Publications by authors named "Kristen Pogreba-Brown"

23 Publications

  • Page 1 of 1

Post-acute sequelae of COVID-19 in a non-hospitalized cohort: Results from the Arizona CoVHORT.

PLoS One 2021 4;16(8):e0254347. Epub 2021 Aug 4.

Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States of America.

Clinical presentation, outcomes, and duration of COVID-19 has ranged dramatically. While some individuals recover quickly, others suffer from persistent symptoms, collectively known as long COVID, or post-acute sequelae of SARS-CoV-2 (PASC). Most PASC research has focused on hospitalized COVID-19 patients with moderate to severe disease. We used data from a diverse population-based cohort of Arizonans to estimate prevalence of PASC, defined as experiencing at least one symptom 30 days or longer, and prevalence of individual symptoms. There were 303 non-hospitalized individuals with a positive lab-confirmed COVID-19 test who were followed for a median of 61 days (range 30-250). COVID-19 positive participants were mostly female (70%), non-Hispanic white (68%), and on average 44 years old. Prevalence of PASC at 30 days post-infection was 68.7% (95% confidence interval: 63.4, 73.9). The most common symptoms were fatigue (37.5%), shortness-of-breath (37.5%), brain fog (30.8%), and stress/anxiety (30.8%). The median number of symptoms was 3 (range 1-20). Amongst 157 participants with longer follow-up (≥60 days), PASC prevalence was 77.1%.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254347PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336814PMC
August 2021

Scoping Review of Postinfectious Sequelae.

Foodborne Pathog Dis 2021 Jul 22:1-15. Epub 2021 Jul 22.

Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA.

Previous economic estimates of infection with and chronic sequelae following infection lack sufficient data to establish the true burden of disease and its chronic sequelae. This scoping review aims to fill this gap by updating existing literature regarding the development of postinfectious sequelae following infection. Literature published between January 1, 2000, and November 6, 2018, in PubMed, EMBASE, and Scopus was searched for a wide range of postinfectious sequelae and economic estimate terms. This scoping review includes summaries from the 108 articles covering 5 main groupings of outcomes (categories are not exclusive) including vision disorders ( = 58), psychological and mental health disorders ( = 27), neurological disorders ( = 17), fetal death and infection ( = 15), and hearing loss ( = 6), as well as a description of other outcomes reported. While the majority of the included studies assessed the incidence of these outcomes postinfection, very few followed participants long-term. These prospective studies are needed to understand the true burden of postinfectious sequelae over the life course, particularly because congenital infection with can lead to severe outcomes for newborns. This scoping review can be used as an important resource for other researchers wishing to conduct future systematic reviews and meta-analyses, as well as for policy makers interested in developing guidance for public and health care partners.
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http://dx.doi.org/10.1089/fpd.2021.0015DOI Listing
July 2021

Enteric Pathogens and Reactive Arthritis: Systematic Review and Meta-Analyses of Pathogen-Associated Reactive Arthritis.

Foodborne Pathog Dis 2021 Sep 13;18(9):627-639. Epub 2021 Jul 13.

Naval Medical Research Center, Silver Spring, Maryland, USA.

The objective of this systematic review and meta-analysis was to estimate the proportion of postinfectious reactive arthritis (ReA) after bacterial enteric infection from one of four selected pathogens. We collected studies from PubMed, Web of Science, and Embase, which assessed the proportion of postinfectious ReA published from January 1, 2000 to April 1, 2018. Papers were screened independently by title, abstract, and full text; papers in English, Spanish, and Portuguese utilizing a case-control (CC) or cohort study design, with a laboratory confirmed or probable acute bacterial enteric infection and subsequent ReA, were included. The proportion of ReA cases was pooled between and across pathogens. Factors that can induce study heterogeneity were explored using univariate meta-regression, including region, sample size, study design, and ReA case ascertainment. Twenty-four articles were included in the final review. The estimated percentage of cases across studies describing -associated ReA ( = 11) was 1.71 (95% confidence interval [CI] 0.49-5.84%); ( = 17) was 3.9 (95% CI 1.6-9.1%); ( = 6) was 1.0 (95% CI 0.2-4.9%); and ( = 7) was 3.4 (95% CI 0.8-13.7%). Combining all four pathogens, the estimated percentage of cases that developed ReA was 2.6 (95% CI 1.5-4.7%). Due to high heterogeneity reflected by high values, results should be interpreted with caution. However, the pooled proportion developing ReA from studies with sample sizes () <1000 were higher compared with  > 1000 (6% vs. 0.3%), retrospective cohort studies were lower (1.1%) compared with CC or prospective cohorts (6.8% and 5.9%, respectively), and those where ReA cases are identified through medical record review were lower (0.3%) than those identified by a specialist (3.9%) or self-report (12%). The estimated percentage of people who developed ReA after infection with , , , or is relatively low (2.6). In the United States, this estimate would result in 84,480 new cases of ReA annually.
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http://dx.doi.org/10.1089/fpd.2020.2910DOI Listing
September 2021

CAFOs, novel influenza, and the need for One Health approaches.

One Health 2021 Dec 8;13:100246. Epub 2021 Apr 8.

The University of Arizona, Mel and Enid Zuckerman College of Public Health, Department of Epidemiology and Biostatistics, USA.

Concentrated animal feeding operations (CAFOs) present highly efficient means of meeting food demands. CAFOs create unique conditions that can affect the health and environment of animals and humans within and outside operations, leading to potential epidemiological concerns that scale with operational size. One such arena meriting further investigation is their possible contribution to novel influenzas. CAFOs present opportunities for cross-species transmission of influenza as demonstrated by reports of swine flu and avian influenza outbreaks. Conditions and pathways leading to novel influenza strains are complex and require varied prevention and intervention approaches. Current challenges for prevention of respiratory viruses entering or leaving swine and poultry CAFOs are multifaceted and include adherence of personal safety measures, lack of training and safety provisions for personnel, and incomplete standardized federal, state, and/or county regulation and enforcement coverage across agricultural systems. This report acknowledges that any proposed CAFO-associated influenza intervention should be cross-organizational, and no single intervention should be expected to provide full resolution. Proposed interventions affect multiple components of the One Health triad, and include seasonal human influenza immunization, PPE regulation and adherence, alternative waste management, general biosecurity standardization and an industry best practices incentive program. Due to the complexity of this problem, multiple anticipated communication, enforcement, and logistical challenges may hinder the full implementation of proposed solutions. General and operation-specific (swine and poultry) biosecurity practices may mitigate some of the risks associated with influenza virus reassortment across species. Education and advocacy can help protect workers, communities, veterinarians and consumers from CAFO-associated influenza virus. To achieve this, there must be more complete communication between CAFOs, governing agencies, health services, animal services, researchers, and consumers to better explore the potential health outcomes associated with CAFOs.
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http://dx.doi.org/10.1016/j.onehlt.2021.100246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091921PMC
December 2021

Knowledge of Sexual Transmission of Zika Virus Among Women Who Are Pregnant or Intend to Become Pregnant, Arizona, 2017.

Public Health Rep 2021 Apr 2:333549211006986. Epub 2021 Apr 2.

Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.

Objectives: Levels of knowledge about the sexual transmission of Zika virus are consistently low in populations at risk of a mosquito-borne outbreak, including among women of childbearing age and women who are pregnant or intend to become pregnant. We investigated the effectiveness of sources of public health messaging about sexual transmission to women who are pregnant or intend to become pregnant in Arizona.

Methods: In 2017, we conducted an Arizona-statewide survey 15 months after the initial release of US guidelines on sexual transmission of Zika virus. We used Poisson regression, adjusting for demographic factors, to estimate the likelihood among women who were pregnant or intended to become pregnant of knowing that Zika virus is sexually transmitted relative to other women of childbearing age. We used multinomial logistic regression models to explore associations with most used health information sources, either in person (eg, medical providers) or online (eg, Facebook), categorized by extent of dependability.

Results: Women who were pregnant or intended to become pregnant had similarly poor knowledge of the sexual transmission of Zika virus as compared with other women of childbearing age (adjusted prevalence ratio = 1.14 [95% CI, 0.83-1.55]). Only about one-third of all respondents reported knowledge of sexual transmission. Reliance on high- vs low-dependability information sources, whether in person or online, did not predict the extent of Zika virus knowledge among women who were pregnant or intended to become pregnant.

Conclusion: As late as the second year of local Zika virus transmission in the United States, in 2017, women in Arizona were not receiving sufficient information about sexual transmission, even though it was available. To prepare for possible future outbreaks, research should explore which aspects of Zika information campaigns were ineffective or inefficient.
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http://dx.doi.org/10.1177/00333549211006986DOI Listing
April 2021

COVID-19 containment on a college campus via wastewater-based epidemiology, targeted clinical testing and an intervention.

Sci Total Environ 2021 Jul 13;779:146408. Epub 2021 Mar 13.

Water & Energy Sustainable Technology (WEST) Center, University of Arizona, 2959 W. Calle Agua Nueva, Tucson, AZ 85745, USA. Electronic address:

Wastewater-based epidemiology has potential as an early-warning tool for determining the presence of COVID-19 in a community. The University of Arizona (UArizona) utilized WBE paired with clinical testing as a surveillance tool to monitor the UArizona community for SARS-CoV-2 in near real-time, as students re-entered campus in the fall. Positive detection of virus RNA in wastewater lead to selected clinical testing, identification, and isolation of three infected individuals (one symptomatic and two asymptomatic) that averted potential disease transmission. This case study demonstrated the value of WBE as a tool to efficiently utilize resources for COVID-19 prevention and response. Thus, WBE coupled with targeted clinical testing was further conducted on 13 dorms during the course of the Fall semester (Table 3). In total, 91 wastewater samples resulted in positive detection of SARS-CoV-2 RNA that successfully provided an early-warning for at least a single new reported case of infection (positive clinical test) among the residents living in the dorm. Overall, WBE proved to be an accurate diagnostic for new cases of COVID-19 with an 82.0% positive predictive value and an 88.9% negative predictive value. Increases in positive wastewater samples and clinical tests were noted following holiday-related activities. However, shelter-in-place policies proved to be effective in reducing the number of daily reported positive wastewater and clinical tests. This case study provides evidence for WBE paired with clinical testing and public health interventions to effectively contain potential outbreaks of COVID-19 in defined communities.
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http://dx.doi.org/10.1016/j.scitotenv.2021.146408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954642PMC
July 2021

Design of the Arizona CoVHORT: A Population-Based COVID-19 Cohort.

Front Public Health 2021 10;9:620060. Epub 2021 Feb 10.

Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States.

This study is a prospective, population-based cohort of individuals with a history of SARS-CoV-2 infection and those without past infection through multiple recruitment sources. The main study goal is to track health status over time, within the diverse populations of Arizona and to identify the long-term consequences of COVID-19 on health and well-being. A total of 2,881 study participants (16.2% with a confirmed SARS-CoV-2 infection) have been enrolled as of December 22, 2020, with a target enrollment of 10,000 participants and a planned follow-up of at least 2 years. This manuscript describes a scalable study design that utilizes a wide range of recruitment sources, leveraging electronic data collection to capture and link longitudinal participant data on the current and emerging issues associated with the COVID-19 pandemic. The cohort is built within a collaborative infrastructure that includes new and established partnerships with multiple stakeholders, including the state's public universities, local health departments, tribes, and tribal organizations. Challenges remain for ensuring recruitment of diverse participants and participant retention, although the electronic data management system and timing of participant contact can help to mitigate these problems.
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http://dx.doi.org/10.3389/fpubh.2021.620060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902773PMC
March 2021

Training and Incorporating Students in SARS-CoV-2 Case Investigations and Contact Tracing.

Public Health Rep 2021 Mar-Apr;136(2):154-160. Epub 2020 Dec 10.

572170 Department of Epidemiology and Biostatistics, University of Arizona, Mel and Enid Zuckerman College of Public Health, Tucson, AZ, USA.

Objectives: In June 2020, Arizona had the fastest-growing number of cases of coronavirus disease 2019 (COVID-19) worldwide. As part of the growing public health response, the University of Arizona Student Aid for Field Epidemiology Response (SAFER) team was able to modify and increase case investigation efforts to assist local health departments. We outline the recommended logistical and management steps to include students in a public health response of this scope.

Methods: From April 1 through September 1, 2020, the SAFER team identified key components of a successful student team response: volunteer training, management that allows more senior students to manage newer students, adoption of case-management software, and use of an online survey platform for students to conduct interviews consistently and allow for data quality control and management.

Results: From April 1 through September 1, 2020, SAFER worked with 3 local health departments to complete 1910 COVID-19 case investigations through a virtual call center. A total of 233 volunteers and 46 hourly student workers and staff members were involved. As of September 2020, students were completing >150 interviews per week, including contact-tracing efforts.

Practice Implications: Developing relationships between applied public health and academic programs can relieve the burden of low-risk, high-volume case investigations at local and state health departments. Furthermore, by establishing a virtual call center, health sciences faculty and students can volunteer remotely during a pandemic with no additional risk of infection.
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http://dx.doi.org/10.1177/0033354920974664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093843PMC
February 2021

Seroprevalence of Toxoplasma gondii in the U.S.: Evidence from a representative cross-sectional survey.

Parasitol Int 2020 Dec 5;79:102175. Epub 2020 Aug 5.

Mercer University, College of Pharmacy, Department of Pharmacy Practice, United States of America. Electronic address:

The National Health and Nutrition Examination Survey (NHANES) evaluates the epidemiology in the U.S. population of certain infectious diseases, including Toxoplasma gondii (T. gondii), a protozoan parasite. This study aims to evaluate the seroprevalence of T. gondii -IgG antibodies using NHANES data to identify risk factors related to T. gondii. Using NHANES 2009-10, 2011-12, and 2013-14 cycles, univariate analyses and logistic regression models were conducted to determine the relationship between T. gondii seropositivity and various risk factors. Across the three cycles, 13.3% of participants tested positive for T. gondii-IgG seroprevalence, with a significant decrease in seroprevalence from the earlier to later cycles. 53.4% of individuals with positive serology were male. The probability of testing positive for T. gondii -IgG significantly increases between four and five times from the 18-29 age group to 70-79 age group. Seroprevalence also differed by ethnicity, with Latinos of any race having two times higher odds of testing positive for T. gondii compared to other ethnicities. Other sociodemographic factors were associated with lower odds of T. gondii seropositivity, including college education, higher household income, and health insurance. Most clinical conditions were not significantly associated with T. gondii, excluding depression, which was observed in 25% of patients positive for T. gondii-IgG. Further research on the influence of this parasite on infected individuals, including predispositions for risk-taking, is needed to better understand the relationship between Toxoplasma gondii, depression, and other mental illnesses.
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http://dx.doi.org/10.1016/j.parint.2020.102175DOI Listing
December 2020

Knowledge and practices of primary care physicians or general practitioners treating post-infectious Irritable Bowel Syndrome.

BMC Gastroenterol 2020 May 25;20(1):159. Epub 2020 May 25.

Department of Epidemiology & Biostatistics, University of Arizona, Mel and Enid Zuckerman College of Public Health, 1295 N Martin Ave, PO Box 245211, Tucson, 85721, AZ, USA.

Background: Post-infectious Irritable Bowel Syndrome (PI-IBS) is a functional bowel disorder which has significant impacts to a patient's quality of life. No IBS-specific biomarker or treatment regimen for PI-IBS currently exists, therefore understanding practice patterns and variance is of interest.

Methods: This online survey of primary care physicians and general practitioners in the USA aimed to understand the knowledge and treatment of PI-IBS within the physician's current practice. Summary statistics are provided with a commentary on implications for practices and treatment of PI-IBS.

Results: Most physician survey respondents (n = 50) were aware of PI-IBS, but less than half discussed this condition as a possible outcome in their patients with a recent gastrointestinal infection. Most physicians indicated that they would treat the patients themselves with a focus on managing IBS through different treatment modalities based on severity. Treatment for PI-IBS followed IBS recommendations, but most physicians also prescribed a probiotic for therapy. Physicians estimated that 4 out of 10 patients who develop PI-IBS will have life-long symptoms and described significant impacts to their patient's quality of life. Additionally, physicians estimated a significant financial burden for PI-IBS patients, ranging from $100-1000 (USD) over the course of their illness. Most physicians agreed that they would use a risk score to predict the probability of their patients developing PI-IBS, if available.

Conclusions: While this survey is limited due to sample size, physician knowledge and treatment of PI-IBS was consistent across respondents. Overall, the physicians identified significant impacts to patient's quality of life due to PI-IBS.
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http://dx.doi.org/10.1186/s12876-020-01305-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249359PMC
May 2020

A critical analysis of recreational water guidelines developed from temperate climate data and applied to the tropics.

Water Res 2020 Mar 9;170:115294. Epub 2019 Nov 9.

University of Michigan, School of Public Health, Department of Epidemiology, 1415 Washington Heights, Ann Arbor, MI, 48109, USA. Electronic address:

Recreational water epidemiology studies are rare in settings with minimal wastewater treatment where risk may be highest, and in tropical settings where warmer temperature influences the ecology of fecal indicator bacteria commonly used to monitor recreational waters. One exception is a 1999 study conducted in São Paulo Brazil. We compared the risk and exposure characteristics of these data with those conducted in the United Kingdom (UK) in the early 1990s that are the basis of the World Health Organization's (WHO) guidelines on recreational water risks. We then developed adjusted risk difference models (excess gastrointestinal illness per swimming event) for children (<10 years of age) and non-children (≥10 years of age) across five Brazil beaches. We used these models along with beach water quality data from 2004 to 2015 to assess spatial and temporal trends in water quality and human risk. Risk models indicate that children in Brazil have as much as two times the risk of gastrointestinal illness than non-children. In Brazil, 11.8% of the weekly water samples from 2004 to 2015 exceeded 158 enterococci CFU/100 ml, the highest level of fecal streptococci concentration measured in the UK study. Risks associated with these elevated levels equated to median NEEAR-Gastrointestinal Illness (NGI) risks of 53 and 96 excess cases per 1000 swimmers in non-children and children, respectively. Two of the five beaches appear to drive the overall elevated NGI risks seen during this study. Distinct enteric pathogen profiles that exist in tropical settings as well as in settings with minimal wastewater treatment highlight the importance of regionally specific guideline development.
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http://dx.doi.org/10.1016/j.watres.2019.115294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6962556PMC
March 2020

Impact of a Novel Antimicrobial Surface Coating on Health Care-Associated Infections and Environmental Bioburden at 2 Urban Hospitals.

Clin Infect Dis 2020 11;71(8):1807-1813

The University of Arizona College of Medicine, Tucson, Arizona, USA.

Background: Approximately 1 in 25 people admitted to a hospital in the United States will suffer a health care-associated infection (HAI). Environmental contamination of hospital surfaces contributes to HAI transmission. We investigated the impact of an antimicrobial surface coating on HAIs and environmental bioburdens at 2 urban hospitals.

Methods: A transparent antimicrobial surface coating was applied to patient rooms and common areas in 3 units at each hospital. Longitudinal regression models were used to compare changes in hospital-onset multidrug-resistant organism bloodstream infection (MDRO-BSI) and Clostridium difficile infection (CDI) rates in the 12 months before and after application of the surface coating. Incidence rate ratios (IRRs) were compared for units receiving the surface coating application and for contemporaneous control units. Environmental samples were collected pre- and post-application to identify bacterial colony forming units (CFUs) and the percent of sites positive for select, clinically relevant pathogens.

Results: Across both hospitals, there was a 36% decline in pooled HAIs (combined MDRO-BSIs and CDIs) in units receiving the surface coating application (IRR, 0.64; 95% confidence interval [CI], .44-.91), and no decline in the control units (IRR, 1.20; 95% CI, .92-1.55). Following the surface application, the total bacterial CFUs at Hospitals A and B declined by 79% and 75%, respectively; the percentages of environmental samples positive for clinically relevant pathogens also declined significantly for both hospitals.

Conclusions: Statistically significant reductions in HAIs and environmental bioburdens occurred in the units receiving the antimicrobial surface coating, suggesting the potential for improved patient outcomes and persistent reductions in environmental contamination. Future studies should assess optimal implementation methods and long-term impacts.
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http://dx.doi.org/10.1093/cid/ciz1077DOI Listing
November 2020

Methodology minute: An overview of the case-case study design and its applications in infection prevention.

Am J Infect Control 2020 03 9;48(3):342-344. Epub 2019 Oct 9.

Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ.

The case-case study design is a potentially useful tool for infection preventionists during outbreak or cluster investigations. This column clarifies terminology related to case-case, case-control, and case-case-control study designs. Examples of practical applications of the case-case study design include determining risk factors for health care-onset versus community-onset infections, or antibiotic-resistant versus antibiotic-susceptible infections.
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http://dx.doi.org/10.1016/j.ajic.2018.11.024DOI Listing
March 2020

Chronic Gastrointestinal and Joint-Related Sequelae Associated with Common Foodborne Illnesses: A Scoping Review.

Foodborne Pathog Dis 2020 02 7;17(2):67-86. Epub 2019 Oct 7.

U.S. Food and Drug Administration, College Park, Maryland.

To strengthen the burden estimates for chronic sequelae of foodborne illness, we conducted a scoping review of the current literature for common foodborne pathogens and their associated sequelae. We aim to describe the current literature and gaps in knowledge of chronic sequelae associated with common foodborne illnesses. A comprehensive search was conducted in PubMed, EMBASE, and Web of Science for peer-reviewed articles published January 1, 2000 to April 1, 2018. Articles available in English, of any epidemiological study design, for 10 common foodborne pathogens (, , , , , , , , , and norovirus) and their associated gastrointestinal (GI)- and joint-related sequelae were included. Of the 6348 titles screened for inclusion, 380 articles underwent full-text review; of those 380, 129 were included for data extraction. Of the bacterial pathogens included in the search terms, the most commonly reported were ( = 104) and ( = 99); ( = 55), ( = 49), ( = 49), and ( = 15) all had fewer results. Norovirus was the only virus included in our search, with 28 article that reported mostly GI-related sequelae and reactive arthritis (ReA) reported once. For parasitic diseases, ( = 26) and ( = 18) had the most articles, and no results were found for . The most commonly reported GI outcomes were irritable bowel syndrome (IBS;  = 119) and inflammatory bowel disease ( = 29), and ReA ( = 122) or "joint pain" ( = 19) for joint-related sequelae. and were most often associated with a variety of outcomes, with ReA ( = 34 and  = 27) and IBS ( = 17 and  = 20) reported most often. This scoping review shows there are still a relatively small number of studies being conducted to understand specific pathogen/outcome relationships. It also shows where important gaps in the impact of chronic sequelae from common foodborne illnesses still exist and where more focused research would best be implemented.
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http://dx.doi.org/10.1089/fpd.2019.2692DOI Listing
February 2020

Post-infectious sequelae after Campylobacter enteric infection: a pilot study in Maricopa County, Arizona, USA.

Pilot Feasibility Stud 2018 22;4:142. Epub 2018 Aug 22.

Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, 1295 N Martin Ave, Tucson, AZ 85719 USA.

Background: Campylobacter is a leading cause of gastroenteritis across the globe caused by the ingestion of contaminated food, water, or contact with animals carrying Campylobacter bacteria. The resulting disease, campylobacteriosis, is usually self-limiting, but cases may develop post-infectious sequelae (PIS) such as gastrointestinal disorders, neurological disorders, and joint disorders. The objective of this study was to estimate a crude incidence rate for PIS among Campylobacter cases in Maricopa County, Arizona, USA and to determine the feasibility of conducting a larger scale study to understand chronic outcomes from campylobacteriosis and salmonellosis.

Methods: The pilot study spanned from August 1, 2016, to August 31, 2017. During this time, cases of campylobacteriosis were reported to the Maricopa County Department of Public Health and interviewed by public health students at the University of Arizona. Initial interviews were conducted using a routine enteric surveillance questionnaire, and eligible cases were recruited and consented into the pilot study. Follow-up with a questionnaire occurred 4 to 6 weeks from the date of each case's initial interview. Data analysis was conducted using STATA SE 14 and included chi-squared tests to determine differences in demographics, symptoms, and exposures between those enrolled in the study and those eligible but not enrolled during the study period and feasibility metrics for the study including enrollment rates, response rates, time to interview, and reasons for non-enrollment. Crude rates with 95% confidence intervals were calculated to estimate PIS.

Results: Of the routine surveillance cases, 102 (36%) enrolled into the pilot study. Of enrolled participants, 68.6% completed the follow-up questionnaire. Most enrolled participants were non-Hispanic White, male, and aged 60 + years. Over half (52.8%, 95% CI 41.1%, 64.5%) of cases experienced PIS approximately 4 to 6 weeks after acute onset of campylobacteriosis.

Conclusions: Results from this pilot study indicate that a larger study is feasible. The larger study will identify the true incidence of PIS and improve the management of patient health among ethnically diverse populations.
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http://dx.doi.org/10.1186/s40814-018-0335-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103860PMC
August 2018

Campylobacter and Ethnicity-A Case-Case Analysis to Determine Differences in Disease Presentation and Risk Factors.

Foodborne Pathog Dis 2018 05 29;15(5):277-284. Epub 2018 Jan 29.

Department of Epidemiology & Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona , Tucson, Arizona.

Background: Rates of Campylobacter infection in Arizona have historically been higher than the national average, with the highest rates in Hispanic populations. The purpose of this retrospective case-case analysis was to determine how risk factors and disease presentation differ by ethnicity (Hispanic vs. Non-Hispanic) in cases of campylobacteriosis from 2012 to 2015 in Maricopa County, Arizona.

Methods: Basic demographics and seasonality, including standardized morbidity ratios (SMRs), were analyzed to determine differences by ethnicity. To determine differences in risk factors, adjusted univariate and multivariable logistic regression was conducted.

Results: There were significant differences by ethnicity by age (1-14 years and >60 years), location of residence (urban vs. suburban), and testing methodology. Most months in the seasonality analysis showed higher than expected values of Hispanic cases based on population distributions (SMR Range: 0.91-1.78, annual mean: 1.23). Differences in disease presentation showed that Hispanics (adjusted for age and location of residence) were more likely to experience vomiting (OR = 1.41) and fever (OR = 1.08), as well as seek care through an urgent care or emergency department (OR = 1.50), than non-Hispanic cases. Hispanics had a higher odds of reporting consumption of tomatoes (OR = 1.45), salsa (OR = 2.35), cilantro (OR = 2.21), queso fresco (OR = 8.53), and sprouts (OR = 1.94) than non-Hispanic cases. Multivariable analyses found queso fresco (aOR = 6.58), cilantro (aOR = 3.93), and animal products (aOR = 0.38) all to be significant by ethnicity.

Conclusions: Hispanics had a higher likelihood of consuming high risk foods, while non-Hispanics were more likely to have environmental exposures linked to Campylobacter infection. Focused questionnaires can reveal differences and contribute to improving public health action/education for specific populations.
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http://dx.doi.org/10.1089/fpd.2017.2337DOI Listing
May 2018

Public Health Surveillance Strategies for Mass Gatherings: Super Bowl XLIX and Related Events, Maricopa County, Arizona, 2015.

Health Secur 2016 May-Jun;14(3):173-84

Super Bowl XLIX took place on February 1, 2015, in Glendale, Arizona. In preparation for this event and associated activities, the Maricopa County Department of Public Health (MCDPH) developed methods for enhanced surveillance, situational awareness, and early detection of public health emergencies. Surveillance strategies implemented from January 22 to February 6, 2015, included enhanced surveillance alerts; animal disease surveillance; review of NFL clinic visits; syndromic surveillance for emergency room visits, urgent care facilities, and hotels; real-time onsite syndromic surveillance; all-hazards mortality surveillance; emergency medical services surveillance, review of poison control center reports; media surveillance; and aberration detection algorithms for notifiable diseases. Surveillance results included increased influenzalike illness activity reported from urgent care centers and a few influenza cases reported in the NFL clinic. A cyanide single event exposure was investigated and determined not to be a public health threat. Real-time field syndromic surveillance documented minor injuries at all events and sporadic cases of gastrointestinal and neurological (mostly headaches) disease. Animal surveillance reports included a cat suspected of carrying plague and tularemia and an investigation of highly pathogenic avian influenza in a backyard chicken flock. Laboratory results in both instances were negative. Aberration detection and syndromic surveillance detected an increase in measles reports associated with a Disneyland exposure, and syndromic surveillance was used successfully during this investigation. Coordinated enhanced epidemiologic surveillance during Super Bowl XLIX increased the response capacity and preparedness of MCDPH to make informed decisions and take public health actions in a timely manner during these mass gathering events.
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http://dx.doi.org/10.1089/hs.2016.0029DOI Listing
May 2017

Are fecal indicator bacteria appropriate measures of recreational water risks in the tropics: A cohort study of beach goers in Brazil?

Water Res 2015 Dec 5;87:59-68. Epub 2015 Sep 5.

University of Michigan, School of Public Health, Department of Epidemiology, USA. Electronic address:

Regulating recreational water exposure to pathogens within the tropics is a major public health and economic concern. Although numerous epidemiological studies estimating the risk to recreational marine water exposure have been conducted since the 1950s, few studies have been done in the tropics. Furthermore, many have suggested that the use of fecal indicator bacteria for monitoring recreational water quality in temperate regions is not appropriate in the tropics. We analyzed a large cohort study of five beaches in Sao Paulo, Brazil, conducted during consecutive weekends in the summer of 1999 that estimated risk to water, sand, and food exposures. Enterococci and Escherichia coli concentrations were measured each day of the study. Elevated risks were estimated for both swimming (OR = 1.36 95% CI: 1.05-1.58) and sand contact (OR = 1.29 95% CI 1.05-1.58). A 1 log increase in enterococci concentration was associated with an 11% increase in risk (OR = 1.11 95% CI: 1.04-1.19). For E. coli a 1-log increase in concentration was associated with 19% increase in risk (OR = 1.19 95% CI: 1.14-1.28). Most countries with beaches in the tropics are lower or middle income countries (LMIC) and rely on tourism as a major source of income. We present data that suggests fecal indicator bacteria such as enterococci are an appropriate indicator of risk in tropical urban settings where contamination is coming from predominantly human sources. Additional studies in tropical settings could help inform and refine guidelines for safe use of recreational waters.
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http://dx.doi.org/10.1016/j.watres.2015.09.001DOI Listing
December 2015

Public health in the field and the emergency operations center: methods for implementing real-time onsite syndromic surveillance at large public events.

Disaster Med Public Health Prep 2013 Oct;7(5):467-74

University of Arizona, Tucson.

Objective: To develop an onsite syndromic surveillance system for the early detection of public health emergencies and outbreaks at large public events.

Methods: As the third largest public health jurisdiction in the United States, Maricopa County Department of Public Health has worked with academic and first-response partners to create an event-targeted syndromic surveillance (EVENTSS) system. This system complements long-standing traditional emergency department-based surveillance and provides public health agencies with rapid reporting of possible clusters of illness.

Results: At 6 high profile events, 164 patient reports were collected. Gastrointestinal and neurological syndromes were most commonly reported, followed by multisyndromic reports. Neurological symptoms were significantly increased during hot weather events. The interview rate was 2 to 7 interviews per 50 000 people per hour, depending on the ambient temperature. Discussion Study data allowed an estimation of baseline values of illness occurring at large public events. As more data are collected, prediction models can be built to determine threshold levels for public health response.

Conclusions: EVENTSS was conducted largely by volunteer public health graduate students, increasing the response capacity for the health department. Onsite epidemiology staff could make informed decisions and take actions quickly in the event of a public health emergency.
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http://dx.doi.org/10.1017/dmp.2013.83DOI Listing
October 2013

Use of an online survey during an outbreak of clostridium perfringens in a retirement community-Arizona, 2012.

J Public Health Manag Pract 2014 Mar-Apr;20(2):205-9

Epidemic Intelligence Service (Dr Yasmin) and Office of Public Health Preparedness and Response (Dr Sunenshine), Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of Arizona, Tucson (Dr Pogreba-Brown); and Maricopa County Department of Public Health, Phoenix, Arizona (Drs Yasmin and Sunenshine and Ms Stewart).

Context: An outbreak of gastrointestinal (GI) illness among retirement community residents was reported to the Maricopa County Department of Public Health. Online surveys can be useful for rapid investigation of disease outbreaks, especially when local health departments lack time and resources to perform telephone interviews. Online survey utility among older populations, which may lack computer access or literacy, has not been defined.

Objective: To investigate and implement prevention measures for a GI outbreak and assess the utility of an online survey among retirement community residents.

Design: A retrospective cohort investigation was conducted using an online survey distributed through the retirement community e-mail listserv; a follow-up telephone survey was conducted to assess computer literacy and Internet access. A case was defined as any GI illness occurring among residents during March 1-14, 2012.

Setting: A barbecue in a retirement community of 3000 residents.

Participants: Retirement community residents.

Intervention: Residents were directed to discard leftover food and seek health care for symptoms. A telephone survey was conducted to assess the utility of online surveys in this population.

Main Outcome Measures: Computer literacy and Internet access of retirement community residents.

Results: Of 1000 residents on the listserv, 370 (37%) completed the online survey (mean age, 69.7 years; 60.6% women); 66 residents (17.8%) reported a GI illness after the barbecue, 63 (95.5%) reported diarrhea, and 5 (7.6%) reported vomiting. Leftover beef from an attendee's refrigerator grew Clostridium perfringens. Of 552 residents contacted by telephone, 113 completed the telephone survey (mean age, 71.3 years; 63.3% women), 101 (89.4%) reported the ability to send e-mail, 82 (81.2%) checked e-mail daily, and 28 (27.7%) checked e-mail on a handheld device. The attack rate was 17.8% for online versus 2.7% for telephone respondents (P < .001).

Conclusions: This outbreak demonstrated the utility of an online survey to rapidly collect information and implement prevention measures among an older demographic.
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http://dx.doi.org/10.1097/PHH.0b013e31829a2cf5DOI Listing
April 2015

Teaching epidemiology concepts experientially: a "real" foodborne outbreak in the classroom.

Public Health Rep 2012 Sep-Oct;127(5):549-55

Epidemiology Program at University of Arizona, Mel and Enid Zuckerman College of Public Health in Tucson, Arizona 85724, USA.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3407858PMC
http://dx.doi.org/10.1177/003335491212700512DOI Listing
November 2012

The effect of policy changes on hepatitis A vaccine uptake in Arizona children, 1995-2008.

Public Health Rep 2011 Jul-Aug;126 Suppl 2:87-96

University of Arizona, Mel and Enid Zuckerman College of Public Health, Division of Epidemiology and Biostatistics, Tucson, AZ 85724, USA.

Objective: In 1995, the first hepatitis A vaccines became available for use. At that time, Arizona had the highest hepatitis A incidence of all 50 states. During that same time period, the Arizona State Immunization Information System (ASIIS) was created to collect information on all immunizations given in the state. Four state-level hepatitis A vaccination policies were enacted according to Centers for Disease Control and Prevention recommendations and local initiatives from 1996 to 2005. Our primary objective was to assess the impact of these policies on vaccine uptake in children.

Methods: Immunization records from ASIIS were used to calculate yearly coverage of children with at least one reported hepatitis A vaccination between 1995 and 2008. Proportions vaccinated were calculated by age group (12-23 months, 24-59 months, 5-9 years, 10-14 years, and 15-19 years) for three regions: Maricopa County; Apache and Navajo counties; and the remaining 12 Arizona counties, which were grouped as one to reflect different target groups for the four policies examined. We calculated percent changes from before and after each policy implementation.

Results: Significantly different percent changes were detected among the three regions that related to the four policies implemented. Percent change in uptake was consistently higher in the regions that were targeted for that specific policy.

Conclusions: Analysis of ASIIS data revealed a major effect of hepatitis A policy recommendations on vaccine uptake in Arizona. Targeting high-risk populations through vaccine recommendations and child care entry requirements was highly successful in achieving higher vaccination coverage.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3113434PMC
http://dx.doi.org/10.1177/00333549111260S211DOI Listing
August 2011
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