) of 250 staff who chose to attend the clinics. Ten cases and 343 controls were enrolled in the case–control study; not all questions were answered. Neither eating meals on campus (P = 0.71) nor sleeping on campus (P = 0.75) were associated with HAV. Fewer cases (57%) than controls (78%) reported always washing their hands before eating (P = 0.18). HAV isolated from 3 cases was molecularly identical to San Diego isolates.ConclusionMolecular and epidemiologic data support that this HAV outbreak among homeless persons was associated with the San Diego outbreak. Crowding and suboptimal hygiene practices might have facilitated campus transmission. Expeditious vaccination might have slowed spread; surveillance is ongoing.Disclosures All authors: No reported disclosures.
ObjectiveDemonstrate the utility of a One Health collaboration during a leptospirosis outbreak to expand outreach in human, environmental and animal health arenas.IntroductionThe One Health paradigm emphasizes cooperation and interdisciplinary collaboration to promote health and well-being among people, animals and the environment. Though the concept of One Health has been around since the 1800’s, the phrase “One Health” was more recently coined, and projects are being developed globally under its sponsorship. Maricopa County Department of Public Health (MCDPH) has been working at a local level to enhance its One Health surveillance efforts and partnerships. This One Health partnership, comprised of representatives from the Arizona Department of Agriculture (ADA), Arizona Department of Health Services (ADHS), Arizona Game and Fish Department (AzGFD), Arizona Veterinary Medicine Association (AzVMA), Centers for Disease Control & Prevention (CDC), MCDPH, Midwestern University (MWU) Veterinary School, and local veterinarians, was employed during a response to the recent emergence of leptospirosis in Maricopa County, Arizona.Leptospirosis is a zoonotic bacterial disease typically prevalent in tropical regions, especially island countries or low-lying areas that flood. In the United States, CDC reports 100-200 human cases annually. Within the last five years, there have been two confirmed travel-associated human cases reported in Maricopa County. However, no locally acquired human or canine leptospirosis cases were reported.Two separate clusters of canine leptospirosis were reported in Maricopa County in 2016; the first was detected in February among canines within a household. To increase awareness in the veterinary community, the AzVMA published an article summarizing the cluster. This article might have aided in the identification of a second larger cluster in November that involved multiple veterinary and boarding facilities throughout Maricopa County. Following both clusters, capacity increased for canine and human surveillance, laboratory testing, and environmental remediation, and discussions were initiated regarding wildlife testing through the efforts of the One Health team.MethodsA coordinated review of canine medical records verified suspicion of leptospirosis within the exposed canine population. A CDC questionnaire was modified by the One Health team and facilities were visited to identify possible sources of canine infection.A Knowledge, Attitudes and Practice (KAP) survey was distributed through the AzVMA to guide veterinary education efforts. Lecture series, educational materials, and health alerts were created with input from One Health agencies for physicians, veterinarians, dog boarding facilities, and owners.CDC subject matter experts assisted in the implementation of a serosurvey of both dog owners and veterinary staff to determine if zoonotic transmission had occurred at the home, veterinary clinic or boarding facility. CDC laboratory testing provided leptospirosis speciation of canine urine specimens.ResultsMedical records were abstracted for 79 suspect leptospirosis canine cases and 48 owners were interviewed to assess their risk and exposure factors for their dogs. Prior to the visit, some facilities had already implemented self-directed infection control activities. No procedural gaps were identified at the four canine boarding facilities and veterinary clinics visited.The KAP survey was completed by 216 Arizona veterinarians and technicians. Educational outreach included three AzVMA newsletter articles distributed to approximately 1,100 registered veterinarians, one fact sheet regarding the leptospirosis vaccine, and three factsheets targeting prevention and infection control messages for boarding facilities, veterinary clinics and the home. A three-part lecture series presented jointly by ADHS, ADA, MCDPH, and MWU was attended by approximately 150 veterinarians. A health alert about the possibility of leptospirosis human cases was distributed by MCDPH to healthcare providers.Eighty-five dogs with either compatible symptoms or exposure were tested through the CDC laboratory, 68 (80%) were positive. Canine testing revealed different leptospirosis species between the two clusters, suggesting it was unlikely that they had a common source of exposure. No zoonotic transmission was identified among the 118 people tested in the serosurvey.ConclusionsPre-existing connections between public health and animal health partners helped facilitate and expand laboratory testing, diagnosis, reporting, outbreak tracking and prevention. The serosurvey provided a novel opportunity to identify cases amongst exposed people and provided insight into zoonotic transmission. Information gained from the KAP survey provided a gap analysis in veterinary services and guided education efforts. Since July 2017, no new canine cases have been reported to public health. However, further studies to identify sources of transmission in wildlife are being developed. The collaborative efforts of multiple agencies culminated in a robust outbreak response and the strengthened processes and relationships can be leveraged for future emerging diseases.
ObjectiveTo demonstrate the utility of the National Syndromic Surveillance Program’s (NSSP) version of the Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) for case detection during a 2017 outbreak of hepatitis A virus (HAV) infection among persons experiencing homelessness in Maricopa County, Arizona.IntroductionOn 3/29/2017, the Maricopa County Department of Public Health (MCDPH) received three reports of confirmed HAV infection from an onsite clinic at Campus A that assists individuals experiencing homelessness, a population at risk for HAV transmission. To identify the scope of the problem, the department initiated rapid HAV infection case detection using NSSP ESSENCE.MethodsMCDPH created a myESSENCE dashboard that searched for chief complaint keywords and discharge diagnosis codes from 15 Maricopa County emergency department and inpatient hospital records using three separate queries: (1) HAV infection; (2) hepatitis virus infection; and (3) HAV infection symptoms combined with terms for homelessness. The dashboard was reviewed retrospectively for the 90 days prior to the initial report of the cluster (12/28/2016 – 3/29/2017). Based on this review, MCDPH epidemiologists decided to use the first query (HAV infection-specific) only, because reviewing the line list for all three queries was resource-intensive and resulted in duplicate cases. The query was monitored every weekday morning from 3/30/2017 to the close of the outbreak on 7/22/2017.ResultsFrom 3/30/2017 – 7/22/2017, MCDPH identified 37 potential HAV infection cases in ESSENCE. Eleven cases were classified as outbreak cases, while the other 26 patients lacked recent HAV infection symptoms, laboratory confirmation, or association with Campus A. All 11 outbreak cases’ records included the ICD-CM-10 code B15.9 (Hepatitis A without hepatic coma), and 3 records included the code Z59 (Problems related to housing and economic circumstances). The HAV infection-specific query in ESSENCE identified 11 (73%) of the 15 total outbreak cases; however, all cases were reported in MEDSIS prior to a being flagged in ESSENCE. On average, cases were reported to MEDSIS 9 days earlier than identified in ESSENCE (range, 0 - 21 days). Of note, ESSENCE helped identify the outbreak index case, previously lost to follow-up, as an individual experiencing homelessness. This information helped MCDPH perform additional follow-up, which revealed that the individual had arrived from San Diego, CA, a city with an ongoing outbreak of HAV infection in their homeless and drug-using population. This epidemiologic link was identified on 3/30/2017, over a month before the Centers for Disease Control and Prevention confirmed a match by genome sequencing between the index case and the neighboring outbreak on 5/5/2017.ConclusionsUse of ESSENCE identified most of the HAV infection cases from this outbreak among individuals experiencing homelessness but no sooner than traditional surveillance methods. However, use of ESSENCE allowed for identification of the outbreak index case, leading to epidemiological linkage to outbreak origin approximately one month prior to molecular laboratory confirmation.
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