Infectious Disease 2016 Outbreak Report

Arizona Department of Health Services Office of Infectious Diseases Services 150 N. 18th Ave., Suite 140 Phoenix, AZ 85007 602-364-3676

Contents

Executive Summary ii 1 | Introduction 1 2 | Notable Outbreaks 3 2a | Outbreak of Cryptosporidiosis Associated with Aquatic Facilities 4 2b | Measles Outbreak in a Detention Facility 7 2c | Investigation of a Local Outbreak of Salmonella Javiana Infections Involving a Seafood Restaurant 9 2d | Outbreaks of Shigellosis in Child Care Facilities 11 3 | Special Circumstances 13 3a | Outbreaks in Healthcare Settings 14 3b | Outbreaks in Schools 16 3c | Outbreaks Identified by Molecular Laboratory Techniques 18 4 | Performance Goals 20 5 | Appendices 26 5a | Outbreak Reporting Requirements and Data Sources 27 5b | Data Tables 28 Outbreaks by exposure county, 2016 29 Outbreaks by exposure county, 2014-2016 30 Outbreaks by month of report, 2014-2016 31 Outbreaks by month of report and county, 2016 32 Outbreaks by type of setting, 2014-2016 33 Outbreaks by type of setting and county, 2016 34 Outbreaks by syndrome category, 2014-2016 35 Outbreaks by syndrome category and county, 2016 36 Outbreaks by mode of transmission, 2014-2016 38 Outbreaks by mode of transmission and county, 2016 39

Infectious Disease Outbreak Report 2016 | i Executive Summary

During 2016, 275 suspected The majority of these outbreaks communicable disease outbreaks were occurred in Maricopa County reported and investigated in Arizona. Of (109 outbreaks; 73%). However, Apache those, 149 were finalized as confirmed the county with the highest rate communicable disease outbreaks. There of outbreaks based on population Mohave was no notable increase in confirmed was La Paz County (1 outbreak; Coconino outbreaks between 2015 and 2016. 4.7 outbreaks per 100,000

persons). Navajo Public health agencies in Arizona Yavapai investigated four notable outbreaks Outbreaks in 2016 were most during 2016, including: often identified in healthcare settings (40; 27%), child care Gila an outbreak of facilities (38; 26%), and schools La Paz cryptosporidiosis associated (28, 19%). Our data indicate that Greenlee with aquatic facilities for most outbreaks in these Graham settings, outbreaks with rapid Maricopa Yuma Pinal an outbreak of measles in a reporting to public health tended detention center to be shorter with fewer Pima salmonellosis outbreak illnesses. Cochise involving a seafood restaurant Most outbreaks (107; 72%) were Santa Cruz shigellosis outbreaks in due to gastrointestinal illnesses, multiple child care facilities including shigellosis and norovirus.

0 outbreaks Statewide, performance goals were met in initiating investigation within 24 hours of report, and confirming etiology. 0.1 - 1.5 outbreaks per 100,000 persons

Infectious Disease Outbreak Report 2016 | ii 1.6 – 3.0 outbreaks per 100,000 persons

>3.0 outbreaks per 100,000 persons

1 | Introduction

Outbreak Detection and Response Arizona Department of Health Services (ADHS) order to provide a profile of the infectious to monitor Arizona’s burden of disease outbreaks that occur in Arizona and of An outbreak is defined as an Case | An instance of infectious disease outbreaks and the timeliness and completeness of outbreak increase in cases of disease in disease in an individual progress in detecting and response. The data analysis allows for improved time or place that is greater than (single person). responding to reported outbreaks implementation of appropriate outbreak control expected. Frequently, an outbreak throughout the state. Variables measures to mitigate the spread of disease and occurs when a common source causes illness in collected include date of outbreak report, prevent future outbreaks from occurring. two or more people from different households. If number of ill cases, outbreak etiology, infectious a condition is rare (e.g. measles) or has serious 2016 Confirmed Outbreaks disease category, outbreak location or setting, public health implications (e.g. bioterrorism mode of transmission, and number of clinical In 2016, there were 149 confirmed infectious agent), an outbreak may involve only one case. specimens collected. These data are collected in disease outbreaks reported in which exposure Outbreak detection, response, and reporting occurred in Arizona. This was an are key components of a state’s public health unremarkable increase compared to 2015. capacity and are essential for prevention and Historically, there was a peak in the number of control of illness in a population. During and outbreaks reported in 2012, with a decrease in after outbreak investigations, public health The number of outbreaks increased in 2013 through 2015. This may be due to officials: 2016. However, the number of outbreaks increased surveillance and reporting of is down in recent years. outbreaks in 2012, statistical variance, or an • Take public health action to stop the actual increase in outbreaks in 2012. spread of illness 233 • Provide education to prevent future outbreaks 180 162 167 • Gather information to assist with future 149 137 outbreak investigations 2011 2012 2013 2014 2015 2016 Collecting and reporting data on infectious disease outbreak investigations allows the

Infectious Disease Outbreak Report 2016 | 1

Ruled-out Outbreaks, Out-of-Arizona Outbreaks, and Clusters

Not all suspected outbreaks that are About half of reported outbreaks are Definitions reported and investigated fit the confirmed. All reported outbreaks are confirmed outbreak definition. investigated. Confirmed outbreak: An increase in cases of Additionally, only confirmed outbreaks disease in time or place that was greater than in which cases were exposed in 54% expected, and a common source was identified Arizona are included in this report, in cases from different households with the unless otherwise noted. 34% same illness. Exposure occurred in Arizona. In 2016, 275 suspected communicable Cluster: Two or more cases from different disease outbreaks were reported and households with a matching pulsed field gel investigated in Arizona. Of the 275 6% 5% electrophoresis (PFGE) pattern, and the investigations conducted, 149 (54%) number of cases represents an increase over were finalized as confirmed Confirmed Cluster Out of Ruled-out Arizona baseline or demographic or epidemiologic communicable disease outbreaks in characteristics indicate a deviation from which cases were exposed in Arizona, expected, but no common source was 94 (34%) were ruled out as not an identified. PFGE is a laboratory technique used outbreak, 17 (6%) were clusters to identify two or more individuals that had identified using pulsed-field gel electrophoresis See section 3c: Outbreaks Identified by similar pathogen strains, indicating their illness (PFGE) that did not have a common exposure Molecular Laboratory Techniques for more may have had a common source. See section 3c: identified, and 15 (5%) were confirmed outbreaks information about outbreaks identified using Outbreaks Identified by Molecular Laboratory in which cases were exposed outside of Arizona. PFGE surveillance. Techniques.

Ruled-out outbreak: After investigation, investigators determined that the event did not resources represent an increase in disease in time or Additional place that was greater than expected, and a Outbreak threshold guide for healthcare common source was not identified. settings and correctional facilities Out of Arizona: Arizona residents were affected by a true increase in disease in time or place Outbreak threshold guide for schools, child that was greater than expected, or a common care establishments, and shelters source of illness was identified, but exposure occurred outside of Arizona.

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2 | Notable Outbreaks

2a | Outbreak of Cryptosporidiosis Associated with Aquatic Facilities 4 2b | Measles Outbreak in a Detention Facility 7 2c | Investigation of a Local Outbreak of Salmonella Javiana Infections Involving a Seafood Restaurant 9 2d | Outbreaks of Shigellosis in Child Care Facilities 11

Infectious Disease Outbreak Report 2016 | 3 2a | Outbreak of Cryptosporidiosis Associated with Aquatic Facilities

On August 2, 2016, the Arizona Department of unique challenge to treated recreational water Health Services was notified of a cluster of venues, such as pools, waterparks, and splash- gastrointestinal illness among players on a pads, because of three main reasons: Coconino County Little League team and family Highlights • Infected persons shed the parasite in their Outbreak members; 36 (71%) of 51 persons became ill 6–7 stool for up to two weeks after diarrhea days after visiting a Maricopa County aquatic Maricopa County resolves. facility on July 22. Maricopa County Department Dates reported to public health: 7/1/2016 – of Public Health simultaneously detected • Cryptosporidium has a very low infectious 12/7/2016 increased laboratory reporting of dose, with ingestion of as few as 10 oocysts Confirmed and probable cases: 437 cryptosporidiosis as of mid-July. Multiple being sufficient to cause disease. patients reported visits to the same Maricopa • Cryptosporidium is extremely chlorine All of Arizona County aquatic facility, as well as multiple tolerant and can survive in a properly Dates reported to public health: 7/1/2016 – additional aquatic facilities, including pools, chlorinated pool for up to 10 days. 12/31/2016 splash-pads, and waterparks. A single fecal contamination Confirmed and probable cases: 523 About Crypto event in a pool can lead to Counties included in the response effort: infection in many Coconino , Maricopa Cryptosporidiosis, swimmers and focal caused by the parasite outbreaks can Cryptosporidium, has quickly turn into emerged as the community-wide leading cause of outbreaks if infected swimming pool- persons swim in For an in-depth look related outbreaks of multiple recreational Using Molecular Characterization to Support diarrhea in the United water venues or Investigations of Aquatic Facility–Associated States and was contaminate other Outbreaks of Cryptosporidiosis — Alabama, responsible for 32 settings. outbreaks in 2016. Arizona, and Ohio, 2016 Cryptosporidium presents a

Infectious Disease Outbreak Report 2016 | 4

Outbreak response Cryptosporidium; probable cases lacked laboratory evidence but had an epidemiologic To determine the magnitude of the outbreak, link to a confirmed case. A total of 437 cases counties interviewed cryptosporidiosis patients, (310 confirmed; 127 probable) of Reported cases of cryptosporidiosis focusing on possible risk factors, particularly cryptosporidiosis were associated with the increased dramatically in 2016. recreational water exposures. In Maricopa outbreak between July 1–December 7, 2016. Of County, a case of cryptosporidiosis was defined the 310 patients with confirmed cases, 260 523 as onset of diarrhea, abdominal cramping, or (84%) were interviewed and 177 (68%) had vomiting on or after July 1, 2016. Confirmed exposure to a public aquatic facility in the two cases had laboratory-based evidence of weeks prior to symptom onset. Stool samples from four cases associated with the Little League cohort and from one Maricopa County 39 fast facts resident were tested by CDC’s CryptoNet and 2015 2016 Crypto identified as the C. hominis IfA12G1R5 subtype, which is the subtype most commonly • Cryptosporidiosis, or “crypto” for short, associated with recreational water outbreaks is a diarrheal illness caused by a of cryptosporidiosis nationwide. parasite. or while diarrhea was ongoing. In total, patients Interventions with confirmed cases swam at 75 aquatic • People become infected when they venues between June 28 and November 9. The ingest the parasite’s infectious life stage Interventions included the promotion of healthy Maricopa County outbreak was declared over on (oocyst) in food or water contaminated swimming messages and remediation of December 7, two maximum incubation periods affected aquatic facilities through with feces. after symptom onset for the last case of hyperchlorination. A properly maintained cryptosporidiosis with exposure to an aquatic • The incubation period ranges from 1– aquatic facility will have a free chlorine level facility. 14 days, with an average of 7 days. between 1–3 parts per million; hyperchlorination requires raising the free Statewide, 523 cases of cryptosporidiosis were • People with crypto experience profuse, chlorine level to 10–20 parts per million for 12- recorded from July 1–Dec 31, 2016 (compared watery diarrhea, lasting 2–3 weeks in 26 hours based on a formula of concentration with 39 cases during the same period in 2015) immunocompetent people. and time sufficient to inactivate the making 2016 a record year for cryptosporidiosis Cryptosporidium parasite. In Maricopa County, in Arizona. The best way to prevent future • A person with crypto can continue to remediation was recommended for any facility outbreaks of cryptosporidiosis is to prevent shed the parasite in his or her stool for named by a patient with a confirmed case of contamination of aquatic facilities through the up to two weeks after the resolution of cryptosporidiosis as someplace that he or she promotion of healthy swimming. diarrhea. swam in the two weeks prior to symptom onset

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Healthy swimming

• Don't swim when you have diarrhea. • Don't swallow pool water. • Shower with soap before swimming to prevent germs on your body from getting in the water. • Take kids on bathroom breaks or check diapers often.

2017 Healthy Swimming Poster Contest Winner Robbie B., age 9, from Maricopa County. For more information about the ADHS Healthy Swimming Contest, visit azhealth.gov/waterborne. Infectious Disease Outbreak Report 2016 | 6

2b | Measles Outbreak in a Detention Facility

On May 25, 2016, Pinal County Public Health immediate and aggressive response. Services District (PCPHSD) was notified by Maricopa County Department of Public Health Epidemiology, laboratory, and emergency

of an individual that was suspected of having response staff immediately began collaborating Highlights Outbreak measles. The individual was a detainee in a U.S. to determine the scope of the outbreak and to implement measures to halt the progression of Known onset dates: Immigration and Customs Enforcement the outbreak as quickly as possible. 5/6/2016 – 6/26/2016 detention facility in Eloy, Arizona in Pinal Confirmed cases: 32 County. PCPHSD contacted the facility, at which County and state health departments activated Counties included in the response effort: point an additional five rash illnesses were their Health Coconino, La Paz, Pima, Pinal, Maricopa, reported. Additionally, PCPHSD was notified Arizona Health Emergency Emergency Mohave, Yavapai, and Yuma that an employee of the same detention facility Operations Center | A Operations statewide multi-agency was being treated at a community medical Centers coordination center with plans center for low-grade fever and rash and was (HEOCs) in order in place to assist in protecting being tested for measles. On that same day, the public from health threats. to respond to this specimens were sent to the Arizona State Public outbreak. Health Laboratory (ASPHL) from the detainee An Epi-Aid was provided by the U.S. Centers for and were PCR positive for measles. Disease Control and Prevention (CDC). Intervention methods included closing In Arizona, a single case of measles is Outbreak | An increase in cases Isolation | Separation of ill the facility to new detainees, considered an outbreak, due to the rapid

persons who have an infectious

of disease in time or place that is vaccinating the detainees with one transmission and serious health disease from those who are greater than expected. dose of MMR, isolating ill individuals, outcomes associated with a single case. healthy. screening visitors, and providing Additionally, some of the detainees in health education and advice to detainees, the facility were from measles-endemic Endemic | Native or regularly

employees, local health agencies, healthcare regions. Thus, these illnesses in found in a particular county or area. providers, and the community. individuals associated with a common detention facility triggered an

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Laboratory specimens from ill individuals were A case was defined as an individual with an contributed to the size and duration of this collected and tested by public health in Arizona, acute febrile rash illness with a positive outbreak. It was the largest measles outbreak in then forwarded to CDC for genotyping. The laboratory result, or with a direct Arizona since 1991, and the largest outbreak of health department offered vaccines on several epidemiological link to a case confirmed by a measles in the U.S. during 2016. occasions to employees, employees’ families, positive laboratory result, associated with the and community members. Additionally, detention facility in Eloy between May 6, 2016 outbreak responders identified detainees that and August 8, 2016. Cases in a total of 32 had been released from the facility patients were identified, 3 during the period of exposure and Period of exposure | The range (9%) of whom were Measles fast facts notified the countries, states, and of time in which a person may hospitalized. No deaths

Arizona counties of destination for have come in contact with an associated with this • Measles is a rash illness caused by a infectious disease. follow-up, including facilities that outbreak were reported. Of virus. had received detainees that had been these cases, 21 (66%) were in transferred from the facility during the period of detainees in the facility, 9 (28%) were in • The rash usually starts on the head exposure. Finally, the outbreak response employees, and 2 (6%) were in former detainees and slowly spreads down the rest of included contacting individuals outside the that had been released from the facility. All the body. Other symptoms include detention center that may have been exposed to cases were associated with the detention high fever, cough, runny nose, and symptomatic employees. facility; there were no community-acquired red, watery eyes. cases. The genotype for this outbreak was D8. • Measles is very easily spread from A retrospective review of medical records of one person to another through detainees combined with serologic testing infectious droplets when someone For an in-depth look identified that the first reported case become ill Notes from the Field: Measles Outbreak on May 6, 2016; the last reported case associated with measles coughs or sneezes. The at a United States Immigration and with this outbreak became ill on June 26, 2016. droplets can be suspended in the air Customs Enforcement Facility –– The outbreak was declared over on for up to two hours, or they may land August 8, 2016, 42 days (two incubation Arizona, May – June 2016 on surfaces. Anyone who breaths the periods) after illness onset of the last air or touches the surfaces Incubation period | The window case. of time that typically passes contaminated by the virus may Slow compliance with vaccination between coming in contact with become infected. an infectious disease and the recommendations, incomplete start of symptoms. implementations of exclusion • Because of the measles vaccine recommendations, and restrictions on (MMR), measles is rare in Arizona enforcing those recommendations likely and in the U.S. Vaccine is up to 99% effective with two doses of MMR. Infectious Disease Outbreak Report 2016 | 8

2c | Investigation of a Local Outbreak of Salmonella Javiana Infections Involving a Seafood Restaurant

On August 10, 2016, Maricopa County Salmonella cases pending subtyping reporting as well. Agencies also coordinated testing of Department of Public Health (MCDPH) identified eating at Restaurant A within the exposure laboratory samples by public health in Arizona culture-confirmed Salmonella enterica serotype timeframe. In Arizona, a group of at least two and CDC to ensure Javiana isolates from two persons who reported cases of Salmonella linked to a common they were linked. Outbreak | An increase eating at a seafood restaurant (Restaurant A). source of exposure is considered an outbreak. in cases of disease in Pulsed-field gel

MCDPH contacted Maricopa County Because there could potentially be a large time or place that is electrophoresis (PFGE) Environmental Services (MCES) to inquire about number of people exposed at a restaurant, greater than expected. and whole genome recent public complaints of illness mentioning public health had to act quickly to identify if sequencing of samples Restaurant A. MCES had received one complaint the source of the outbreak was related to were performed, which are like DNA on August 4 regarding someone who became Restaurant A or not. fingerprints that help match each patient sick with gastrointestinal illness one day after Epidemiology laboratory environmental eating at Restaurant A in Phoenix. MCES , , and services staff collaborated to investigate the performed an environmental assessment of the Highlights scope and source of the outbreak and prevent Outbreak restaurant at MCDPH’s request this same day further illness. County and state health Known onset dates: 6/28/2016 – 9/17/2016 and did not observe any violations. On August U.S. Confirmed and probable cases: 50 15, the Arizona Department of Health Services departments worked together with the Centers for Disease Control and Prevention States where cases resided: Arizona, Colorado, (ADHS) notified MCDPH of a cluster of five S. (CDC) to determine if this outbreak was limited Indiana, Nevada, Texas, and Wisconsin Javiana cases in Maricopa County (one reported Counties in Arizona where cases resided: Maricopa, to just Arizona or if it was affecting other states eating at Restaurant A) and two additional Yavapai, and Pinal

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sample to the outbreak strain of S. Javiana, according to the Food Code. restaurant diners, laboratory evidence and case- because there can be many different types of control study results indicated shrimp was the S. Javiana matching the outbreak PFGE pattern Salmonella. Investigative methods included possible outbreak source. It is possible that was isolated from portioned repackaged interviewing persons with laboratory-reported Salmonella survived the 145°F recommended uncooked shrimp, halibut, and a freezer door S. Javiana infection to find out what they ate shrimp cooking temperature, and this outbreak S. Weltevreden was isolated from a box and where, performing case-finding through handle. of S. Javiana was likely prolonged by cross- of unopened frozen shrimp. Intervention passive surveillance and identifying ill meal contamination within the restaurant. Because methods included cleaning of Restaurant A and companions, gathering information from food handlers have many opportunities to educating employees, and removing any Restaurant A about any ill workers and contaminate and cross-contaminate food during contaminated foods that tested positive for gathering food and environmental samples for preparation, food safety training and for Salmonella. Any foods that tested positive for testing, and performing a case-control study to employers to provide adequate sick leave is Salmonella in original packaging (the frozen try to determine the risk of illness among essential. box of shrimp) underwent traceback and were people who were sick and people who were not recalled. sick who ate certain foods at Restaurant A.

With no further reports of illness or complaints A case was defined as diarrheal illness in a associated with Restaurant A, this investigation fast facts person during July–September 2016 and Salmonella was closed on October 3, 2016. Among exposure in Arizona; confirmed cases had S. • Salmonellosis is a gastrointestinal disease Javiana isolate yielding outbreak-related caused by bacteria. PFGE patterns; probable cases had diarrheal illness and an epidemiologic link to a • Salmonella enterica serotype Javiana (S. confirmed case. A total of 50 S. Javiana cases Unfried cooked shrimp was 6.5 times Javiana) is the sixth most common were identified (40 confirmed and 10 more likely to be associated with illness. Salmonella strain identified in the United probable); illness onset range was June 28– States. September 17, 2016. Ten (43%) of 23 patients visited an emergency department for their • Salmonella infections most often cause illness, 7 (29%) of 24 were hospitalized, and no gastroenteritis that can range from mild to deaths were reported. Thirty-three (73%) of 45 severe and sometimes develop into patients interviewed reported eating at potentially serious infections, including Restaurant A. Among 21 case-patients and 31 bacteremia or endovascular infections. control subjects, unfried cooked shrimp was • Salmonellosis is estimated to cause 1.2 6.5 times more likely to be associated with million illnesses each year in the United illness. No restaurant workers reported States, with approximately 23,000 illness, and foods were reportedly cooked hospitalizations and 450 deaths.

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2d | Outbreaks of Shigellosis in Child Care Facilities

During 2016, Arizona experienced numerous

shigellosis outbreaks in child care centers, Outbreak Highlights accounting for 280 illnesses from 28 The number of shigellosis outbreaks in Number of cases: 280 separate facilities. One outbreak occurred in child care facilities increased by tenfold Number of facilities: 28 La Paz County and 27 occurred in Maricopa between 2015 and 2016. Counties affected: La Paz and Maricopa County. Most of these outbreaks were reported during the first half of 2016. 28

The number of shigellosis outbreaks in child care facilities in the state increased by tenfold in 2016 compared to 2015. Due to The number of shigellosis cases more these outbreaks, as well as an overall than doubled in 2016. 3 increase in disease in the community, the 1 1231 number of shigellosis cases reported to 2014 2015 2016 public health more than doubled compared to 2015. In 2016, 20% of all shigellosis cases abdominal cramps. Only humans and some in the state were associated with an outbreak in Shigella. People can 549 a child care facility, compared to three percent non-human primates carry of cases in 2015. spread Shigella to others easily as only a small 376 number of bacteria are needed to cause About shigellosis infection. Transmission occurs Fecal-oral route | Transmission through the fecal-oral route. 2014 2015 2016 Shigellosis is an occurs when fecal matter intestinal illness (poop) from a sick person gets An outbreak of shigellosis occurs spread in child care centers and schools

caused by the bacteria into the mouth of another when three or more cases, not from Shigella, causing person, due to poor hand the same household or family, are because young children often put hands and hygiene; contaminated food, diarrhea (sometimes detected within a one-week period. objects in their mouths and are less likely to water, or objects; or certain adequately wash their hands. bloody), fever, and sexual practices. Shigellosis outbreaks can easily

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Interventions During the response to these outbreaks, to participating facilities in order to help the MCDPH’s strict enforcement of these exclusion facility and staff address potential problems In order to control outbreaks of shigellosis criteria ensured that additional children were with infection control or diapering procedures. within child care centers during 2016, Maricopa not infected. County Department of Public Health (MCDPH) MCDPH provided Shigella training to all took the following actions: MCDPH provided outbreak intervention registered child care centers in the county. recommendations to child care facilities MCDPH invoked the Arizona Administrative experiencing outbreaks. In February 2016, MCDPH issued a letter to all Code exclusion rule. child care directors in Maricopa County. This When two or more cases were identified within letter directed recipients to video training Arizona Administrative Code During 2016, the the same child care facility, a communicable modules developed by communicable disease stated that a shigellosis case with diarrhea will disease nurse investigator contacted the facility nurse investigators and community health be excluded from working in or attending a to provide awareness and to identify the scope nurses. The training modules provided child care establishment until one of the of the outbreak. Maricopa County information about the illness caused by following: Environmental Services Department dispatched Shigella, why it is a problem in child care

• Two successive cultures negative for sanitarians to conduct an inspection of the settings, strategies to prevent spread, and public Shigella are obtained or child care facility, looking for deficiencies in health’s role in controlling the disease. • areas that may have contributed to disease Treatment is maintained for 24 hours and Conclusion diarrhea is resolved. transmission, particularly diaper changing areas, restrooms, snack and meal prep areas, In summary, the increase in outbreaks of The same exclusion criteria apply to a person illness policies, and proper disinfection shigellosis at child care centers in 2016 with diarrhea that is a contact to a person with procedures. Additionally, nurse consultants primarily affected facilities within Maricopa Shigella. Maricopa County Child Care Health with the County. In response, MCDPH took public health Consultation Program performed site visits action and the number of outbreaks has since returned to expected levels. Shigella fast facts • Shigellosis is a diarrheal illness that is only carried • Transmission most often occurs person-to-person, although transmission can by humans (and some non-human primates). occur via contact with a contaminated object, food contaminated by an infected person, or sexual contact. • Shigella infections cause diarrhea, abdominal cramps, and fever, and illness can range from mild • People that are most likely to get shigellosis are young children, especially to severe. those in child care settings, travelers to developing countries, individuals with weakened immune systems, and men who have sex with men.

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3 | Special Circumstances

3a | Outbreaks in Healthcare Settings 14 3b | Outbreaks in Schools 16 3c | Outbreaks Identified by Molecular Laboratory Techniques 18

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3a | Outbreaks in Healthcare Settings

During 2016, 49 suspected outbreaks in Outbreaks in healthcare settings were primarily healthcare settings were reported to and due to gastrointestinal illnesses (73%), most of investigated by public health in both acute-care which were due to confirmed or suspected and non-acute-care facilities. Of those, 40 were norovirus infections. confirmed outbreaks and 9 were ruled out. Healthcare facilities were the most Respiratory illnesses were responsible for 15% of common settings for outbreaks. Outbreaks in healthcare settings represented outbreaks in healthcare settings in 2016. While 27% of outbreaks in Arizona during 2016. This Healthcare facilities 27% this is a decrease from 2015 (21%), it is still much is a decrease in number and percent higher than 2014 (5%). Child/daycare facilities 26% compared to 2014 and 2015. However,

outbreaks in healthcare settings represented All other settings 20% the largest proportion of outbreaks in Arizona. Schools 19%

Prisons 5% Food service settings 3%

Most outbreaks in healthcare facilities The percent of outbreaks that were due to GI illness. Outbreaks due to occurred in healthcare facilities respiratory illnesses were up in 2015 and decreased in 2016. 49 outbreaks were 2016, compared to 2014.

87% 34% reported and 73% 33% 64% (n=55) (n=47) 27% (n=40) investigated in 21% 15% 2014 2015 2016 5% healthcare settings in 2014 2015 2016 2016.

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Outbreaks in healthcare settings were most Rapid often reported by a staff member within the healthcare setting, such as an infection The majority preventionist, physician, or other medical (83%) of reporting staff. This underscores the importance of observant and watchful personnel within outbreaks each facility who partner with public health that were to identify, respond to, and prevent reported was outbreaks. 83% promptly Outbreaks due to pathogens with short ended in less incubation periods, such as influenza, than a week. associated norovirus, and unknown gastrointestinal with shorter

pathogens, tended to resolve more quickly and outbreaks Outbreaks with reporting delay had a smaller mean number of total ill persons tended to have more cases per when reported to the health department outbreak. promptly. For 83% of these outbreaks that were 46 reported within two days of first illness onset, with fewer the outbreak was of short duration (less than 29 one week). 21 In contrast, over half (53%) of short-incubation illnesses. outbreaks that had a major reporting delay (more than one week) lasted two weeks or Prompt Slight Major longer and had a greater mean number of total reporting delay delay ill persons.

Prompt reporting | Slight delay | Report received Major delay | Report Report received within 2 more than 2 weekdays but within received more than 7 weekdays of first onset. weekdays after first onset 7 weekdays of first onset. Infectious Disease Outbreak Report 2016 | 15

3b | Outbreaks in Schools

During 2016, 28 outbreaks occurred in school Across all school ages, the largest decrease settings, making up 19% of outbreaks in all occurred in elementary school settings, from 25 settings. Compared to 2014 and 2015, this is a outbreaks in 2015 to only nine outbreaks in 2016. decrease in both number and percent of outbreaks. Interestingly, during this same time period, There was a sharp decline in the percent of child care facilities in Arizona were severely outbreaks in elementary schools (K-6) in affected by outbreaks. There were 38 outbreaks 2016. During the same time, there was a in child care facilities in 2016, representing 26% marked increase in the percent of outbreaks in of all outbreaks, a sharp increase compared to child care facilities. A large proportion of outbreaks in 2016 2014 and 2015. The vast majority of outbreaks in 26% occurred in schools and child care facilities. child care facilities in 2016 were caused by 18% shigellosis. Because there is significant cross- 10% Healthcare facilities 27% over between children in elementary schools 8% 7% 6% Childcare facilities 26% and children in child care facilities, it is All other settings 20% noteworthy that the outbreak burden in these 2014 2015 2016 settings was vastly different. Schools (K-12) 19% Prisons 5% See section 2d: Outbreaks of Shigellosis in Child Care Facilities for more information about Food service settings 3% shigellosis outbreaks in child care centers in 2016.

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Most outbreaks in schools were attributed to Control measures for 100% of outbreaks in The public health-school health partnership respiratory transmission and person-to-person schools were initiated within one day of report may have decreased the duration of outbreaks transmission via the fecal-oral route. This to the health department. Most common control caused by pathogens with short incubation emphasizes the importance of providing measures include health education and advice periods, including influenza, norovirus, and education to children and parents regarding for both cases and contacts to cases, exclusion unknown respiratory or gastrointestinal diseases spread through these means. of ill persons, and cleaning and disinfection. pathogens. For the majority (86%) of outbreaks reported within two weekdays of first onset, the

Outbreaks outbreak ended in less than one week.

Most outbreaks in schools were spread via reported quickly respiratory and fecal-oral transmission. tended to have 43% 39% rapid control The majority (86%) of outbreaks with prompt 14% measures and reporting ended in less than a week. 4% Respiratory Fecal-oral Skin-to-skin Other quicker resolution. transmission transmission transmission transmission mode

86% Control measures for outbreaks in schools were initiated within one day of report to the Outbreaks in schools were almost always health department. These measures include: identified through a report from schools. In some circumstances, outbreaks in schools Health education and advice 96% were identified when routine interviews Exclusion of ill persons 89% with persons diagnosed with a Cleaning and disinfection 57% communicable disease indicated that others Contact screening and assessment 21% were ill from a common source. Health alert 7%

Chemoprophylaxis | Prevention Chemoprophylaxis 4%

of infectious disease by the use of medications or vaccines.

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3c | Outbreaks Identified by Molecular Laboratory Techniques

Pulsed-field gel electrophoresis, or PFGE, is a other epidemiologic characteristics indicate a the number of PFGE-matched isolates laboratory diagnostic method to compare deviation from expected, and identify a common represents an increase over baseline, or genetic factors of certain bacterial pathogens. source of illness. demographic or other epidemiologic This method is used routinely for every characteristics indicate a deviation from When a common source is identified and the specimen of Salmonella, Listeria, and Shiga expected. exposure occurred in Arizona, the PFGE match toxin-producing E. coli that is received at the is finalized as a confirmed outbreak. Unless PFGE matches are ruled out when the number Arizona State Public Health Laboratory. PFGE can help investigators determine if the genetic otherwise noted, only confirmed outbreaks are of PFGE-matched isolates does not represent an included in other sections of this report. characteristics of individual cases’ bacterial increase over baseline, demographic or other epidemiologic characteristics do not indicate a pathogens are indistinguishable. This can PFGE matches are finalized as clusters when no indicate that the cases were infected from the deviation from expected, and no common common source of illness was identified, and source of illness was identified. same source. Some PFGE patterns occur more frequently than others, thus matches of Outbreaks that include PFGE-matched Arizona common PFGE patterns may not indicate a residents in which a common source was common source. identified but exposure occurred outside of The mean number of cases was higher Arizona are recorded as out of Arizona. Investigation of groups of PFGE-matched when a source was identified, and lower cases is recorded differently than when no source was identified or when During 2016, the mean number of cases was investigations of outbreaks identified through matches were . higher when a source was identified, other means. PFGE-matched cases are compared to when there was no source investigated when two or more ill persons 6.3 identified or when the matches were . from different households have PFGE patterns This may be due to ongoing investigation that are identical with specimens collected resulting in case finding for outbreaks with a 3.5 within 14 days of each other. known source. However, a higher number of PFGE-matched cases may increase the Once the PFGE match is detected, 3.0 likelihood that the investigation will identify a investigators work to determine if the number common source. of PFGE-matched cases represents an increase over baseline, determine if the demographic or

Infectious Disease Outbreak Report 2016 | 18 2016 PFGE Investigations In 2016, a total of 92 groups of PFGE-matched cases were identified using PFGE, almost Definitions double compared to 2015 (59). Of the 92 investigations conducted, 12 (13%) were confirmed with a common source identified, 17 (18%) were clusters that did not have a common Confirmed outbreak: A common source was identified in exposure identified, 53 (58%) were ruled out, and ten (11%) had exposure outside of two or more cases from different households with a Arizona. Unless otherwise noted, only confirmed PFGE-matched clusters with a common matching PFGE pattern. Exposure occurred in Arizona. source identified are included in the other sections of this report. Cluster: Two or more cases from different households confirmed with a with a matching PFGE pattern. The number of cases 12 common source represents an increase over baseline or demographic or identified. epidemiologic characteristics indicate a deviation from expected, and no common source was identified.

Ruled-out outbreak: Two or more cases from different clusters with no households with a matching PFGE pattern. After common exposure investigation, the number of cases did not represent an 17 increase over baseline or demographic or epidemiologic identified. characteristics did not indicate a deviation from 92 expected. No common source was identified. groups of PFGE-matched A common source was identified in two or more cases from different households with a cases identified through matching PFGE pattern, but exposure occurred outside PFGE cluster detection. 53 of Arizona. ruled out. Additional resource Pulsed-field gel electrophoresis (CDC) common exposure 10 outside of Arizona.

Infectious Disease Outbreak Report 2016 | 19

4 | Performance Goals

ADHS utilizes MEDSIS Outbreak Module to collect a standardized set Initiate investigation within of outbreak summary form 24 hours of receipt of report. 98% elements based on the Centers for Disease Control and Prevention target = 90% (CDC) performance indicators. These indicators are meant to be Report to ADHS within 24 used by state and local health hours of receipt of report. 93% agencies to evaluate the performance of their outbreak target = 95% response and control programs and identify specific needs for Submit summary reports to improvement. See section 5a: ADHS within 30 days of 86% Outbreak Reporting Requirements completion of investigation. and Data Sources for more target = 100% information about MEDSIS Outbreak Module. Collect at least 2 stool specimens during GI illness 57% Note: Multistate outbreaks and outbreak investigations. outbreaks for which exposure target = 60% occurred outside of Arizona are excluded from all performance goals. Confirm etiology. 50%

target = 50%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Infectious Disease Outbreak Report 2016 | 20

Goal: Initiate investigation within 24 hours of receipt of

report.

Why it’s important: By starting the investigation as soon as 10 out of 12 counties Investigations were initiated possible, the investigation team initiated investigation of is able to confirm that an within 24 hours for 98% of all outbreaks within 24 hours for at outbreak has occurred, work to outbreaks. least 90% of outbreaks. identify the source, and implement measures to prevent additional illnesses. Delayed response may result in more illnesses or inability to gather target = 90% necessary information for the investigation.

Includes: All investigation statuses, all morbidities. Met Target: 90% Not Met No outbreaks reported

Results: Met statewide. Met in ten of 12 counties.

Infectious Disease Outbreak Report 2016 | 21

Goal: Report outbreaks to ADHS within 24 hours of receipt of report.

Why it’s important: Rapid Outbreaks were reported to reporting to ADHS ensures a ADHS in OBM within 24 hours for 6 out of 12 counties reported unified, collaborative response to outbreaks to ADHS within 24 hours for at 93% of outbreaks. outbreaks and allows for least 95% of outbreaks. cohesion in responding to events statewide. Additionally, rapid reporting to ADHS allows for accurate collection of relevant data, before information is lost. target = 95%

Includes: All investigation statuses, all morbidities.

Target: 95% Met Not Met

No outbreaks reported

Results: Not met statewide. Met in six of 12 counties.

Infectious Disease Outbreak Report 2016 | 22

Goal: Submit summary reports to ADHS within 30 days after completion of the investigation.

Why it’s important: Completing summary reports quickly ensures that data are available for ADHS Outbreak summary reports were to summarize for quarterly submitted within 30 days for 3 out of 10 counties submitted reporting, producing a more 86% of outbreaks. summary reports within 30 days for 100% complete picture of outbreak of outbreaks. response throughout the year. Additionally, ADHS uses data from summary reports to report to CDC. target = 100% Excludes: Ruled-out outbreaks, and outbreaks due to conjunctivitis, scabies, non- reportable diseases, and Met influenza. Not Met Target: 100% No outbreaks reported

Results: Not met statewide. Met in three of 10 counties.

Infectious Disease Outbreak Report 2016 | 23

Goal: Collect at least two specimens during gastrointestinal illness outbreak investigations.

Why it’s important: Collecting specimens during outbreak At least two specimens were investigations is the method by 4 out of 9 counties collected at least collected during 57% of GI which investigators are able to 2 specimens for at least 60% of GI illness illness outbreaks. identify the pathogen causing the outbreaks. outbreak.

Includes: Outbreaks due to GI illnesses. target = 60% Excludes: Ruled-out outbreaks.

Target: 60%

Met Not Met No outbreaks reported

Results: Not met statewide. Met in four of 9 counties.

Infectious Disease Outbreak Report 2016 | 24

Goal: Confirm etiology.

Why it’s important: Confirming the etiology via laboratory testing is an important key to determining the vehicle through An etiology was confirmed for which the pathogen was 5 out of 10 counties reported a transmitted. Confirmed etiology 50% of outbreaks. confirmed etiology for at least 50% of also allows investigators to outbreaks. provide targeted recommendations for preventing future outbreaks.

Excludes: Ruled-out outbreaks, target = 50% and outbreaks due to conjunctivitis, scabies, non- reportable diseases, and influenza.

Target: 50% Met Not Met No outbreaks reported

Results: Met statewide. Met in five of 10 counties.

Infectious Disease Outbreak Report 2016 | 25

5 | Appendices

5a | Outbreak Reporting Requirements and Data Sources 27 5b | Data Tables 28

Infectious Disease Outbreak Report 2016 | 26 5a | Outbreak Reporting Requirements and Data Sources

In Arizona, healthcare providers, healthcare (OBM) was introduced in 2014 to help users The descriptive epidemiology included in institutions, correctional facilities, and report, manage, and share information about this report is based on data from OBM for administrators of schools and shelters are outbreaks. OBM’s integration into MEDSIS outbreaks reported in 2014-2016. Since the required to report outbreaks of infectious allows users to easily link existing MEDSIS publication of the 2014 Infectious Disease diseases to their county health department cases to an outbreak, create new cases to link Outbreak Summary Report, errors within under Arizona Administrative Code (A.A.C.) to an outbreak, and retrieve outbreak data for 2014 outbreak data have been corrected. R9-6-202 and R9-6-203 and Arizona Revised analysis. Notable features of the OBM Additionally, some outbreak reports have Statutes (A.R.S.) Title 36. Hotels, motels, and include the Outbreak Summary Forms page, been updated with information not available resorts are also required to report contagious which can automatically calculate fields at the time that the 2014 outbreak report was or epidemic diseases occurring in their within the form using case information that published. These corrections and updates are establishments within 24 hours under A.R.S. has been entered, and the Outbreak Long included in this report. Thus, there are some 36-622. Outbreaks are reportable to ADHS Form Creation page, which allows users to discrepancies between 2014 outbreak data within 24 hours after a county health create outbreak-specific investigation forms. contained herein and data in the 2014 department receives a report (A.A.C. R9-6- Furthermore, public health partners can Infectious Disease Outbreak Summary 206F). The information provided at the time share outbreak information within OBM to Report. of report includes location/setting of better coordinate outbreak investigations Data was analyzed in Statistical Analysis outbreak, number of cases and suspect cases, across jurisdictions. System (SAS) 9.4. Graphs and figures the date reported, the disease suspected, and important contact information. Population denominators used in this report presented in this report were created in are from the ADHS Bureau of Public Health Microsoft Office Excel 2010 and Microsoft The communicable disease surveillance Statistics. Population denominators were Office Word 2010. system and reporting tool used by public estimated using the 2015 population health in Arizona is the Medical Electronic projections obtained from the Office of Disease Surveillance Intelligence System Employment and Population Statistics (MEDSIS). An extension of the case-based within the Arizona Department of surveillance in MEDSIS, Outbreak Module Administration. Infectious Disease Outbreak Report 2016 | 27

5b | Data Tables

Outbreaks by exposure county, 2016 29 Outbreaks by exposure county, 2014-2016 30 Outbreaks by month of report, 2014-2016 31 Outbreaks by month of report and county, 2016 32 Outbreaks by type of setting, 2014-2016 33 Outbreaks by type of setting and county, 2016 34 Outbreaks by syndrome category, 2014-2016 35 Outbreaks by syndrome category and county, 2016 36 Outbreaks by mode of transmission, 2014-2016 38 Outbreaks by mode of transmission and county, 2016 39

Infectious Disease Outbreak Report 2016 | 28 Outbreaks by exposure county, 2016

Outbreak Exposure County Frequency Percent Population Rate per 100,000 Apache County 1 1 72,131 1.4 Cochise County 1 1 128,343 0.8 Coconino County 3 2 142,560 2.1 Gila County 0 0 54,333 0.0 Graham County 0 0 38,303 0.0 Greenlee County 0 0 10,433 0.0 La Paz County 1 1 21,247 4.7 Maricopa County 109 73 4,137,076 2.6 Mohave County 3 2 205,764 1.5 Navajo County 0 0 110,413 0.0 Pima County 11 7 1,013,103 1.1 Pinal County 6 4 413,312 1.5 Santa Cruz County 0 0 50,581 0.0 Yavapai County 2 1 220,189 0.9 Yuma County 2 1 217,730 0.9 Exposure occurred in multiple counties 1 1 Exposure occurred in multiple states 9 6 Total 149 100 6,835,518 2.2

Infectious Disease Outbreak Report 2016 | 29 Outbreaks by exposure county, 2014-2016

Outbreak Exposure County 2014 2015 2016 Apache County 0 0 1 Cochise County 0 0 1 Coconino County 5 6 3 Gila County 2 1 0 Graham County 0 2 0 Greenlee County 0 1 0 La Paz County 2 1 1 Maricopa County 102 84 109 Mohave County 0 3 3 Navajo County 0 3 0 Pima County 29 18 11 Pinal County 8 5 6 Santa Cruz County 1 0 0 Yavapai County 6 5 2 Yuma County 1 1 2 Exposure occurred in multiple counties 1 2 1 Exposure occurred in multiple states 10 5 9 Total 167 137 149

Infectious Disease Outbreak Report 2016 | 30 Outbreaks by month of report, 2014-2016

Month of Report 2014 2015 2016 January 22 12 18 February 30 16 21 March 15 14 24 April 21 17 21 May 15 13 17 June 12 5 8 July 6 6 5 August 4 7 6 September 9 13 5 October 5 10 9 November 12 8 10 December 16 16 5 Total 167 137 149

Infectious Disease Outbreak Report 2016 | 31 Outbreaks by month of report and county, 2016

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total Jan 0 0 1 0 15 0 2 0 0 0 0 0 18 Feb 0 0 0 1 17 1 1 0 0 0 0 1 21 Mar 0 0 0 0 21 0 1 0 1 1 0 0 24 Apr 1 0 0 0 17 0 1 1 0 1 0 0 21 May 0 1 0 0 11 0 2 1 1 0 0 1 17 Jun 0 0 0 0 4 1 0 1 0 0 1 1 8 Jul 0 0 0 0 2 0 0 1 0 0 0 2 5 Aug 0 0 2 0 3 0 1 0 0 0 0 0 6 Sep 0 0 0 0 3 1 0 0 0 0 0 1 5 Oct 0 0 0 0 5 0 2 2 0 0 0 0 9 Nov 0 0 0 0 10 0 0 0 0 0 0 0 10 Dec 0 0 0 0 1 0 1 0 0 0 0 3 5 Total 1 1 3 1 109 3 11 6 2 2 1 9 149

No outbreaks were confirmed in 2016 in the following counties: Gila, Graham, Greenlee, Navajo, and Santa Cruz.

Infectious Disease Outbreak Report 2016 | 32 Outbreaks by type of setting, 2014-2016

2014 2015 2016 Healthcare Setting 55 47 40 Child/Daycare 11 11 38 School 41 40 28 Home or Work Setting 3 5 11 Other 23 17 9 Prison/Detention Center 5 5 7 Food Service 13 8 5 Unknown 14 4 5 Hotel/Motel 2 0 3 Recreational Water Venue 0 0 3 Total 167 137 149

Infectious Disease Outbreak Report 2016 | 33 Outbreaks by type of setting and county, 2016

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total Healthcare Setting 0 0 1 0 30 1 7 0 0 1 0 0 40 Child/Daycare 0 0 0 1 35 0 1 0 1 0 0 0 38 School 0 0 0 0 26 0 1 1 0 0 0 0 28 Home/Workplace 0 0 0 0 5 0 0 0 1 0 0 5 11 Other 1 1 0 0 5 0 1 0 0 0 1 0 9 Prison/Det. Center 0 0 0 0 2 0 0 4 0 1 0 0 7 Food Service 0 0 0 0 3 1 1 0 0 0 0 0 5 Unknown 0 0 0 0 1 0 0 0 0 0 0 4 5 Hotel/Motel 0 0 1 0 1 0 0 1 0 0 0 0 3 Recr. Water Venue 0 0 1 0 1 1 0 0 0 0 0 0 3 Total 1 1 3 1 109 3 11 6 2 2 1 9 149

No outbreaks were confirmed in 2016 in the following counties: Gila, Graham, Greenlee, Navajo, and Santa Cruz.

Infectious Disease Outbreak Report 2016 | 34 Outbreaks by syndrome category, 2014-2016

2014 2015 2016 GI Illness 110 81 107 Respiratory 21 28 20 Parasitic Skin Infestations 14 11 10 Rash Illness 6 7 8 Other 16 10 4 Total 167 137 149

Infectious Disease Outbreak Report 2016 | 35 Outbreaks by syndrome category and county, 2016

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total GI Illness 1 0 3 1 77 2 9 2 1 1 1 9 107

Shigellosis 34 Norovirus (suspect) 33 Unknown GI illness 15 Salmonellosis 10 Norovirus (confirmed) 9 Cryptosporidiosis 2 Shiga toxin-producing E. coli 1 Clostridium difficile 1 Typhoid fever 1 Listeriosis 1

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total Respiratory 0 1 0 0 17 1 1 0 0 0 0 0 20

Influenza virus 7 Pertussis 6 Unknown respiratory illness 6 Legionellosis 1

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total Parasitic Skin 0 0 0 0 7 0 0 3 0 0 0 0 10 Infestations Scabies 10

Infectious Disease Outbreak Report 2016 | 36 Outbreaks by syndrome category and county, 2016, continued

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total Rash Illness 0 0 0 0 6 0 0 1 0 1 0 0 8

Varicella (chickenpox) 4 Hand, foot, and mouth disease 2 Measles 1 Unknown rash illness 1

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total Other 0 0 0 0 2 0 1 0 1 0 0 0 4

Conjunctivitis, acute 2 Acute flaccid myelitis 1 MRSA 1

No outbreaks were confirmed in 2016 in the following counties: Gila, Graham, Greenlee, Navajo, and Santa Cruz.

Infectious Disease Outbreak Report 2016 | 37 Outbreaks by mode of transmission, 2014-2016

2014 2015 2016 Fecal-oral 83 58 80 Respiratory 22 27 20 Foodborne 20 19 18 Skin-to-skin 15 12 10 Other* 20 15 11 Animal exposure 7 3 5 Waterborne 0 3 5 Total 167 137 149

*Includes outbreaks of undetermined transmission mode, and outbreaks that may have had multiple modes of transmission.

Infectious Disease Outbreak Report 2016 | 38 Outbreaks by mode of transmission and county, 2016

Multi- Multi- Apache Cochise Coconino La Paz Maricopa Mohave Pima Pinal Yavapai Yuma county state Total Fecal-oral 1 0 1 1 67 0 7 1 0 1 1 0 80 Respiratory 0 1 0 0 16 1 1 1 0 0 0 0 20 Foodborne 0 0 0 0 8 1 2 1 0 0 0 6 18 Skin-to-skin 0 0 0 0 7 0 0 3 0 0 0 0 10 Other* 0 0 0 0 8 0 1 0 1 1 0 0 11 Animal exposure 0 0 0 0 1 0 0 0 1 0 0 3 5 Waterborne 0 0 2 0 2 1 0 0 0 0 0 0 5 Total 1 1 3 1 109 3 11 6 2 2 1 9 149

*Includes outbreaks of undetermined transmission mode, and outbreaks that may have had multiple modes of transmission.

Infectious Disease Outbreak Report 2016 | 39