CDC recommends that clinicians:

• Prioritize Bicillin® L-A to treat pregnant women with syphilis and infants diagnosed with congenital syphilis.
• Consider alternative prophylactic regimens for patients with acute rheumatic fever or rheumatic heart disease (i.e., twice daily administration of oral penicillin V is an alternative).
• Have a plan for connecting pregnant cases to treatment if benzathine or at critical levels. This can include regularly checking with nearby clinics on supply availability.

ADHS recommends that Arizona clinicians treating syphilis:

• Maintain efforts to acquire BPG for pregnant women to prevent congenital and risk of congenital syphilis Clinicians can submit a medical request form for BPG to Pfizer: Medical Request Form | Pfizer Hospital US and should cc’ sti@azdhs.gov on their request.
• Consider the imported alternative: Lentocilin©
• While there are storage and administration differences between Lentocilin© and Bicillin® L-A, it is considered equivalent in terms of dosing and safety. The use of these BPG alternatives during pregnancy has been endorsed by multiple organizations including the American College of Obstetricians and Gynecology and the Society for Maternal-Fetal Medicine. The drugs have the same active ingredient (benzathine benzylpenicillin also known as penicillin G benzathine), doses, and dose schedule as Bicillin® L-A.

ADHS continues to monitor supplies and work with counties and tribes who are at critical supply levels to identify options for connecting pregnant cases to care. There is an ADHS resource page with situational updates, available resources, and recommended guidance to assist partners in navigating the shortage.

Please take a moment to look through the spring newsletter attached.  

November 10th, 2025

Increase in E. coli O157:H7 cases in Arizona 

The Arizona Department of Health Services (ADHS) reports a two-fold increase of E. coli cases compared to what has been seen historically statewide during the month of October. Notably, there has also been an increase in hospitalizations of cases with hemolytic uremic syndrome (HUS).

ADHS recommends that healthcare providers statewide:

●     Suspect the diagnosis of E. coli O157 H:7 infection on children presenting with abdominal pain, bloody diarrhea, vomiting and fever.

●     Identify risk factors (consumption of raw or undercooked beef, unpasteurized milk, animal exposures at petting zoos) on pediatric patients presenting with concerning symptoms.

●     Initiate appropriate diagnostic testing for suspected cases, including stool studies (culture or GI PCR panel if available) and complete blood count (CBC), complete metabolic panel (CMP) and peripheral blood smear if suspecting HUS.

●     Provide supportive management for patients, understanding the potential risk of progression to HUS if exposing the patient to antibiotics.

●     Keep in mind the rapid progression and potential complications associated with HUS. We encourage expert consultation in cases that might require further diagnostic testing or specialized medical care.

●     Report suspect E. coli O157 to the local health department: County Health Department Contacts.

E. coli O157 H:7, often described as enterohemorrhagic E. coli (EHEC) or shiga-toxin producing E. coli (STEC) is a strain of E. coli that causes a severe intestinal infection in humans. CDC reports about 70,000 cases annually. E. coli O157:H7 has been associated with the consumption of various foods including raw and undercooked beef, leafy greens, unpasteurized milk, as well as exposures in petting zoos and daycare centers. Some common symptoms are abdominal pain, diarrhea, bloody stools, fever, fatigue, and nausea.

Hemolytic Uremic Syndrome (HUS) is a complication of a shiga-toxin E. coli infection that can lead to acute kidney injury, hemolysis, thrombocytopenia, and other severe complications that can lead to permanent health problems or death. HUS complicates 2–15% of diagnosed E. coli O157:H7 cases, depending on age, and occurs less commonly after infections due to non-O157 STEC. Anyone can develop HUS, but it is more common in children 5 years or younger.

Thank you for your continued collaboration and partnership.

Action Steps

Health care providers:

●    Consider infant botulism as part of the differential diagnosis based on correlating symptoms. Constipation can be the initial symptom, followed by difficulty feeding (sucking and swallowing), a weak and altered cry, and lack of head control.

●    Call the California Infant Botulism Treatment and Prevention Program immediately at 510-231-7600 for consultation of suspect cases. Consultation is available 24/7.

●    Provide supportive care and begin treatment with BabyBIG® (obtained from California Department of Health) as soon as possible if clinical consultation supports infant botulism. Do not wait for laboratory confirmation.

●    Contact your local public health to get testing approval, then send clinical specimens to the Arizona State Public Health Laboratory (ASPHL) for forwarding to CDC.

●    Report all suspect cases to the local health department by phone immediately: County Health Department Contacts.

Background

CDC and public health officials in several states, the Infant  BotulismTreatment and Prevention Program, and FDA are investigating a multistate outbreak of infant botulism linked to ByHeart Whole Nutrition infant formula. One case has been reported in Arizona. Infant botulism occurs when swallowed Clostridium botulinum spores germinate in an infant’s large intestine and produce toxin. Infant botulism often starts with constipation but is usually first noticed as difficulty feeding (sucking and swallowing), a weak and altered cry, and lack of head control.

As of November 8, 2025, 13 infants with suspected or confirmed infant botulism have been reported from 10 states as part of this outbreak: Arizona, California (2), Illinois (2), Minnesota, New Jersey, Oregon, Pennsylvania, Rhode Island, Texas (2), and Washington. Laboratory confirmation for some cases is ongoing. Illness onset dates range from mid-August to November 2025. All 13 infants were hospitalized and treated with BabyBIG. No deaths have been reported. Infants ranged in age from 16 to 157 days.

ByHeart Whole Nutrition Infant Formula is available for sale online and at major retailers nationwide.

Laboratory Testing

If clinical consultation supports infant botulism, begin treatment with BabyBIG® as soon as possible. Do not wait for laboratory confirmation. Confirmatory testing for botulism uses the mouse bioassay to identify toxin in feces and can take up to two weeks to get results. Contact your local health jurisdiction to get approval for testing prior to sending clinical specimens. Ideally, 10 grams of feces should be collected. If an enema is needed, use sterile, non-bacteriostatic water. 

Save powdered infant formula consumed by suspected infant botulism patients. If the patient is confirmed to have botulism, the CDC may test the powdered infant formula. The CDC is not testing formula of asymptomatic patients.

For more information

●    FDA: Outbreak Investigation of Infant Botulism: Infant Formula (November 2025) (https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-investigation-infant-botulism-infant-formula-november-2025)

●    CDC: Infant Botulism Outbreak Linked to Infant Formula, November 2025 (https://www.cdc.gov/botulism/outbreaks-investigations/infant-formula-nov-2025/index.html)

●    CDC: Clinical Overview of Infant Botulism (https://www.cdc.gov/botulism/hcp/clinical-overview/infant-botulism.html)

●    ADHS Botulism (https://www.azdhs.gov/preparedness/epidemiology-disease-control/foodborne/index.php#botulism)

New World screwworm (NWS) myiasis has re-emerged in Central and South American countries and is spreading northwards towards the U.S. border, and it is considered a threat to the U.S. food supply and national security.

New World screwworm (NWS) myiasis is a parasitic infestation caused by the larvae of the Cochliomyia hominivorax fly. These larvae can infest living tissues such as the skin and bodily cavities of most warm-blooded animals and humans.

Arizona healthcare providers are encouraged to: 

●       Consider NWS in patients with recent travel to Mexico, and Central and South America:

○       With visible larvae or eggs in a wound, ears, eyes, nose, mouth, or other body orifice, or

○       Who report a painful site with sensation of movement, foul odor, bloody discharge, swelling, and destruction of healthy tissue.

●      Notify local public health regarding suspected NWS infestations.

●       Collect all larvae and eggs:

○       Fully submerge all larvae and eggs in 70% ethanol (or 70% or greater isopropanol or 5-10% formalin) in a leak-proof container to kill the larvae and eggs, and preserve them for identification.

○       Submit the collected larvae (pictures and/or sample) to the Arizona Department of Health Services in coordination with your local public health.

○       Do not dispose of any larvae or eggs in the trash or on the ground.

Resources:

●      For images of NWS larvae see the CDC Image Library on the clinical overview page.

●       CDC Clinician Outreach and Communication Activity (COCA) call (October 2024)

On September 12th, Governor Katie Hobbs announced an executive order to ensure access to COVID-19 vaccine for all Arizonans.

Today, via press release, Governor Katie Hobbs, in partnership with the Arizona Department of Health Services (ADHS), announced its issuance of a standing order ensuring access to 2025-2026 COVID-19 vaccines to all Arizonans 6 months of age and older. This standing order was created in consultation with the Arizona Board of Pharmacy and serves as a prescription enabling pharmacists and health care providers in Arizona to administer the vaccine to any who wishes to receive it. This standing order was developed in alignment with current scientific evidence and vaccine recommendations of professional bodies, including:

• American Academy of Pediatrics 
• American Academy of Family Physicians 
• American College of Obstetrics and Gynecology

While the standing order will assist in enabling access to the COVID-19 vaccine at pharmacies across Arizona without the need for an individual prescription, it does not ensure insurance coverage. ADHS will continue to work with our insurance providers throughout the state to understand coverage decisions. We recommend that patients and providers continue to review and discuss coverage for vaccination.

This is an unprecedented time for public health practice, with information changing rapidly. ADHS is committed to continuing to bring evidence-based public health guidance and recommendations to our health care community and the public. To assist us in delivering on our mission, ADHS is pleased to welcome Dr. Richard Carmona to our ranks as a Public Health Medical Advisor. Dr. Carmona’s decades of experience as a public health professional and medical practitioner, including service as the 17th Surgeon General of the United States, will be an asset in our ongoing work to implement scientific and evidence-based practices.

ADHS will be reviewing the decisions made at the CDC’s Advisory Committee on Immunization Practices (ACIP) yesterday and today. In addition to keeping our website updated with the most current information, ADHS will issue a health care provider update in the coming days with any additional guidance related to immunization access and immunization recommendations.

Sincerely,

Nicole Witt, MPH
Assistant Director
Arizona Department of Health Services

Recommended actions: 

• Check inventory to assess impact of the recall and follow the guidance issued by Pfizer. 
• Prioritize use of BPG
• ADHS current BPG Dose Conservation Guidance. 
• CDC is recommending prioritizing Bicillin® L-A to treat pregnant women with syphilis and infants diagnosed with congenital syphilis. CDC is also recommending considering using alternative prophylactic regimens for patients with acute rheumatic fever or rheumatic heart disease (i.e., twice daily administration of oral penicillin V is an alternative ). 
• BPG supply options: 
• For clinics in need of BPG for the treatment of pregnant women with syphilis to prevent congenital and risk of congenital syphilis only, please submit a medical request form to Pfizer: Medical Request Form | Pfizer Hospital US
• Imported alternatives to Bicillin L-A include: Lentocilin^© and Extencilline  

• Please notify stdshortages@cdc.gov and sti@azdhs.gov if you experience challenges to securing benzathine to treat pregnant women with syphilis.
• Call public health for testing and treatment information to assist with diagnosis and staging of syphilis cases:
• Maricopa County: 602-506-STIS (7847)
• Outside Maricopa County: 602-364-4571

Plague is endemic in northern Arizona, above 4,500 feet elevation, as well as in areas of northern New Mexico, southern Colorado and California.

Arizona healthcare providers are encouraged to:

●     Consider plague in your differential diagnosis for patients with risk factors and compatible clinical signs:

○     Fever, headache, chills, and weakness and one or more swollen, painful lymph nodes (bubonic plague).

○     Fever, chills, extreme weakness, abdominal pain, shock, and possibly bleeding into the skin and other organs (septicemic plague); Septicemic plague can occur as the first symptom of plague or may develop from untreated bubonic plague.

○     Fever, headache, weakness, and a rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery mucous (pneumonic plague). Pneumonic plague is the most serious form of the disease and is the only form of plague that can be spread from person to person.

●     Obtain a detailed patient history: flea bites, exposure to areas with rodents or contact with sick or dead animals are risk factors in endemic areas.

●     Start appropriate treatment as soon as plague is suspected and do not wait for diagnostic test results:

○     Fluoroquinolones (ciprofloxacin or levofloxacin) and aminoglycosides (gentamicin or streptomycin) are first-line treatments in the United States

○     Regimens depend on the clinical presentation of plague, patient’s age and other factors such as pregnancy.

○     If patients with pneumonic or septicemic plague do not receive timely, appropriate antibiotic therapy, the disease can progress rapidly to death.

○     Pneumonic plague is the only form of infection that can be transmitted person-to-person. If pneumonic plague is suspected, immediate droplet precautions should be implemented until 48 hours after initiation of effective therapy against Yersinia pestis.

●     If plague is suspected, pre-treatment specimens should be taken. Specimens should be obtained from appropriate sites for isolation of the bacteria, based on the clinical presentation, and may include: lymph node aspirate, routine blood cultures or respiratory specimens.

●     Contact your local health department upon suspicion of a plague case. Public health will assist with specimen testing, infection control precautions and identifying those in need of prophylaxis as well as investigating the source of the infection.

Source:

https://www.cdc.gov/plague/hcp/diagnosis-testing/index.html

The sessions, open to all healthcare personnel and health departments, consist of a 30-40 minute presentation on a stewardship topic followed by open discussion. The first portion of the call will also be recorded and made available on our website for later reference.

Meeting details:

• Dates: the 3rd Wednesday of even months
• Time: 1-2pm MST-Arizona
• Registration Link:
  •  https://us02web.zoom.us/meeting/register/_g--hq48Qsa3O2w3h_fvdg

See the attached flyer for further information regarding our next session, which will be held Wednesday, August 20th.

Input on future topics and speakers is also encouraged via this Google Form.

It is with sadness that we share the passing of Richard Davis, EdD, PA-C Emeritus, DFAAPA, a past president of the Arizona State Academy of PAs (ASAPA), who passed away peacefully on June 15, 2025, at the age of 75.

Dr. Davis was a distinguished leader in the physician assistant profession whose legacy spanned military service, clinical practice, education, and professional advocacy. A proud veteran of the United States Air Force, Rick dedicated 20 years to military service before transitioning into a remarkable career in PA education and healthcare administration.

In Arizona, Rick made a lasting impact as the founding director of the PA program at A.T. Still University. His leadership helped lay the foundation for a program that continues to educate and inspire future generations of PAs. He later served as president of ASAPA, where his vision and advocacy helped shape the state's PA community and promote the profession locally and nationally.

Rick's influence extended far beyond Arizona. At Nova Southeastern University, he served as program director, associate dean, and ultimately dean of the College of Allied Health and Nursing. Under his guidance, the college grew exponentially in both size and scope. His innovative leadership led to the creation of several academic programs and helped expand access to healthcare education across Florida and Puerto Rico. He later served as vice president of the Regional Campus Network at NSU, further amplifying his national impact.

Dr. Davis was widely respected for his mentorship, strategic insight, and unwavering dedication to students and colleagues alike. Whether advocating for veterans through the AAPA Veterans Caucus, serving on the ARC-PA, or guiding PA doctoral students at ATSU in his retirement, he remained committed to advancing the profession and supporting those around him.  Rick's life was grounded in service, purpose, and family. He approached every role, with students, peers, and loved ones, with quiet strength, integrity, and compassion. His contributions to PA education and professional development were matched only by the personal impact he had on those fortunate enough to work with or be mentored by him.

ASAPA is deeply grateful for Dr. Davis's service to our Academy and to the PA profession. He leaves behind a legacy of leadership, innovation, and inspiration that will not be forgotten. We extend our heartfelt condolences to his family and friends.

As of June 5th, 2025, there have been 1,168 confirmed cases of measles reported in the United States and 17 outbreaks.

ADHS recommends that healthcare providers statewide:

• Suspect the diagnosis of measles on patients presenting with fever and rash, especially if unvaccinated, history of domestic travel to an area with a known outbreak or recent international travel.
• Minimize exposures of patients and staff by implementing appropriate infection prevention measures, including the use of well fitting masks, immediate airborne isolation when available or a private room with door closed if unavailable and using the last appointment of the day.
• Immediately report and coordinate specimen collection (nasopharyngeal swab and urine) with the local health department.
• Ensure that patients are adequately vaccinated. Offer the MMR vaccine to those patients who are not immunized.
• Ensure all clinical staff are adequately vaccinated.
•  Healthcare workers should receive two doses of MMR, regardless of year of birth, unless they have documentation of previous immunity.

Measles typically presents in adults and children as an acute viral illness characterized by a prodrome with high fever (>101 °F), cough, coryza, and conjunctivitis followed by a generalized maculopapular rash several days later. The rash usually starts on the face (starting at the hairline), extends down the body, and can involve palms and soles; the rash can be initially faint and become confluent, lasting several days. The rash fades in the same order that it appears. Koplik spots are occasionally seen on examination of the buccal mucosa. Signs and symptoms typically appear 7 to 21 days after exposure.

Measles is highly contagious. Approximately 90% of persons lacking immunity who are exposed to the measles virus will develop the disease. The virus is transmitted by airborne particles or direct contact with the respiratory secretions of an infected person. It can live for up to 2 hours in an airspace where an infected person has coughed or sneezed. Individuals with measles are infectious from 4 days before rash onset through 4 days after rash onset (9 days total).

Additional Resources:

• Navajo County Public Health Services District
• ADHS Measles Surveillance Toolkit
• ADHS Measles Homepage
• ADHS Guide to Laboratory Services: Microbiology
• CDC HAN: Expanding Measles Outbreak in the United States and Guidance for the Upcoming Travel Season
• CDC: Clinical Overview of Measles
• CDC: Measles Vaccine Recommendations
• CDC: Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings

Thank you for your continued collaboration and partnership.

Arizona Department of Health Services

Health and Wellness for all Arizonans

The ASAPA 2025 election results are in!

The results are as follows:

President Elect: Thomas Hartman, DMSc, MS, PA-C

Treasurer: Melanie Lyon, PA-C

Directors at Large:
Tiffany Cooke, DMSc, PA-C & Rob Hoy, MPAS, PA-C

AAPA House of Delegates:
Melinda Rawcliffe, MSPAS, DMSc, PA-C & Clay Walker, PA-C

A big thank you to the candidates for their time and commitment to serve in their new roles starting in July! Congratulations!

Sincerely,

Allyson Hamacher, PA-C
Elections Chair

Please take a moment to look through the spring newsletter attached.  

Syphilis in Arizona: Broadened coverage/reimbursement for syphilis screening and testing under AHCCCS

There is an ongoing syphilis outbreak in Arizona among women and babies. In 2022, Arizona had the third highest rate of congenital syphilis in the United States.

Effective October 2024, the Arizona Health Care Cost Containment System (AHCCCS) updated the Medical Policy Manual (AMPM) to ensure that ALL individuals ages 15 years and above receive annual syphilis screening.  

Testing is based on age alone. All members 15 years and older should be tested at least annually. 

New updates are contained within AMPM 411. III.B.2.b.i page 3, 420. III.B.8 page 4, and 430. III.A.9.c page 5. 

Updated Policies are effective October 1, 2024. 

Key points regarding updated policies: 

• There is no upper age limit 
• Policy applies regardless of sex
• Testing for persons 15 years and older is included, regardless of risk factors and/or rates of infection within the County of residence. 
• Members have the ability to opt-out of testing (like any other testing) 
• There are no changes to existing billing codes or reimbursement rates 
• This screening is outside of existing pregnancy screening requirements, as outlined in AMPM 410

To further prevent and combat maternal syphilis, AHCCCS published a CYE 26 DAP PUBLIC NOTICE including Maternal Syphilis Program (MSP) protocols to ensure that all pregnant individuals receive necessary testing and interventions in hospitals and emergency department settings to promote the health and well-being of both mother and child. 

For additional resources on syphilis prevention, screening and treatment, please refer to:

2021 STI Treatment Guidelines or azdhs.gov/syphilis for updated information on the outbreak.

Summary:

In late January, 2025 the Texas Department of State Health Services reported a measles outbreak occurring in the South Plain region of the state. Outbreak related cases have now been identified in both Texas,  New Mexico, and Oklahoma. To date, 258 cases and 2 measles-related deaths have been reported in Texas, New Mexico, and Oklahoma. 97.7% of reported cases were unvaccinated or had unknown vaccination status.

At this time, Arizona has no confirmed measles cases in 2025. However, given ongoing outbreaks in neighboring states, there is an increased risk of imported measles cases. It is crucial that healthcare providers in Arizona remain vigilant in identifying suspected cases, ensuring timely testing, and reinforcing MMR vaccination, particularly for travelers and communities with lower vaccination coverage.

Background:

Measles typically begins with a prodrome of fever, cough, runny nose, and conjunctivitis that lasts 2-4 days, followed by a maculopapular rash that typically starts on the face and hairline before spreading downward to the neck, trunk, arms, legs, and feet. Severe health complications can occur, including pneumonia, encephalitis, and death. Signs and symptoms typically appear 7 to 21 days after exposure

Measles is highly contagious. Approximately 90% of persons lacking immunity who are exposed to measles virus will develop the disease. The virus is transmitted by airborne particles or direct contact with respiratory secretions of an infected person. It can live for up to 2 hours in an airspace where an infected person has coughed or sneezed. Individuals with measles are infectious from 4 days before rash onset through 4 days after rash onset (9 days total).

Vaccination is the best way to prevent measles. Two doses of the MMR vaccine provide 97% protection against measles. 

Recommendations for Healthcare Professionals: 

Prepare:

Healthcare providers should ensure that all patients without evidence of immunity, particularly those planning international travel, are up to date on MMR vaccination per ACIP recommendations:

• Children should receive two doses of MMR, with the first dose at 12-15 months and the second at 4-6 years (before school entry).
• Adults who are not at high risk of exposure should have at least one documented dose of MMR or other evidence of immunity.
• Adults at high risk of exposure, including students in post-secondary institutions, healthcare workers, and international travelers should have two documented doses of MMR.
• Patients without evidence of immunity who are traveling internationally should plan to be fully vaccinated against measles at least 2 weeks before they depart for travel:
• Infants 6-11 months of age should receive one dose of MMR vaccine before travel. These infants will still need to complete the routine MMR childhood series.
• Children 12 months or older should receive two doses of MMR vaccine before travel, separated by at least 28 days.
• Teenagers and adults without evidence of measles immunity should receive two doses of MMR vaccine before travel, separated by at least 28 days.

Healthcare systems should ensure all healthcare providers have presumptive evidence of immunity to measles, ensure they can rapidly retrieve healthcare provider immunization status in case of exposures and offer postexposure prophylaxis when indicated.

Suspect:

Consider measles as a diagnosis for patients presenting with a maculopapular rash accompanied by symptoms such as fever, cough, runny nose, and conjunctivitis. Extra consideration should be made for patients with no previous MMR vaccine, or with history of international travel or domestic travel to locations with known measles cases. Additionally, providers should consider atypical presentations of measles, especially on some previously vaccinated or immunosuppressed individuals. 

Be aware that some patients recently vaccinated with MMR may develop a mild rash within 3 weeks of vaccination. This usually does not require measles testing or public health intervention since a person with a rash due to a vaccine reaction is not infectious. However, if a recently vaccinated patient has measles-like symptoms accompanied by a known or suspected measles exposure history, consultation and additional testing may be required by the local health department to evaluate for acute measles. 

Isolate:

Suspected measles cases should not remain in public waiting rooms or common areas and should be immediately isolated in an airborne infection isolation room (AIIR), or in a private room with a closed door until an AIIR is available. Whenever possible, healthcare facilities should implement triage procedures to identify and separate suspected measles patients upon arrival. Standard and airborne precautions should always be in place when interacting with a suspected or confirmed measles case.

Report:

Providers should notify their local health department of the suspected measles case within 24 hours. Local public health will work with providers to arrange for specimens to be forwarded to the Arizona State Public Health Lab (ASPHL) for testing.

Test:

Healthcare providers should collect nasopharyngeal or throat swabs and urine specimens from suspected measles cases for testing at the ASPHL. 

• Collection: Nasopharyngeal (NP) or throat swabs should be collected and placed into viral transport media (VTM) or universal transport media (UTM). At least 10mL of urine should be collected.
• Storage & Transport: NP swabs, throat swabs, and urine specimens should be refrigerated at 2-8°C and shipped within 72 hours. If delayed, freeze at -70°C and transport on dry ice
• Turnaround Time: PCR results are typically available within 1-5 days, with serology results in 3-5 days upon receipt by CDC

Manage:

In coordination with local health departments, provide appropriate measles Post-exposure prophylaxis (PEP) to close contacts without evidence of immunity, as soon as possible after exposure, either with MMR vaccine (within 72 hours) or immunoglobulin (within 6 days). The choice of PEP is based on elapsed time from exposure or medical contraindications to vaccination.

Resources:

• ADHS Measles Surveillance Toolkit
• ADHS Measles Homepage
• ADHS Guide to Laboratory Services:  Microbiology 
• CDC HAN: Expanding Measles Outbreak in the United States and Guidance for the Upcoming Travel Season
• CDC: Clinical Overview of Measles
• CDC: Measles Vaccine Recommendations 
• CDC: Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings

Support HB 2134
Arizona House Health & Human Services Committee Hearing

Dear Colleagues,

The Arizona State Association of Physician Assistants (ASAPA) is pleased to announce that our bill, HB 2134, will be heard in the Arizona State House Health and Human Services Committee on Monday, February 10th, at 2:00 p.m.

This bill serves two key purposes:

1. Clarifying Collaboration Language – We aim to amend last year’s bill by removing the term “oversight” from the description of collaboration. This adjustment will eliminate confusion among PAs, employers, the Arizona Regulatory Board of Physician Assistants (ARBoPA), and the Governor’s Regulatory Review Council. The revised language will clearly differentiate collaboration from supervision, facilitating a smoother transition to collaboration status for experienced PAs and ultimately improving access to care for Arizonans.
2. Ensuring Licensure Standards – HB 2134 will codify the requirements for obtaining an Arizona PA license, ensuring that all PAs, including those applying through the Universal Recognition pathway, meet the same rigorous standards. This change will prevent individuals who have been licensed in other states or U.S. territories without completing PA school or passing the Physician Assistant National Certifying Exam (PANCE) from obtaining an Arizona license.

Action Needed: Make Your Voice Heard

We strongly encourage you to contact your legislators to express your support for HB 2134. Legislators need to hear from constituents—not just ASAPA—on the importance of this bill.

You can find your legislators and their contact information by visiting: https://www.azleg.gov/findmylegislator/.

Your advocacy is essential to ensuring the success of this bill and strengthening the PA profession in Arizona.

Thank you for your support!

Best regards,
Carlos Gutierrez EdD, MMS, PA-C
President, ASAPA

My name is Carlos Gutierrez, and I proudly serve as the President of the Arizona State Association of Physician Assistants (ASAPA). Over the past year, ASAPA has been deeply involved in addressing significant issues related to the implementation of the Rules initially established by the regulatory body (the Board) to enforce HB2043. This legislation, co-authored with input from ASAPA, was designed to reduce administrative burdens associated with PA practice in Arizona. Our primary concern centered on the requirement for a signed agreement between a collaborative PA and a collaborating physician or entity for a PA to practice collaboratively after completing 8,000 hours of clinical practice. These Rules effectively mandated a supervision agreement, which we believe misaligned with the legislative intent of HB2043.

In response, ASAPA formally petitioned the Arizona Governor's Regulatory Review Council (GRRC) to void Rules R4-17-402(B-G). On July 30, 2024, the GRRC ruled in our favor, determining that the Rules exceeded the agency’s statutory authority and did not adhere to the requirements of HB2043. Consequently, R4-17-402(B-G) was declared void. Following this ruling, ASAPA promptly notified the Board of our intent to collaborate in crafting Rules that faithfully reflect the legislative intent of HB2043 as a co-author of the bill.

ASAPA is grateful for the Board’s willingness to engage in meaningful dialogue during this post-GRRC rulemaking process. After meeting with the Board in good faith, I submitted the Association’s final endorsed and edited Draft Proposal to the Board’s Executive Director on October 15, 2024. We were pleased to receive confirmation from the Board that they “endorse” the amendments and plan to present the proposal at the Board’s December 4, 2024 meeting with the intention of acceptance.

ASAPA thanks the Board for their cooperation throughout this process. We anticipate the Board will approve the amended Draft Proposal as collaboratively developed, ensuring alignment with the statutory language of HB2043. Details regarding the agenda and location for the December 4, 2024, meeting can be found at AZPA.gov. As the sole advocacy organization for Arizona PAs, ASAPA will have representatives present at the meeting in assuring PAs in Arizona can optimally practice in teams through collaboration.
Thank you for your continued support of Arizona’s PAs and for working together to uphold the integrity of our profession and the legislative process.

Carlos Gutierrez EdD, MMS, PA-C
President
Arizona State Association of Physician Assistants

Join ASAPA today and become a vital part of Arizona's advocacy for PAs! Together, we can strengthen our profession and make a lasting impact. Click here to learn more and sign up.

Healthcare workers who have been present in any healthcare facility, including outpatient settings or traditional healers, in Rwanda within the last 21 days and are returning to the United States will be subject to post-arrival symptom monitoring by local and tribal public health departments in coordination with ADHS. Recommendations include exclusion from all work duties in a U.S. healthcare facility until 21 days after their last presence in a healthcare facility in Rwanda.

Arizona healthcare facilities are encouraged to post contact information for local or tribal public health departments in easily visible locations. Contact your local or tribal public health department immediately if MVD is suspected. The local or tribal health department will provide instructions for further assessment and will work with ADHS to coordinate care and testing for the patient.

Arizona healthcare facilities should be ready to isolate and manage patients with exposure risks and symptoms compatible with MVD until receiving a negative Marburg virus test result on a sample collected ≥ 72 hours after symptom onset. If a sample collected is <72 hours after symptom onset and is negative, the patient should remain in the healthcare facility and another test should be performed on a new sample taken ≥ 72 hours after initial symptom onset.  Patients should be held in isolation at their presenting medical facility and cared for by personnel wearing appropriate PPE, pending test results. If a patient tests positive, the local or tribal public health department will work with ADHS to coordinate transfer to a Regional Emerging Special Pathogens Treatment Center. 

Please share this information with all personnel who might conduct screening and triage activities or be responsible for initial clinical management of patients (e.g., including infection prevention, Emergency Medical Services, outpatient, and Emergency Department personnel). 

General Marburg Information

1. About Marburg Disease | Marburg Virus Disease | CDC
2. History of Marburg Disease Outbreaks | Marburg Virus Disease | CDC
3. Marburg in Rwanda | Travel Notice | Traveler’s Health | CDC

Clinician Resources

1. Clinical Guidance for Ebola Disease | CDC
2. Recommendations for organizations sending U.S.-based healthcare or emergency response personnel to areas with viral hemorrhagic fever (VHF) outbreaks | CDC
3. Viral Hemorrhagic Fevers | CDC Yellow Book 2024
4. Marburg Virus Disease: Interim Recommendations for Public Health Management of U.S.-based Healthcare Personnel Returning from Rwanda

U.S. Healthcare Settings

1. Interim Guidance for Preparing Frontline Healthcare Facilities for Patients Suspected to Have Ebola Virus Disease (EVD) | CDC
2. Interim Guidance for Preparing Ebola Assessment Hospitals | CDC

The high rates of syphilis and congenital syphilis in Arizona continue.  Patients infected with syphilis must receive correct and adequate treatment.  Fortunately, the widespread shortage of treatment options for syphilis is resolving and treatment options are expanding.   

Arizona providers are recommended to: 

1. Resume using penicillin G benzathine as the first line therapy in all persons infected with syphilis. The multi-year benzathine shortage has improved and supply is available.  
• Penicillin G benzathine is still the first-line treatment for syphilis and the only recommended treatment for pregnant people infected with syphilis. 
• Providers can email sti@azdhs.gov if they are experiencing penicillin G benzathine supply issues or distributor caps. 
2. Be aware that the treatment supply of penicillin has been expanded with the FDA-approved importation of Lentocilin©, a Portuguese-manufactured version of penicillin G benzathine. The company will sell the drug at $15 per dose, which may aid providers pre-stocking treatment in their clinic.
• Lentocilin can be ordered by emailing support@toprx.com or by calling 1-800-542-8677. Providers can review the prescribing information prior to placing an order. 

For further clarification, please see the 2021 STI Treatment Guidelines, the CDC webpage on Bicillin availability, or contact sti@azdhs.gov.

I write to you to share an important update regarding the practice of our profession in Arizona. At the Arizona State Association of Physician Assistants (ASAPA), our mission is to advocate for the physician assistant (PA) profession, particularly in navigating legislative and regulatory landscapes.

Recently, ASAPA played a pivotal role in the passage of Arizona House Bill 2043 (HB2043). This legislation permits experienced PAs with at least 8,000 hours of clinical practice to practice medicine without a supervision agreement, provided they collaborate, consult, or refer to appropriate health care professionals based on patient needs and practice policies. The bill was signed into law by the Governor on April 17, 2023. Following this, the Arizona Regulatory Board of Physician Assistants (the Board) was mandated to begin the rulemaking process for the new statute.

ASAPA has been actively engaging with the Board throughout this process. However, recent communications from the Board suggested a misunderstanding regarding our involvement. We would like to clarify that ASAPA has been present and engaged, as documented in the Board's meeting minutes and publicly available video recordings of the sessions on August 17, 2023, and November 9, 2023. Despite these efforts, our representatives and others in attendance were not given the opportunity to provide informed feedback on the new rules due to the timing of public comments during the Board's meetings.

After careful consideration of the rules implemented by the Board for HB2043, which came into effect on December 31, 2023, ASAPA expressed concerns that these rules did not fully align with the legislative intent of the bill. We communicated these concerns to the one of the bill sponsors, the Honorable Arizona House Representative Selina Bliss, who in turn reached out to the Board's Executive Director, Ms. Patricia McSorley, to discuss the intent of the bill. Despite this dialogue, the concerns remained unresolved.

Subsequently, on March 8, 2024, ASAPA felt it necessary to petition the Arizona Governor’s Regulatory Review Council (GRRC) to review and address the rules, which we believed exceeded the Board’s statutory authority and did not align with the intended purpose of the legislation. Specifically, our petition involved [R4-17-402 (B-G)]…promulgated by the Arizona Regulatory Board of Physician Assistants…because the Rules exceed[ed] the Board’s statutory authority, [we]re unduly burdensome, conflict[ed] with the statute, and [we]re unnecessary to specifically fulfill a public health, safety, or welfare concern; and [ASAPA asked that GRRC] declare the Rules invalid.” (Attorneys for Petitioner Arizona State Association of Physician Assistants, 2024). We want to emphasize that ASAPA's objective is to ensure the rules accurately reflect the collaborative framework agreed upon in the bill despite the claims of the Arizona Medical Association (ArMA) who, on April 5, 2024, wrote to Ms. McSorley in displeasure erroneously claiming that our petition was seeking “independent practice” (ArMA, 2024).

We are pleased to inform you that GRRC has reviewed our petition and declared the specific rules in question void, recognizing that they exceed the Board’s authority and are inconsistent with the statute. We extend our gratitude to all who supported this effort, including Rep. Bliss, Council members, and our partners at the American Academy of Physician Assistants (AAPA) and other organizations.

ASAPA remains committed to participating in the new rulemaking process to advocate for accessible and high-quality health care in Arizona. We hope to work collaboratively with the Board to represent our profession effectively and to ensure the best outcomes for our patients.

ASAPA understands that PAs should be legally allowed to practice to the fullest extent of our education and experience and the law, without accusations of scope-creep. Therefore, we encourage you to support our efforts by engaging with the Board and advocating for a collaborative approach to the rulemaking process. You can reach out to the Executive Director of the Board at patricia.mcsorley@azmd.gov.

Another great way to support our work is by joining our organization. We are an organization full of volunteer PAs wanting our profession to progress to better serve our communities. You can join at www.asapa.org

Thank you for your continued support as we strive to advance the practice of PAs in Arizona.

Sincerely,
Carlos Gutierrez EdD, MMS, PA-C
President
Arizona State Association of Physician Assistants

• Consider hantavirus infection for patients with a history of rodent exposure and the following signs and symptoms:
  ○ Early Symptoms: Early symptoms include fatigue, fever and muscle aches, especially in the large muscle groups—thighs, hips, back, and sometimes shoulders. There may also be headaches, dizziness, chills, and gastrointestinal problems, such as nausea, vomiting, diarrhea, and abdominal pain. About half of all HPS patients experience these symptoms. Rhinorrhea and sore throat are absent. Symptoms can be mild and mimic other conditions, so it is important to keep a high level of suspicion if there is a history of rodent exposure. At this stage, hematological findings may reveal thrombocytopenia (low platelet count) and elevated peripheral white blood cell count.
  ○ Late Symptoms (cardiopulmonary stage): Usually four to 10 days after the initial illness, the late symptoms of HPS appear. These include coughing and shortness of breath associated with chest x-ray findings of diffuse airspace disease similar to acute respiratory distress syndrome (ARDS), as the lungs fill with fluid. Hematological findings at this stage include thrombocytopenia, hemoconcentration (elevated hemoglobin and hematocrit), markedly elevated peripheral blood white cell count with pronounced left shift, often with immunoblasts. Elevated liver aminotransferases and low serum albumin may also be seen.
• If HPS is suspected, a chest radiograph and routine blood work, especially a complete blood count, should be obtained. In the context of a rodent exposure, HPS should be strongly considered if the chest x-ray demonstrates diffuse pulmonary infiltrates in association with thrombocytopenia and leukocytosis with left-shift. The patient will require emergency medical care even before diagnosis, and initiating extracorporeal membrane oxygenation (ECMO) at the earliest sign of decompensation has an 80% survival rate.
• Submit serum sample for hantavirus IgM testing at the Arizona State Public Health Laboratory (ASPHL) for high suspect cases instead of testing commercially. Commercially available IgM testing can be false positive and thus should be confirmed at ASPHL.
• Notify local public health regarding suspected hantavirus illness and to coordinate testing at ASPHL.
• Be aware that not all hantavirus infections fit the above criteria. Keeping a high level of suspicion in the context of a high risk exposure (e.g., history of cleaning out a shed with noted exposure to rodent feces) will help minimize missed cases of this potentially fatal infection.

HPS is a severe and sometimes fatal respiratory illness caused by hantaviruses. Hantavirus is spread from rodents (primarily the deer mouse in Arizona) to people through airborne transmission from viral droplets spread through handling or stirring up materials contaminated with rodent urine, saliva or feces. Areas around the home or work where rodents may live (e.g., houses, barns, outbuildings, and sheds) are potential sites where people may be exposed to the virus. Hantavirus is not spread person-to-person. Although cases have historically been found across Arizona, they are most reported in the northern part of the state.

Signs of hantavirus infection usually occur within 1–5 weeks after exposure; however, a faster symptom onset can occur.

For more information visit:
https://www.cdc.gov/hantavirus/hcp/clinical-overview/index.html

Google Meet - Video Link: https://meet.google.com/wzc-wype-kck

Google Meet - Live Stream (For those who cannot join the above Video Link): https://stream.meet.google.com/stream/683cb01d-f228-4613-9e12-01dd2e6536a9

Kevin Kupferer, PA-C, DHSC
President, ASAPA

CDC recommends that providers discuss utilizing doxy PEP with all gay, bisexual, and other men who have sex with men (MSM) and transgender women (TGW) with a history of at least one bacterial STI (specifically syphilis, chlamydia, or gonorrhea) during the past 12 months.

Prescribing Doxycycline as Postexposure Prophylaxis (doxy PEP)

• Screen and treat doxy PEP patients for syphilis, HIV, and multiple sites for chlamydia and gonorrhea at initial visit and follow-up assessment visits.
• Counsel patients about both the benefits and potential harms prior to starting doxy PEP.
• Prescribe 200 mg of doxycycline to be taken within 72 hours (ideally within 24 hours or as soon as possible) after condomless sex.
• Reassess ongoing need for doxy PEP every 3-6 months.

The ADHS Office of HIV & Hepatitis C Services is hosting a webinar:

Doxycycline for the Prevention of Bacterial STIs ("DoxyPEP") on Thursday, June 27th from 12pm-1pm MST. The webinar will include a review of the newly released CDC guidance.

CME is available. Register at this link:
https://us02web.zoom.us/webinar/register/WN_oLLnHygeTA2i9FW4yXoSEQ

APDIC Recommendations for Providers:

• Be alert for patients presenting with serotonergic-like effects, including, but not limited to, seizures, clonus, rigidity, and CNS depression (requiring intubation). 
• Provide supportive care with benzodiazepines, anticonvulsants, antiemetics, and oxygen. 
• Please report cases to the Poison Center (1-800-222-1222) for assistance with patient management and reporting. Poison Centers can also facilitate lab testing.  

APDIC Recommendations for the Public: 

• Individuals should use extreme caution if purchasing “microdosing” products. 
• These products are not FDA-approved, and the ingredients listed may not be accurate. 
• Serious adverse effects, such as seizures, hallucinations, and loss of consciousness, have occurred after ingestion of these products.   

FDA Recommendations for the Public:

• Do not eat, sell, or serve Diamond Shruumz- Brand Microdosing Chocolate Bars until further notice. 
• FDA’s investigation is ongoing.

Sincerely,

Allyson Hamacher, PA-C
Elections Chair

To ensure you receive the reminder emails from Survey Monkey please complete the two step Opt In process.

1. Enter the email used in your ASAPA profile on the Opt In page.
2. Click on the CONFIRM link in the email you receive from Survey Monkey.  

The Arizona Department of Health Services (ADHS) recommends that healthcare providers statewide:

• Maintain a high level of clinical suspicion for meningococcal disease, especially with high risk populations.
• Current increases in disease are disproportionately affecting people ages 30–60 years, Black or African American people, and people with HIV.
• Be aware that patients with invasive meningococcal disease may present with atypical presentations such as sepsis, bacteremia, and septic arthritis.
• Ensure that all people who are recommended to receive meningococcal vaccination, are up-to-date on their meningococcal vaccine, including people at increased risk (e.g., with HIV).
• If meningococcal disease is suspected,
• Start immediate antibiotic treatment for meningococcal disease as this is critical.
• Initiate immediate routine specimen collection for diagnosis, including blood cultures and cerebrospinal fluid (CSF) samples; report and coordinate additional testing with the local health department.
• Order an antibiotic susceptibility test for isolates since some strains (not ST 1466) are resistant to ciprofloxacin.

Meningococcal disease, caused by the bacterium Neisseria meningitidis, is a rare but severe illness with a case-fatality rate of 10–15% even with appropriate antibiotic treatment. Meningococcal disease most often presents as meningitis, with symptoms that may include fever, headache, stiff neck, nausea, vomiting, photophobia, or altered mental status; or as meningococcal bloodstream infection, with symptoms that may include fever and chills, fatigue, vomiting, cold hands and feet, severe aches and pains, rapid breathing, diarrhea, or, in later stages, a dark purple rash. While initial symptoms of meningococcal disease can at first be non-specific, they worsen rapidly, and the disease can become life-threatening within hours.

Four serogroups circulate in the United States (B, C, W, and Y) and all are preventable with vaccines (MenACWY and MenB). MenACWY vaccines are routinely recommended for adolescents and for people with other risk factors or underlying medical conditions, including HIV, complement deficiencies, asplenia and treatment with complement inhibitor medications (i.e. eculizumab). All 11-12 year olds should receive a MenACWY vaccine, and a booster dose is recommended at 16 years of age.

Additional Resources:

• Healthcare providers
• Clinical information | Meningococcal Disease | CDC
• Meningococcal Vaccination: Information for Healthcare Professionals | CDC

•  Everyone
• Signs and Symptoms | Meningococcal Disease | CDC
•  Meningococcal Vaccination | CDC

Thank you for your continued collaboration and partnership.

Arizona Department of Health Services

Health and Wellness for all Arizonans

•          NEW: Screen sexually active individuals aged 15-44 for syphilis annually (adopted from CDC guidance). 
•          NEW: Implement opt-out screening for syphilis for pregnant people and people of childbearing capacity with unknown pregnancy status in Emergency Departments, Urgent Care, and other healthcare and/or outreach settings. In settings where follow-up is uncertain, it is recommended to use a rapid/point of care test and offer same day treatment following a positive result prior to discharge.
•          Updated: Include opt-out screening for syphilis in Emergency Departments, Urgent Care, and other healthcare and/or outreach settings that serve people with addiction/Substance Use Disorder.

Clinicians should continue to: 

•          Screen all pregnant women at first prenatal visit, third trimester, and delivery regardless of risk.
•          Create electronic reminder systems for clinicians to screen for syphilis if there is no documented screening after 1st prenatal visit and/or after 32-week visit.
•          Ensure all positive syphilis screens are followed up with appropriate treatment. Encourage those patients screening positive in the ED or Urgent Care to follow up with their primary care provider for ongoing care.
•          Screen sexually active men who have sex with men (MSM) annually and every 3-6 months if at increased risk.
•          Screen sexually active, HIV positive persons at least annually and every 3-6 months if at increased risk.

If you have any questions regarding the new screening recommendations please contact sti@azdhs.gov.

For more information: 

• 2021 STD treatment guidelines
• 2021 STD Treatment Summary

Confirmed Measles Exposure in Arizona – Suspect, Isolate, and Report

The Arizona Department of Health Services (ADHS) and Maricopa Department of Public Health (MCDPH) identified a confirmed exposure of measles in Maricopa County. MCDPH is working to identify and notify anyone who may have been exposed.

ADHS recommends that healthcare providers statewide:

• Suspect measles as a diagnosis for patients presenting with fever and rash, especially with a history of international travel as cases are on the rise globally.           
• Minimize exposures of patients and staff.  This includes using well fitting masks, immediate airborne isolation when available or using the last appointment of the day.
• Immediately report and coordinate specimen collection (nasopharyngeal swab and urine) with the local health department.
• Ensure that patients are adequately vaccinated. Offer the MMR vaccine to those patients who are not immunized.
• Ensure all clinical staff are adequately vaccinated.
  •  Healthcare workers should receive two doses of MMR, regardless of year of birth, unless they have documentation of previous immunity.

Measles typically presents in adults and children as an acute viral illness characterized by a prodrome with high fever (>101 °F), cough, coryza, and conjunctivitis followed several days later by a generalized maculopapular rash. The rash usually starts on the face (starting at the hairline), proceeds down the body and may include the palms and soles, appears discrete but may become confluent, and lasts several days. The rash fades in the same order that it appears. Koplik spots are occasionally seen.  Signs and symptoms typically appear 7 to 21 days after exposure.

Measles is highly contagious. Approximately 90% of persons lacking immunity who are exposed to measles virus will develop the disease. The virus is transmitted by airborne particles or direct contact with respiratory secretions of an infected person. It can live for up to 2 hours in an airspace where an infected person has coughed or sneezed. Individuals with measles are infectious from 4 days before rash onset through 4 days after rash onset (9 days total).

Additional Resources:

• ADHS Measles website

• ADHS Measles Resources for Health Professionals website

• Maricopa County Department of Public Health Measles website

• CDC Measles for Healthcare Providers website

Thank you for your continued collaboration and partnership.

Arizona Department of Health Services

Health and Wellness for all Arizonans

Thank you,
Arizona Health Alert Network

Ongoing recall of lead chromate-contaminated cinnamon applesauce pouches

Background 

The Arizona Department of Health Services (ADHS) is collaborating with the Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) to investigate a link between high blood lead levels (BLLs) and children consuming certain cinnamon-containing apple purée and applesauce products. Children who have consumed the recalled product and have subsequently been found to have elevated blood lead levels have been identified in multiple states, including Arizona. CDC recommends using the blood lead reference value (BLRV) of 3.5 µg/dL to identify children with BLLs that are higher than most.

Detailed descriptions of recalled products containing lead chromate are listed below. FDA product testing identified high levels of lead and chromium in recalled products. 

Recommendations for Clinicians/Healthcare Providers:

1. Order a venous blood lead test at the earliest opportunity if a child has consumed these products. Refer to ADHS’s Childhood Lead Screening and clinical management recommendations. The American Academy of Pediatrics has also published clinical guidance for managing lead exposure in children.
2. Discuss with parents/guardians the health effects of lead exposure in children. Talk with parents/guardians about the recall due to high lead levels and recommend that they stop serving the products. Most children who have lead exposure are asymptomatic but can be identified through screening.
3. Contact the Childhood Lead Poisoning Prevention Program at healthyhomes@azdhs.gov, to report the cases of individuals with BLLs above the CDC Reference Level (3.5 µg/dL) who reported consuming the product.  
4. Medical treatment for chromium exposure is supportive, as indicated from the clinical presentation. Acute ingestion of chromium exceeding dietary recommendations may result in abdominal pain, nausea, vomiting, diarrhea, anemia, and renal and hepatic dysfunction. There is no specific antidote to treat chromium exposure, and there is no evidence to support the use of chelation therapy.
5. Contact your local poison center (1-800-222-1222) for advice on diagnosing and managing lead and chromium toxicity.

Recalled Products

WanaBana, Schnucks, and Weis brands have voluntarily recalled certain lots of the following products that were tested and found to contain high levels of lead chromate:

• WanaBana brand apple cinnamon fruit purée pouches
• Schnucks brand cinnamon-flavored applesauce pouches
• Weis brand cinnamon applesauce pouches

The recalled products were manufactured after November 2022. The local counties conducted site visits to ensure the recalled products were not sold at Dollar Tree Stores. ADHS has identified a total of 703 cases with a confirmed blood lead level above 3.5 µg/dL, including 163 refugee cases since November 2022.

For more information:

• FDA: Investigation of Elevated Lead Levels: Cinnamon Applesauce Pouches (November 2023)
• CDC: Lead Poisoning Outbreak Linked to Cinnamon Applesauce Pouches
• CDC’s Clinician Outreach and Communication Activity (COCA Now) announcement
• Chromium Factsheet for Health Professionals
• CDC issued the following Health Alert Network (HAN) Health Advisory on November 13, 2023. https://emergency.cdc.gov/han/2023/han00500.asp

Questions?

If you have questions about the treatment guidelines, please contact your local Poison Control. If you want to report a public health case, please contact the Childhood Lead Poisoning Prevention Program at 602-291-9170.

Thank you,
Arizona Department of Health Services

• HB2043 Final Bill
• Board interpretation of amendments
• FAQs from the Board 
• Notice of final rulemaking

ASAPA feels strongly that these rules go against the law passed and the legislative intent of HB 2043, these rules will not allow PA practice to move forward as intended.  HB 2043 and the rules are scheduled to go into effect on December 31, 2023.  ASAPA has worked tirelessly during the rulemaking process to ensure that the rules were acceptable for PAs in Arizona and will continue to do so.  With that, ASAPA is pursuing every avenue possible, including potential legal action, to stop these rules from going into effect. 
 
If you want to reach out to the board regarding these rules, you are encouraged to do so before the end of the year.  The board’s contact information is provided below.
 

• Phone: (480) 551-2700
• Email: questions-noreply@azmd.gov

 
We wanted to send an update regarding sending emails to the board as several people have experienced a bounce back message using the email address listed above.  If your email doesn’t go through to the above address, please re-send your email to patricia.mcsorley@azmd.gov.
 
ASAPA appreciates your help and support as we continue to strive to improve PA practice in Arizona.  Thank you! 
 
Sincerely,
Amanda Shelley, MPAS, PA-C
Legislative Chair, ASAPA

ASAPA has been engaged in the ongoing rulemaking process for the implementation of HB 2043, our PA practice modernization bill, that was passed in the 2023 legislative session.  As you may be aware, part of the success of passing HB 2043 is that it removes the requirement for a practice agreement between physicians and PAs with more than 8,000 hours.  As the Arizona Regulatory Board of Physician Assistants (Board) has developed rules for the implementation of this bill, they have finalized regulations that still require ‘written policies’ regarding collaboration for PAs with more than 8,000 hours.  The detailed requirements that go into these written policies essentially mimic the requirement for a practice agreement, which defeats the progress made with passing HB 2043, thus making the new system more burdensome for PAs and employers. The Board has provided the following information on their website regarding these proposed regulations.

• HB2043 Final Bill
• Board interpretation of amendments
• FAQs from the Board 
• Notice of final rulemaking

ASAPA feels strongly that these rules go against the law passed and the legislative intent of HB 2043, these rules will not allow PA practice to move forward as intended.  HB 2043 and the rules are scheduled to go into effect on December 31, 2023.  ASAPA has worked tirelessly during the rulemaking process to ensure that the rules were acceptable for PAs in Arizona and will continue to do so.  With that, ASAPA is pursuing every avenue possible, including potential legal action, to stop these rules from going into effect. 
 
If you want to reach out to the board regarding these rules, you are encouraged to do so before the end of the year.  The board’s contact information is provided below.

• Phone: (480) 551-2700
• Email: questions-noreply@azmd.gov

ASAPA appreciates your help and support as we continue to strive to improve PA practice in Arizona.  Thank you! 

 
Sincerely,
Amanda Shelley, MPAS, PA-C
Legislative Chair, ASAPA

This email is being sent to update you and provide you with information regarding some important changes to the Physician Assistant Practice Act after the enactment of HB 2043 and effective December 31,2023. HB 2043, (link attached).

The new legislation allows for collaborative practice for licensed Arizona physician assistants who have worked at least 8,000 clinical hours, and who are certified by the Board to work without supervision. The anticipated requirements for certification for collaborative practice are set forth in the attached links, which also includes a link for frequently asked questions (FAQs) and the recently adopted rules for collaborative practice.

The application will be available on the ARBoPA website later in December.

In addition, the new legislation changes the requirements needed in Supervision Agreements between the physician assistant and the supervising physician or the physician's employer. Previously, the law mandated a physician assistant could only perform the health care tasks delegated by a supervising physician, the new legislation allows for a physician assistant to provide “any legal medical service for which the physician assistant has been prepared by education, training and experience and that the physician assistant is competent to perform” including the tasks previously identified in the statute. Health care tasks are no longer required to be specifically delegated by a supervising physician. A Supervision Agreement that describes the physician assistant’s scope of practice and prescribing authority is nonetheless required prior to performing health care tasks.

Please take the time to familiarize yourself with the changes that will become effective on December 31, 2023. If you have any questions for regarding HB 2043, please send an email to:

questions-noreply@azmd.gov and Board Staff will respond.

Patricia McSorley
Executive Director

Arizona Medical Board

Arizona Regulatory Board of Physician Assistants

Background

Based on laboratory confirmed cases, the 2023-2024 RSV season has started in Arizona.

For the 2023–2024 RSV season, the manufacturer of nirsevimab has reported a limited and therefore insufficient supply of 100mg dose prefilled syringes of nirsevimab to protect all eligible infants weighing ≥5 kg. Additionally, supply of the 50mg dose prefilled syringes may also be limited during the current RSV season given current demand.

Of note, there is no reported supply concern of the RSVpreF vaccine (Abrysvo, Pfizer) indicated for pregnant women, 32-26 weeks gestation.

For patients <8 months of age, Arizona clinicians should know:

1. For infants weighing <5 kg, ACIP recommendations are unchanged.  Early administration (ideally in the first week or two of life) before the infant weighs > 5kg will help protect newborns as well as mitigate the shortage of 100mg doses. Encourage parents to vaccinate their children early to avoid missing this window.

• For infants born before October 2023, administer a 50mg dose of nirsevimab now.
• For infants born during October 2023 and throughout the RSV season, administer a 50mg dose of nirsevimab in the first week of life.

1. For infants weighing ≥5 kg, prioritize using 100mg nirsevimab doses in infants at highest risk of severe RSV disease:

• Young infants aged <6 months.
• American Indian and Alaska Native infants aged <8 months.
• Infants aged 6 to <8 months with conditions that place them at high risk of severe RSV disease: premature birth at <29 weeks’ gestation, chronic lung disease of prematurity, hemodynamically significant congenital heart disease, severe immunocompromise, severe cystic fibrosis (either manifestations of severe lung disease or weight-for-length less than 10th percentile), neuromuscular disease or congenital pulmonary abnormalities that impair the ability to clear secretions.

1. Follow AAP recommendations for palivizumab-eligible infants aged <8 months when the appropriate dose of nirsevimab is not available.
2. Do not use two 50mg doses of nirsevimab for infants weighing ≥5 kilograms (≥11 pounds). Since 50mg doses are also in relatively limited supply, these should be reserved for infants weighing <5 kilograms (<11 pounds), to preserve doses for newborns born during the fall and winter season who will be at increased risk for severe RSV illness because of their young age. Furthermore, healthcare providers should be aware that insurers may not cover the cost of two 50mg doses for an individual infant.

For patients 8-19 months of age, Arizona clinicians should:

1. Note that in palivizumab-eligible children aged 8–19 months who are entering their second RSV season, suspend using nirsevimab for the 2023–2024 RSV season. These children should receive palivizumab per AAP recommendations.
2. Continue offering nirsevimab to American Indian and Alaska Native children aged 8–19 months who are not palivizumab-eligible and who live in remote regions, where transporting children with severe RSV for escalation of medical care may be challenging, or in communities with known high rates of severe RSV among older infants and toddlers.

For pregnant women, Arizona clinicians should:

1. Encourage pregnant people to receive RSVpreF vaccine (Abrysvo, Pfizer) during 32 weeks’ gestation through 36 weeks and 6 days’ gestation to prevent RSV-associated lower respiratory tract disease in infants. Only the Pfizer RSVpreF vaccine (Abrysvo) is approved and recommended for use in pregnant people. The GSK RSVpreF3 vaccine (Arexvy) should not be used in pregnant people.
2. Note that either RSVpreF vaccination or nirsevimab immunization for infants is recommended to prevent RSV-associated lower respiratory tract disease in infants, but administration of both products is not needed for most infants.

For more information on the RSV vaccines and therapeutics visit:

• CDC Nirsevimab Recommendations
• ACIP and AAP Nirsevimab Recommendations
• CDC RSV Vaccine Recommendations
• ADHS Blog

Thank you,
Arizona Health Alert Network

Nationwide and within Arizona, the RSV season has been less predictable in its seasonality, which makes it difficult to determine when to begin administering palivizumab (Synagis). 

To aid in your clinical decision making, ADHS is notifying healthcare providers that Arizona is currently seeing an increase in RSV cases. The current increase reflects 3 weeks of rising RSV case counts in Arizona, which in past seasons has marked the start of an RSV surge in hospitalizations, and clinicians should consider the use of palivizumab as a prophylactic regimen in prevention of RSV.

Arizona clinicians should:

• Review the updated AAP guidance on the use of palivizumab.
• Have a low threshold for the initiation of palivizumab for prophylactic use in high-risk pediatric patients.
• Review the ADHS dashboard highlighting RSV trends in Arizona when considering the use of palivizumab.
• If RSV case counts remain high into the spring, the use of palivizumab may be indicated past the usual 5 month series. If this is the case, the AAP will publish further guidance on extended use as deemed necessary.
• Test for RSV in infants that have increased work of breathing or other signs of respiratory distress, and monitor these patients closely, as their clinical course can worsen significantly.  

In addition to infants, children under the age of 4, and older adults are particularly at risk for severe outcomes from RSV. Treatment for RSV remains supportive.

Clinicians should also consider administering the newly approved nirsevimab (Beyfortus), a monoclonal antibody product designed to protect infants and young children at increased risk from severe RSV disease (FDA Announcement). The intramuscular injection is a single dose recommended for all infants younger than 8 months born during or entering their first RSV season. For children between 8 and 19 months, a dose is recommended at the start of their second RSV season if the child is at increased risk of severe RSV. See the CDC’s HAN for more information on the use of nirsevimab and palivizumab this respiratory season.

Thank you,
Arizona Health Alert Network

With summer just around the corner, the Arizona Department of Health Services (ADHS) is preparing for an expected increase in mpox (formerly monkeypox) cases in the coming weeks as people gather for festivals and other events. There have been recent clusters reported in parts of the U.S. even amongst vaccinated individuals, and recently a new infection of mpox was reported in Maricopa County.

Screen your patients at higher risk for acquiring mpox, including gay, bisexual, and other men who have sex with men, and transgender or nonbinary people and persons with HIV regardless of vaccination or travel history. Continue immunizing your patients at risk or anyone who asks to be vaccinated against mpox.

Providers can refer patients to their county health department for vaccination or to obtain free vaccines for their patients.

The mpox vaccine, JYNNEOS, is a two (2) dose vaccine approved for the prevention of smallpox and mpox. The second dose should be given four (4) weeks after the first dose. If more than 35 days has elapsed since the first dose was given, administer the second dose as soon as possible. People who are vaccinated should continue to avoid close, skin-to-skin contact with someone who has mpox because infection may occur in fully vaccinated persons.

A vaccine booster and postexposure prophylaxis (PEP) are not recommended for fully vaccinated persons.

Treatment should be considered for use in people who have severe disease or involvement of anatomic areas that might result in serious sequelae that include scarring or strictures or who are at high risk for severe disease, such as individuals with immunocompromising conditions or people with advanced HIV.

In Arizona, providers can call 1-888-352-0540 to reach the 24/7 Arizona TPOXX Healthcare Provider Clearinghouse to obtain Tecovirimat for their eligible patients as determined by the federal EA-IND requirements. Assistance in determining eligibility is also provided to clinicians, as needed. Report all suspected mpox cases to your local health department.

Here is a link to a TPOXX access flowsheet for Arizona:
https://www.azdhs.gov/documents/preparedness/epidemiology-disease-control/mpox/tpoxx-flow-chart.pdf

Resources Available

Center for Disease Control and Prevention Health Alert Potential Risk for New Mpox Cases
https://emergency.cdc.gov/han/2023/han00490.asp

Arizona Department of Health Services Mpox Page
https://www.azdhs.gov/preparedness/epidemiology-disease-control/mpox/index.php

Arizona Mpox Dashboard (Epidemiological Data)
https://www.azdhs.gov/preparedness/epidemiology-disease-control/mpox/dashboard/

Maricopa County Mpox Resources for Healthcare Providers
https://www.maricopa.gov/5843/Healthcare-Providers

Pima County Mpox Resources for Healthcare Providers
https://www.pima.gov/2066/Resources-for-Providers

ADHS Resources For Healthcare Professionals
https://www.azdhs.gov/preparedness/epidemiology-disease-control/mpox/index.php#healthcare-professionals

Centers for Disease Control and Prevention Resources For Healthcare Professionals
https://www.cdc.gov/poxvirus/mpox/clinicians/index.html

Questions?

Please reach out to Ricardo Fernández by email at ricardo.fernandez@azdhs.gov

Thank you,
Arizona Department of Health Services

May 2023 Outbreak of Cyclosporiasis  - Consider in Differential Diagnosis

Since May 2023, 41 cyclosporiasis cases have been reported to the Arizona Department of Health Services, compared with approximately 4 cases each May and June from the previous four years. Five patients with cyclosporiasis have been hospitalized this year.

Patients in this year’s surge of cases have reported eating romaine lettuce and other fresh produce from area restaurants and grocery stores. The increase in the number of cyclosporiasis cases and a potential association with fresh produce items is concerning. It is important to ensure cases are reported and specimens are tested, which will allow public health officials to collect exposure information and relevant records to identify the source and take proper mitigation measures.

Cyclosporiasis is a GI illness caused by the protozoan, Cyclospora cayetanensis. People become infected with Cyclospora by consuming contaminated food or water. Imported fresh produce, including lettuce, basil, and berries have been linked to past outbreaks in the US in prior years. People living or traveling in countries where cyclosporiasis is endemic may be at increased risk for infection.

Symptoms of cyclosporiasis begin an average of 7 days (range, 2 days to ≥2 weeks) after ingestion of sporulated oocysts (the infective form of the parasite).

Symptoms of cyclosporiasis may include the following:

• Watery diarrhea (most common)
• Loss of appetite
• Weight loss
• Cramping
• Bloating
• Increased flatulence/gas
• Nausea/Vomiting
• Fatigue
• Low grade fever/malaise

Recommendations for Healthcare Professionals

Differential Diagnosis

• Consider cyclosporiasis in the differential diagnosis of acute and/or prolonged diarrhea and suspected protozoal GI illness.
• Patients who report frequent consumption of romaine lettuce or salads from restaurants or stores should be higher on the differential diagnosis.
• Patients with a history of international travel to tropical/subtropical regions are also at increased risk of cyclosporiasis.
• Immunocompromised patients with cyclosporiasis can be at increased risk for complications and may need special consideration.

If cyclosporiasis is suspected:

• Order diagnostic testing for cyclosporiasis including:
• PCR GI panel that includes Cyclospora spp.
• Stool ova and parasites exam 
• Be aware that not all labs will automatically include Cyclospora testing on the O&P panel unless it is specifically requested, and due to intermittent shedding, a single negative stool specimen does not exclude the diagnosis.  Several specimens may be required, especially if diarrheal symptoms persist.
• Request laboratories forward positive Cyclospora specimens to Arizona State Public Health Laboratory for genotyping.
• Ask the patient about relevant exposures, including consumption of fresh (uncooked) produce, and international travel.
• Report the suspected case to the local health agency.

Treatment

• Trimethoprim-sulfamethoxazole (TMP-SMX) twice daily for 7-10 days is the recommended treatment for immunocompetent individuals. Immunocompromised patients may need higher doses and/or longer courses of antibiotic therapy. 
• See the CDC resource page for health professionals for specific dosing guidelines and further information on the treatment of cyclosporiasis.
• See the attached health-care provider FAQ sheet.

If a person ill from cyclosporiasis is not treated, symptoms can persist for several weeks to a month or more. Some symptoms, such as diarrhea, can return; and some symptoms, such as fatigue, may continue after the gastrointestinal symptoms have gone away. While the infection is usually not life threatening, immunocompromised populations are at heightened risk of severe illness. Oocysts take one to several weeks to sporulate dependent upon temperature to become infective, so person to person spread is unlikely.

Source: CDC Cyclospora webpage

Thank you,
Arizona Health Alert Network

This spring Arizona has been experiencing an increase in hantavirus activity. A total of five human cases, including one death, have been reported since April 2023 from four counties. This increase is likely due to the rainy winter recorded in Arizona, which increases vegetation often resulting in higher rodent population. Three of the cases reported in 2023 had Hantavirus Pulmonary Syndrome (HPS).  This is an increase in our usual case rate:  In the last eight years, Arizona has reported 0–4 cases each year, spread across several counties in the state.  

HPS is a severe and sometimes fatal respiratory illness caused by the infection with hantaviruses. Hantavirus is spread from rodents (primarily the deer mouse in Arizona) to people through airborne transmission from viral droplets spread through handling or stirring up materials contaminated with rodent urine, saliva or feces. Hantavirus is not spread person-to-person.

Cases of human hantavirus infection occur sporadically in rural areas of the western United States. Areas around the home or work where rodents may live (e.g., houses, barns, outbuildings, and sheds) are potential sites where people may be exposed to the virus.

Signs of hantavirus infection usually occur within 1–5 weeks after exposure; however, a faster onset of symptoms can occur.

Arizona healthcare providers are strongly encouraged to:

• Collect a serum sample and test for hantavirus IgM for patients with a history of exposure to rodent urine, saliva or feces, and the following signs and symptoms:
• Early Symptoms: Early symptoms include fatigue, fever and muscle aches, especially in the large muscle groups—thighs, hips, back, and sometimes shoulders. There may also be headaches, dizziness, chills, and gastrointestinal problems, such as nausea, vomiting, diarrhea, and abdominal pain. About half of all HPS patients experience these symptoms.  Symptoms can be mild and mimic other conditions, so with history of exposure, it is important to keep a high level of suspicion.
• Late Symptoms (cardiopulmonary stage): Usually four to 10 days after the initial phase of illness, the late symptoms of HPS appear. These include coughing and shortness of breath, and pulmonary changes on chest x-ray as the lungs fill with fluid.
• Be aware that not all hantavirus infections fit the above criteria, including the recent fatality, likely secondary to underlying medical conditions and other patient characteristics. Keeping a high level of suspicion in the context of a high risk exposure (ie. history of cleaning out a shed with noted exposure to rodent feces, for example) will help minimize missed cases of this potentially fatal infection.
• Notify local public health regarding suspected hantavirus illness or to coordinate testing at the Arizona State Public Health Laboratory.
• Advise patients how to control rodent infestations and take precautions (such as airing closed buildings out, wearing a respirator) before higher risk activities that would put them in contact with rodents and/or rodent droppings Activities that kick up rodent dropping-infested dust are particularly high risk.

For more information visit:

https://www.cdc.gov/hantavirus/technical/hps/clinical-manifestation.html

https://www.cdc.gov/hantavirus/technical/hps/diagnostics.html 

Thank you,
Arizona Health Alert Network

With the signing of H.B. 2043, PAs in the Grand Canyon State are now empowered to expand patient care through more modernized, team-based healthcare. In addition to removing the supervision agreement for those PAs with 8,000 or more hours, the legislation will also update who is responsible for the care provided by the PA, allow the Arizona Board of Physician Assistants to determine appropriate regulations for changes in specialty, and allows for direct payment to PAs. The new law will take effect at the end of the calendar year.

“Our bill sponsors, Representative Selina Bliss, Representative John Gillette, and Senator Eva Burch, were instrumental in getting our bill heard and passed through to the governor. I wish to thank past and present legislative advocates Amanda Shelley PA-C, Sarah Bolander PA-C, Jennifer Feirstein PA-C,  Jacob Gubler PA-C, and our entire Legislative Affairs Committee for setting the stage for a successful legislative year.  Additionally, I can honestly say that we could not have passed this bill without the grassroots efforts of our membership. Our team worked tirelessly to ensure lawmakers understand how updated PA practice laws help to address our state's growing needs for access to quality healthcare, especially in rural and underserved communities." ASAPA President Melinda Rawcliffe, MPAS, DMSc, PA-C, said. 

Disclaimer: The Arizona Regulatory Board of PAs is the governing body of the law. ASAPA will not be able to legally advise individuals or companies on the application of the new law.

CDC has reported that STI Programs are struggling to procure enough penicillin G benzathine – the first-line recommended treatment for syphilis. The manufacturer anticipates the issue will be resolved within the next two months. Although supply is available from select wholesalers at this time, ADHS recommends the following strategies for clinics/providers:

• Inventory current supply. If you have less than a two-month supply of penicillin G benzathine and cannot procure more, prioritize treatment with long-acting penicillin G benzathine for infants and persons who are pregnant.
• Continue syphilis screening efforts – cases are continuing to rise among persons under the age of 35 and Arizona has the highest rate of congenital syphilis in the US.
• Doxycycline is a suitable alternative therapy for nonpregnant persons if you have less than a two-month supply of penicillin G benzathine and need to reserve doses for pregnant patients.
• If you have a patient in need of treatment for syphilis but do not have the recommended therapy available, contact your local health department to arrange for treatment.
• Notify ADHS at sti@azdhs.gov, the FDA at drugshortages@fda.hhs.gov, and Pfizer Supply Continuity Team at 844-646-4398 (select 1 and then select 3) if you experience difficulty procuring benzathine penicillin G or other drugs that impact treatment of STIs.

*Additional alternative therapies can be found in the full 2021 STD treatment guidelines and the 2021 STD Treatment Summary chart

Please refer to the FDA website for the latest updates on drug supply availability.

**Missed doses spaced >9 days apart are not acceptable during pregnancy. If a dose is missed or delayed >9 days, the pregnant patient will have to restart the full course of therapy. 

For more information:

• 2021 STD Treatment Guidelines
• 2021 STD Treatment Summary
• CDC Dear Colleague Letter
• Email us at sti@azdhs.gov

Thank you,
Arizona Health Alert Network

Cases of Candida auris (C. auris) have been identified in Arizona. So far this year, 19 clinical cases and 18 screening cases have been reported. Current and previous years’ case counts can be found on the ADHS Disease Data, Statistics & Reports Page. It is important for healthcare providers to quickly identify C. auris in a healthcare environment so that healthcare facilities can take special precautions to stop its spread.

Key Recommendations for Healthcare Providers, Facilities and Staff:

1. Notify the receiving facility or unit of the patient’s C. auris infection or colonization status, including the recommendation of Transmission-Based Precautions. Transfer notification of patients with MDROs is required under AAC R9-6-305. The decision to discharge a patient from one level of care to another should be based on clinical criteria and the ability of the accepting facility to provide care, not on the presence or absence of infection or colonization.
2. Immediately report suspected cases, clusters, and outbreaks of C. auris to your local health department. Work with your local health department to conduct screening of contacts to detect colonized individuals. Ensure specimens get forwarded to the Arizona State Public Health Laboratory for confirmatory testing.
3. Follow standard hand hygiene practices when caring for patients with C. auris. Alcohol-based hand sanitizer is the preferred hand hygiene method for C. auris when hands are not visibly soiled. If hands are visibly soiled, wash with soap and water. Wearing gloves is not a substitute for hand hygiene, but is an important part of contact precautions.
4. Use Contact Precautions to manage patients with C. auris in acute care hospitals and long-term acute care hospitals. Manage residents with C. auris in nursing homes using either Contact Precautions or Enhanced Barrier Precautions.
5. Place patients in a single-patient room while on Contact Precautions. When single rooms are not available, facilities may choose to cohort patients with C. auris together in the same room. Follow recommended practices to reduce transmission in all shared rooms.
6. Clean and disinfect daily and upon discharge or transfer:
1. the patient care environment
2. reusable equipment with recommended products, including focus on shared mobile equipment (e.g., glucometers, blood pressure cuffs)
7. Use an Environmental Protection Agency (EPA) - registered hospital-grade
   disinfectant effective against C. auris (List P). Disinfectants effective against C. difficile spores (List K) may be used for the disinfection of C. auris if other products are not accessible. Follow all manufacturer’s directions and apply the product for the correct contact time.
8. Ensure that your healthcare facility lab is identifying all yeast isolates obtained from a normally sterile site (e.g., bloodstream, CSF) to the species level so that appropriate initial antifungal treatment can be administered based on the typical, species-specific susceptibility patterns.

Arizona public health officials track and respond to each case of C. auris. The Arizona Department of Health Services (ADHS) works closely with local health departments, laboratory partners, and healthcare facilities to identify cases, conduct investigations, and implement containment and prevention measures to reduce the spread.

Key containment response elements may include identifying potentially exposed individuals, coordinating screenings to detect colonization, infection control assessments, and laboratory surveillance. Healthcare facilities are encouraged to reach out to their local health departments if they have any questions. Additionally, the ADHS Office of Healthcare-Associated Infections (HAI) can be contacted at hai@azdhs.gov.

Additional Resources:

1. ADHS Disease Data, Statistics & Reports Page
2. ADHS Candida auris Homepage
3. CDC Tracking Candida auris Page
4. CDC Candida auris Homepage

Thank you,
Arizona Health Alert Network

The Centers for Disease Control and Prevention (CDC) has detected an increase in extensively drug-resistant (XDR) Shigella infections (shigellosis). In 2022, about 5% of Shigella infections reported to CDC were caused by XDR strains, compared with 0% in 2015. XDR Shigella strains are resistant to all commonly recommended empiric antibiotics.

Shigella spp. are transmitted by the fecal-oral route, either directly through person-to-person contact including sexual contact, and/or indirectly through contaminated food, water, and other routes.

• Shigellosis typically causes inflammatory diarrhea that can be bloody and may also lead to fever, abdominal cramping, and tenesmus. Infections are generally self-limiting and usually last 5-7 days.

Recommendations for Healthcare Professionals

Diagnosis

• Consider shigellosis in the differential diagnosis of acute diarrhea, especially for patients at higher risk for Shigella infection, including:

○ Young children
○ Gay, bisexual, and other men who have sex with men (MSM)
○ People experiencing homelessness / people unstably housed
○ International travelers
○ Immunocompromised persons
○ People living with HIV

• If shigellosis is suspected:

○ Ask the patient about relevant exposures and social history, including sexual activity, housing status, and international travel.
○ When ordering diagnostic testing for Shigella, stool culture is preferred for patients who will require antimicrobial treatment.

• If a culture-independent diagnostic test (CIDT) is performed, request a reflex culture if positive.
• If a stool culture is positive for Shigella spp., order antimicrobial susceptibility testing (AST) to inform treatment selection.

Considerations for Sexual Health

Increases in drug-resistant Shigella infections have been described among adult men and may be associated with transmission among MSM. Cases of shigellosis co-occurring with other sexually transmitted infections (STIs), including HIV, have been described among MSM.

• Take a sexual history if shigellosis is suspected.
• People with acute proctitis and concern for sexually transmitted proctocolitis or enteritis should be tested for other STIs, including HIV, syphilis, gonorrhea, and chlamydia at exposed sites.
• Clinicians should encourage all persons with STIs to notify their sex partners and urge them to seek medical evaluation and treatment. Exceptions to this practice include circumstances posing a risk for intimate partner violence.
• Counsel patients to abstain from sex (anal, oral, penile, or vaginal) on days while experiencing diarrhea, and for two weeks afterwards. Patients should closely follow safer sex practices for at least another 2 weeks after resuming sex to prevent the spread of Shigella bacteria that may remain in stool.

Adapted from CDC XDR Shigella HAN. You can find the complete version here.

Thank you,
Arizona Health Alert Network

Please see the attached HAZMAT Spill Clinical Guidance provided by Pima County. The intent of the guidance is to provide a situational update on the hazmat situation that occurred on the I-10 in Pima County as well as to provide clinical guidance to Arizona's medical provider community on potential exposures. The HAZMAT Spill Clinical Guidance shared within this communication is designed for the medical provider community.

Please contact your medical provider, Poison Control at 1-800-222-1222, or the Pima County Health Department Epidemiology team at 520-724-7797 (Option 4) for further information and clinical guidance. Additional clinical information is referenced below.

For updates from the incident’s Unified Command, please visit https://www.azdps.gov/news/ims/92

For updates directly from Pima County www.pima.gov/acidspill

Thank you,
Arizona Health Alert Network

The Arizona Center for Rural Health is looking for experienced and less experienced medication assisted treatment (MAT) providers to participate in the AzMAT Mentors Program. The program is designed to support less experienced MAT providers to increase their capacity to provide MAT services. These are difficult times and providing evidence-based treatment for people with opioid use disorders (OUD) is important and effective.

Please find our flyers attached.

If you have questions, email us at mat-mentors@arizona.edu. Visit our website at https://crh.arizona.edu/mentor. 

Thank you, 

AzMAT Mentors Program
University of Arizona
Center for Rural Health 
https://crh.arizona.edu/

Please take a moment to look through the fall newsletter attached.  

Arizona is currently seeing a spike in RSV cases with over 5 times the number of reported cases compared to the previous five year average.  For the second year in a row, RSV is not following its typical seasonality by starting in late fall and peaking in February. Instead, RSV cases are starting in late summer and early fall, potentially peaking at an earlier date.

With this change in RSV seasonality, there are updated recommendations for the use of palivizumab as a prophylactic regimen in the prevention of RSV.

Arizona clinicians should:

• Review the updated AAP guidance on the use of palivizumab.
• Have a low threshold for the initiation of palivizumab for prophylactic use in high-risk pediatric patients.
• Review the ADHS dashboard highlighting RSV trends in Arizona when considering the use of palivizumab.
• If RSV case counts remain high into the spring, the use of palivizumab may be indicated past the usual 5 month series. If this is the case, the AAP will publish further guidance on extended use as deemed necessary. 

Infants, children under the age of 4, and the elderly, are particularly at risk.  Test for RSV in those infants that have increased work of breathing or other signs of respiratory distress, and monitor these patients closely, as their clinical course can worsen significantly.  Treatment for RSV remains supportive.

Thank you,
Arizona Health Alert Network

The recent multiple measles cases detected in Arizona are a reminder that the disease is still present and unvaccinated individuals are at risk of infection from the virus, especially with increased international travel. This is an opportunity to ensure all healthcare staff are up-to-date on their vaccinations and to remind patients of the importance of vaccinations and encourage unvaccinated or undervaccinated individuals to get up to date on their vaccines.

Healthcare Providers and Facilities Should:

●     Immediately mask and room patients presenting with a febrile rash illness. Place patients in airborne isolation if available or a private room with the door closed if an airborne isolation room is not available; obtain a complete vaccine and travel history.

●     Consider measles as a diagnosis for unvaccinated patients with a febrile rash illness and immediately report this to your local health department.

●     Coordinate with your local health department for specimen collection, transport, and testing for suspected measles cases available through the Arizona State Public Health Laboratory.

○     A urine sample and a nasopharyngeal swab should be collected for PCR testing.

●     Ensure your staff is fully immunized and vaccinate those who are not.

○     Healthcare workers should receive two doses of MMR, regardless of year of birth, unless they have documentation of previous immunity.

●     Encourage unvaccinated and undervaccinated patients to get up-to-date on their vaccines including the MMR.

Resources:

CDC Measles for Healthcare Providers

Measles Infection Control in Healthcare Settings

AZ Measles resources for Health Professionals

Measles Clinician Fact Sheet

Measles FAQs for Providers

Local Health Department Contacts

Thank you,
Arizona Health Alert Network

ASAPA has been actively working on our Optimal Team Practice Bill, and we have been in continued conversations with the physician organizations.  We believe we are very close to an agreement, and our bill, SB 1367, is on the Senate Health and Human Services Committee agenda for this Wednesday, February 16th.  There are still a couple of topics we are negotiating and the bill posted is an early draft that was essentially entered as a 'placeholder' bill. There will be changes to the posted bill that are still in line with what was presented at the OTP town hall we held on January 6^th (presentation attached).

We need all PAs (and physicians if possible) to sign in to support this bill.

You can sign in your support through the Request to Speak system, if you already have an account.

If you do not have an account through the RTS system, our lobbying team, Goodman Schwartz Public Affairs, will sign you up if you complete this form.

Please sign in your support by Tuesday, February 15th, so it can be seen by the time the bill is heard on Wednesday.

Thank you,

Please see the attached Arizona Vaccine News.  The intent of Arizona Vaccine News is to summarize local, national, and international vaccine information that affects Arizona.

Feel free to distribute ADHS' Arizona Vaccine News to any of your partners who may be interested. 

Past issues of Arizona Vaccine News can be found at: https://www.azdhs.gov/preparedness/epidemiology-disease-control/immunization/index.php#news

Thank you,
Arizona Health Alert Network

Oral antiviral medications provided by the U.S. Government are available to eligible Arizona patients infected with COVID-19. These therapies have been shown to decrease severity of disease in high risk patients to help avoid hospitalization or death due to severe COVID-19. They are an extremely important treatment to utilize as we continue to experience this  COVID-19 surge across our state. Both medications have also been shown to be effective against the Omicron variant. These antivirals are available at select pharmacies across the state by prescription only. Given limited federal supply of these therapeutics, availability of these antiviral products may vary at each pharmacy location.

On January 7, 2022, the Arizona Department of Health Services (ADHS) and the Arizona Vaccine and Antiviral Prioritization Advisory Committee (VAPAC) approved the strong recommendation that healthcare professionals utilize tiered prioritization for the use of Paxlovid (nirmatrelvir/ritonavir) and Molnupiravirto help ensure equitable access of these therapeutics for the most vulnerable patients. Given increased supply of these antivirals across Arizona, ADHS has now approved the use of these oral antivirals in eligible patients of both Tier 1 and Tier 2 categories.

Tier 1 eligible patients include:

• Patients 70 years of age or older;
• OR who have major immune suppression (i.e., HIV, severe primary immunodeficiency, cancer and/or transplant patients, or patients on chronic steroids or other immunosuppressive drugs)

Tier 2 expands eligible patients to include:

• Tier 1 and Age 50 years or older with one or more CDC high risk conditions for COVID-19 disease progression. CDC High Risk Health Conditions include (listed alphabetically):
• Cancer
• Chronic kidney disease
• Chronic liver disease
• Chronic lung diseases
• Dementia or other neurological conditions
• Diabetes (type 1 or 2)
• Down syndrome
• Heart conditions
• HIV infection
• Immunocompromised state (weakened immune system)
• Mental health conditions
• Overweight and obesity
• Pregnancy
• Sickle cell disease or thalassemia
• Smoking & Tobacco Use
• Solid organ or blood stem cell transplant
• Stroke or cerebrovascular disease, which affects blood flow to the brain
• Substance use disorders
• Tuberculosis

Full Prioritization Criteria and a pharmacy locator map may be found at Azhealth.gov/antivirals or Azhealth.gov/antivirales (Spanish).

Eligible patients should be started on these antivirals as soon as possible after confirmed diagnosis of COVID-19 AND within 5 days of symptom onset. Prescribers are responsible for determining patient eligibility as outlined in the Emergency Use Authorizations (EUAs) and Health Care Provider Fact Sheets prior to issuing prescriptions for either of these products. There are many clinical considerations including potential drug interactions, reproductive concerns, and dosage adjustments associated with these therapies. 

Health care providers and patients can call 211 or the Arizona Poison Control Systems COVID-19 Hotline (844-542-8201) for locations of pharmacies that were allocated federal supply of these medications nearest them, or visit the ADHS Antivirals for COVID-19 website and map for treatment locations.

For additional questions, email the ADHS COVID-19 Therapeutics Team at therapies@azdhs.gov.

Thank you,
Arizona Health Alert Network

COVID-19 infections are at record levels across Arizona and our state’s health care systems are being severely affected.  Arizona now has access to therapies that can decrease severity of disease in our most vulnerable patients and help them avoid hospitalization or death due to severe COVID-19.  Oral antivirals are available at select pharmacies across the state by prescription only. Please note availability of these antiviral products may vary at each location.

The Arizona Department of Health Services (ADHS) convened the Arizona Vaccine and Antiviral Prioritization Advisory Committee (VAPAC) today.  VAPAC has approved the strong recommendation that healthcare professionals utilize tiered prioritization for the use of Paxlovid (nirmatrelvir/ritonavir) and Molnupiravir in patients meeting the following Tier 1 criteria due to extremely limited supply statewide. 

Tier 1 eligible patients include:

• Patients 70 years of age or older;
• OR who have major immune suppression (i.e., HIV, severe primary immunodeficiency, cancer and/or transplant patients, or patients on chronic steroids or other immunosuppressive drugs)

Full Prioritization Criteria and a pharmacy locator map may be found at Azhealth.gov/antivirals or Azhealth.gov/antivirales (Spanish).

Eligible patients should be started on these antivirals as soon as possible after confirmed diagnosis of COVID-19 AND within 5 days of symptom onset.

Prescribers should ensure patient eligibility as outlined in the EUAs and Health Care Provider Fact Sheets prior to writing the prescription. Please note that there are many clinical considerations including potential drug interactions, reproductive concerns, and dose adjustments associated with these therapies. 

Health care providers and patients can call 211 or the Arizona Poison Control Systems COVID-19 Hotline (844-542-8201) for locations of pharmacies carrying the medications nearest them, or visit the ADHS Antivirals for COVID-19 website and map for treatment locations.

For additional questions, email the ADHS COVID-19 Therapeutics Team at therapies@azdhs.gov.

Thank you,
Arizona Health Alert Network

The Food and Drug Administration (FDA) granted an Emergency Use Authorization (EUA) on December 23, 2021, for the second antiviral called Molnupiravir for the outpatient treatment of mild to moderate COVID-19 in adults 18 years and older who are at high risk for progressing to severe COVID-19, including hospitalization or death.

Pending formal recommendations from the Arizona Vaccine and Antiviral Prioritization Advisory Committee (VAPAC) in the coming weeks, at this time Arizona Department of Health Services (ADHS) strongly recommends healthcare professionals prioritize the use of Molnupiravir in patients meeting the following due to extremely limited supply statewide: 

• Patients 70 years of age or older;
• AND with severe underlying health conditions, (i.e., advanced lung disease, end stage cardiac disease, or those with severe blood or neurological disorders);
• OR who are immunocompromised (i.e., HIV, cancer and/or transplant patients, or patients on chronic steroids for rheumatological conditions)

Eligible patients should be started on Molnupiravir as soon as possible after confirmed diagnosis of COVID-19 AND within 5 days of symptom onset. 

****Limitations of Use for Reproductive Health:****

There are significant precautions related to reproductive health and pregnancy. Medical prescribers should familiarize themselves with the EUA fact sheet for healthcare prescribers before prescribing Molnupiravir.

As initial supplies are severely limited, Molnupiravir is available only in select pharmacies throughout Arizona. Healthcare professionals can call 211 or the Arizona Poison Control Systems COVID-19 Hotline (844-542-8201) for the location of a pharmacy carrying Molnupirarvir nearest them. 

For additional questions, email the ADHS COVID-19 Therapeutics Team at therapies@azdhs.gov.

Thank you,
Arizona Health Alert Network

The Food and Drug Administration (FDA) granted an Emergency Use Authorization (EUA) for the first oral antiviral called Paxlovid (nirmatrelvir/ritonavir) for the outpatient treatment of mild to moderate COVID-19 in adult and pediatric patients age 12 years and older who are at high risk for progressing to severe COVID-19, including hospitalization or death.

Pending formal recommendations from the Arizona Vaccine and Antiviral Prioritization Advisory Committee (VAPAC) in the coming weeks, Arizona Department of Health Services (ADHS) strongly recommends healthcare professionals prioritize use in patients meeting the following due to extremely limited supply statewide:

• Patients 70 years of age or older;

• AND with severe underlying health conditions,  ie. advanced lung disease, end stage cardiac disease, or those with severe blood or neurological disorders;

• OR who are immunocompromised (ie. HIV, cancer and/or transplant patients, or patients on chronic steroids for rheumatological conditions)

Eligible patients should be started on Paxlovid as soon as possible after confirmed diagnosis of COVID-19 AND within 5 days of symptom onset. For those individuals with moderate renal or liver disease, modified dosing may be necessary.

As initial supplies are severely limited, Paxlovid is available only in select pharmacies throughout Arizona. Healthcare professionals can call 211 or the Arizona Poison Control Systems COVID-19 Hotline (844-542-8201) for locations of pharmacies carrying Paxlovid nearest them.

For additional questions, email the ADHS COVID-19 Therapeutics Team at therapies@azdhs.gov.

Thank you,
Arizona Health Alert Network

On December 16, 2021, Governor Doug Ducey signed Executive Order 2021-21 - Enhanced Surveillance Advisory: Monitoring and Preventing the Spread of COVID-19. 

Key provisions of this order include the following:

• Continuance of COVID-19 line list reporting requirements by all licensed hospitals, as defined in Arizona Administrative Code (“A.A.C.”) R9-10-101(108)
• Continuance of hospital reporting through EMResources of ICU beds, ventilators, and ECMOs by hospitals as defined in A.A.C. R9-10-101(108)
• Continuance of reporting of results of all COVID-19 tests by laboratories as defined in A.R.S § 36-451(4) 
• Continuance of COVID-19 vaccine reporting requirements by individuals, healthcare providers, or local health agencies administering COVID-19 vaccines
• Continuance of the Post Acute Care Capacity Tracker reporting for specialized care institutions
• New reporting requirements for hospitals, as defined in A.A.C. R9-10-101, at noon every 24 hours

o   Number of patients pending transfer out of system, greater than 24 hours
o   Number of holds awaiting an inpatient bed
o   Number of intubations performed each day for respiratory distress
o   Number of COVID-19 positive patients or patients with suspected COVID-19 discharged per day 

• Discontinuation of two reporting requirements into EMResource for hospitals, as defined in A.A.C. R9-10-101 (ECMO reporting still required into the ECMO Tracker)

o   Number of ECMOs in use
o   Number of ECMOs available for use

For more information and full reporting requirements, see E.O. 2021-21. 

Thank you,
Arizona Department of Health Services

There is a new dashboard view in EMResource to help facilitate the hospital system’s awareness of where there are open beds. This view highlights the bed availability for the following 8 bed types:

• Adult ICU beds
• Telemetry beds
• Medical-Surgical beds
• PEDS ICU beds
• General PEDS beds
• ED beds
• Psych or behavioral beds
• Other beds (Could include OB beds, recovery beds, or others)

The reporting for each of these fields is for immediately available staffed beds. This view will assist the hospital systems to see where there are available beds to help with potential transfer and situational awareness. 

Each bed availability category can be updated in several ways.

1. Navigate to your hospital’s main summary page “Detail View” and update each of the fields there; or

2. You can click on the key icon (next to your facility’s name) to update your statuses; or

3. Update the data directly in the “Statewide Bed Availability” view

1. You can switch views by hovering your mouse over “View” within the main toolbar and then clicking “Statewide Bed Availability

a. You can make the “Statewide Bed Availability” view your default view by hovering your mouse over “Preferences” in the main toolbar and clicking “User Info”.

i. Click the dropdown for “Default View” and click on “Statewide Bed Availability”

ii. Scroll all the way down to the end of the page and click save

iii. Scroll all the way down to the end of the page and click save

Thank you,
Arizona Department of Health Services

On October 8, 2021, Governor Doug Ducey signed Executive Order 2021-19 - Enhanced Surveillance Advisory: Monitoring and Preventing the Spread of COVID-19.

 Key provisions of this order include the following:

•        Continuance of COVID-19 line list reporting requirements by all licensed hospitals, as defined in Arizona Administrative Code (“A.A.C.”) R9-10-101(108)
•        Continuance of hospital reporting through EMResources of ICU beds, ventilators, and ECMOs by hospitals as defined in A.A.C. R9-10-101(108)
•        Continuance of reporting of results of all COVID-19 tests by laboratories as defined in A.R.S § 36-451(4)
•        Continuance of COVID-19 vaccine reporting requirements by individuals, healthcare providers, or local health agencies administering COVID-19 vaccines
•        Continuance of the Post Acute Care Capacity Tracker reporting for specialized care institutions
•        New Reporting requirements for hospitals, as defined in A.A.C. R9-10-101, with an ECMO program 

 Hospitals with an ECMO program shall report the following to ADHS in a Department-required format* every 24 hours:

•        Number of total ECMO circuits at the facility;
•        Number of ECMO circuits in use at the facility;
•        Number of ECMO circuits available for ECMO candidates;
•        Number of ECMO circuits anticipated to open today;
•        Number of ECMO circuits not reserved, but not able to be used due to staff, supplies, or administrative restrictions; and
•        Number of ECMO candidates on the facility’s waitlist.

*The required format is the ADHS ECMO Tracker, a web-application which has been utilized by ECMO Coordinators since August 2021. Hospital ECMO Coordinators will be notified of this new requirement on the weekly Arizona Surge Line call on Wednesday, October 13, 2021.

For more information and full reporting requirements, see E.O. 2021-19 and ADHS Hospital Reporting Resources.

Thank you,
Arizona Department of Health Services

Arizona’s Record-High West Nile Virus Season: Consider WNV/SLE in your Differential

This year Arizona is experiencing a record high West Nile Virus (WNV) season, especially in Maricopa County.  A total of 96 WNV human cases and 5 deaths have been reported in the state this year (as of 9/17/2021), with more cases being reported each day. This is the highest number of cases for August and September since 2010.  WNV has also been detected in record numbers of Culex mosquitoes collected this year in Maricopa County.

The majority of WNV infections are asymptomatic; however, infections in the elderly and immunocompromised individuals can result in neuroinvasive diseases that can be fatal.

Arizona healthcare providers are encouraged to:

• Consider collecting serum and/or cerebrospinal fluid a week after symptom onset test for both West Nile Virus (WNV) and St. Louis Encephalitis virus (SLE) for patients with the following signs:  

• Nonspecific signs of fever, headache, myalgia, arthralgia, rash, and weakness
• Signs of neuroinvasive disease (meningitis, encephalitis, paralysis, or other acute signs of central or peripheral neurologic dysfunction).

• Notify local public health regarding suspected WNV illness or if there are questions on diagnostic testing.
• Advise patients on how to prevent mosquito bites.

For more information, visit:

https://www.azdhs.gov/preparedness/epidemiology-disease-control/mosquito-borne/index.php

https://www.cdc.gov/westnile/healthcareproviders/index.html

https://www.cdc.gov/sle/technical/symptoms.html

We are the National Society of Black Physician Assistants (NSBPA), an organization whose mission is to, “create a culturally responsible Physician Assistant workforce that adequately represents the diversity found in our world, and focuses on eradication of health disparities, especially in Black communities.”

We are reaching out to inform your members that our mentorship program is seeking qualified PA-Cs to fill mentor roles for our second mentorship cohort that launches in January 2022. The application will be available via this link starting today. Please feel free to share this information widely.

Our mentorship structure is simple – creation of geographically similar “families” consisting of pre-PA students, current PA students, and practicing certified PAs of varying experience levels, who can interact remotely due to current pandemic restrictions (via Zoom, e-mail, and group texts) with the goal of in-person shadowing and interactions in the future. The NSBPA will provide structured events prior to the start, and throughout the mentorship process to ensure expectations and goals are communicated to all participants. This structure will increase accessibility to practicing PAs of color, increase knowledge of the profession and PA school process, and foster a community of support for all participants.

We recognize the lack of diversity in our field and the unique challenges many BIPOC (Black, Indigenous, and People of Color) Physician Assistant students, and practicing PA-Cs, face. We believe an adequately diverse and humanity-driven field supports our mental health and wellbeing, as well as our patients. Please join us.

Questions or concerns? Please email us at theNSBPA@gmail.com or check out our website for more information. 

Sincerely,

The National Society of Black Physician Assistants

Kathryn Reed, PA-C
Founder and President

Helen Gaim, PA-C
Vice President

Mariah Jones, PA-C
Secretary

Erica Williams, PA-C
Media Chair

The COVID-19 pandemic has spurred a tremendous healthcare system response, and the Arizona Department of Health Services thanks you for providing excellent care and medical guidance, and for being a source of immediate healthcare access for Arizona residents. 

 As part of enhancing access to care, given the increasing numbers of COVID-19 cases across the state, we encourage your administration of monoclonal antibody (mAb) products as a readily available post-exposure prophylactic as well as therapeutic option for eligible COVID-19 patients presenting to your facility. Monoclonal antibodies are now available for administration by either subcutaneous injection or as an intravenous infusion. Both sotrovimab and casirivimab/imdevimab are currently recommended by the National Institutes of Health for administration within outpatient care settings. These agents have evidence to suggest that they are effective against several circulating COVID-19 variants, including Delta.

The Food and Drug Administration (FDA) has granted an Emergency Use Authorization (EUA) for the mAb therapeutic agents sotrovimab and casirivimab/imdevimab for treatment of mild/moderate COVID-19 in non-hospitalized patients, due to evidence that both of these therapies can reduce high risk patients’ SARS-CoV-2 viral loads and their risk of COVID-19 disease progression. It is recommended that mAb treatment is initiated as soon as possible after high risk patients test positive for SARS-CoV-2 and within 10 days of symptom onset. 

The FDA has also now expanded that EUA for casirivimab/imdevimab (REGEN-COV) to include post-exposure prophylaxis (PEP) for patients 12 years and older who have been exposed to an individual with COVID-19, and are either not fully vaccinated against COVID-19 or are not expected to mount an adequate immune response due to an immunocompromising condition, and are therefore at risk of progression to severe disease.  PEP is recommended to start as soon as possible after known exposure, ideally within 96 hours.   

In order to enhance the public’s access to mAbs and reduce COVID-19 hospitalizations in Arizona, hospital systems, primary care offices, pharmacies, home health agencies, as well as urgent cares are encouraged to offer administration of these therapeutics, for both treatment and/or as PEP. Facilities may order REGEN-COV without charge from the distributor, AmerisourceBergen, or Sotrovimab directly from GlaxoSmithKline. Demand for these products in Arizona remains lower than expected despite increasing rates of COVID-19, highlighting the need to increase accessibility of COVID-19 therapeutic agents for high-risk patients in our state.  

In conjunction with ASPR/HHS, ADHS is facilitating a webinar for Arizona clinicians to further discuss monoclonal antibody administration in the outpatient setting. 

The zoom webinar is scheduled for Tuesday August 31, at 11am Arizona time, and can be accessed via this link: https://hhsasproea.zoomgov.com/j/1618100479?pwd=Vnh6bzhIa1BEY1IzWUN3LzlKNmtsUT09

Webinar ID: 161 810 0479

Passcode: 570746

We greatly appreciate your efforts to make these therapeutics widely accessible across all Arizona communities.

Resources:  

• NIH: COVID-19 Treatment Guidelines: Anti-SARS-CoV-2 Monoclonal Antibodies 
• HHS: Combat COVID-19 Resources for Healthcare Professionals
• HHS: Monoclonal Antibody Playbook
• IDSA: Guidelines on the Treatment and Management of Patients with COVID-19  
• FDA: Fact Sheet for Providers, Casirivimab/imdevimab EUA 
• FDA: Fact Sheet for Providers, Sotrovimab EUA 
• ASPR: Overview of Direct Order Process for COVID-19 Therapeutics 
• GSK: Ordering Sotrovimab (Section 2)
• Project ECHO: mAbs in Urgent Care Settings
• HHS: Federal Therapeutics Distribution Locator
• HHS: Administering Monoclonal Antibodies for COVID-19 in Your Facility
• HHS: Subcutaneous Injection instructions for Healthcare Providers

Thank you,
Arizona Health Alert Network

 As of April 12, more than 6.8 million doses of Johnson & Johnson (J&J) COVID-19 vaccine have been administered in the United States.  The CDC and FDA are reviewing data involving six reported cases of a rare and severe type of blood clot in women between the ages of 18 and 48 after receiving the J&J vaccine. In these cases, a blood clot called cerebral venous sinus thrombosis (CVST) was seen in combination with low levels of blood platelets (thrombocytopenia).  Until these cases are further reviewed, the CDC and FDA are recommending a pause in the use of the J&J vaccine. This recommendation does not impact the Moderna or Pfizer vaccines.

In Arizona, approximately 122,000 doses of the J&J vaccine have been administered to date.   Out of an abundance of caution and following the recommendations by the FDA and CDC, ADHS recommends a pause in the use of the J&J vaccine until the federal investigative process is complete.

While these adverse events appear to be extremely rare, there are important implications for Arizona providers:

1. If there is concern that an individual may be experiencing CVST or other clot formation (severe headache, abdominal pain, leg pain, or shortness of breath) within three weeks of J&J COVID-19 vaccination, providers are asked to check for low platelets and consider the possibility of blood clots.  Such adverse events should be immediately reported to the Vaccine Adverse Events Reporting System (VAERS).
2. Treatment of CVST is different from the treatment that might typically be administered.  Do not use heparin to treat patients with thrombotic events and thrombocytopenia following receipt of J&J COVID-19 vaccine unless heparin-induced thrombocytopenia testing is negative (platelet factor 4 [PF4] enzyme-linked assay (ELISA)).  See further details in the CDC HAN link below.
3. If providers have J&J vaccine, they should pause administration until federal analysis of the CVST cases is completed, unless vaccination with J&J vaccine appears clinically relevant or necessary. 
4. The CDC and FDA guidance to pause J&J vaccine does not apply to Pfizer and Moderna vaccines.  State and local vaccination sites should continue to provide Pfizer and Moderna COVID-19 vaccines.  All patients who receive COVID-19 vaccines should be encouraged to participate in CDC’s V-SAFE program in order to maintain robust vaccine safety monitoring.
5. Patients who are interested in receiving the Pfizer or Moderna vaccine can be directed to azhealth.gov/findvaccine to make an appointment or find a location offering the vaccines.

The Arizona Department of Health Services appreciates your partnership, dedication to the scientific process and care of individuals.  Updated guidance will be provided as it develops.

References:

• HealthAlert: “CasesofCerebralVenousSinusThrombosiswithThrombocytopeniaafterReceiptoftheJohnson & JohnsonCOVID-19 Vaccine” (CDC.gov)
• JointCDCandFDAStatementonJohnson & JohnsonCOVID-19 Vaccine
• VaccineAdverseEventsReportingSystem (HHS.gov)
• ArizonaCOVID-19 VaccineLocations (ADHS.gov)

Thank you,
Arizona Health Alert Network

Distributed via the CDC Health Alert Network
March 31, 2021, 4:00 PM ET 
CDCHAN-00441

Acute Non-Viral Hepatitis of Unknown Etiology
Potentially Associated with an Alkaline Water Product

Summary

Five cases of acute non-viral hepatitis of unknown etiology in children were reported to the Southern Nevada Health District (SNHD) between November and December 2020. The Centers for Disease Control and Prevention (CDC) is assisting the SNHD in investigating a potential link between these illnesses and the consumption of an alkaline water product called “Real Water” and other possible etiologies. The purpose of this Health Alert Network (HAN) Advisory is to advise clinicians and health departments to have a high index of suspicion for cases of acute non-viral hepatitis and to report any cases to their local health authority.

Background

CDC and the U.S. Food and Drug Administration (FDA) were notified of five cases of acute non-viral hepatitis of unknown etiology in children by the SNHD in Nevada on March 13, 2021. The cases occurred in children ranging in ages from seven months to five years who presented to a hospital between November 10, 2020, and December 3, 2020, with signs and symptoms of vomiting, poor intake, and fatigue. Laboratory testing on the patients showed elevated hepatic transaminases, hyperbilirubinemia, coagulopathy, and a negative viral hepatitis serology panel. All patients required transfers to a pediatric tertiary-care specialty liver unit because of concerns for acute liver failure and the possible need for liver transplantations. All children recovered and were discharged home. In addition to these cases, several adults and other children living in the cases’ households reported similar but mostly less severe symptoms including nausea, vomiting, anorexia, and fatigue.

Information to date from the preliminary epidemiologic investigation supports that there is a strong link between these cases of acute non-viral hepatitis and Real Water alkaline water. Real Water, Inc. owns this brand of alkaline water and has headquarters in Mesa, Arizona. This product is available in 5-gallon, 3-gallon, 1 gallon, 1.5 liters, 1 liter, and 500 ml bottles, and “Real Water” concentrate. Bottles and concentrate products are available for purchase online and in stores nationwide. Real Water has issued a recall on their products. The FDA advises consumers, restaurants, and retailers not to drink, cook with, sell, or serve Real Water alkaline water until more information is known about the cause of the illnesses. Further, FDA advises that Real Water not be given to pets.

Recommendations

For Clinicians

1. Counsel your patients (or their caregivers and guardians) to stop drinking, cooking with, or using Real Water until more is known about the cause of the illnesses per FDA recommendations.
2. Educate your patients on the signs and symptoms of acute hepatitis due to any cause, which may include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-colored stools, joint pain, and yellow skin or eyes; and the importance of seeking medical care.
3. Maintain a high index of suspicion for non-viral hepatitis in your differential diagnosis of acute hepatitis in adults and children presenting with compatible clinical findings.
4. Obtain a more detailed exposure history in patients when you suspect acute non-viral hepatitis. Possible etiologies associated with acute non-viral hepatitis include exposure to medications, contaminated water or food, dietary and herbal supplements, traditional or home remedies, wild-growing mushrooms and plants, and chemicals such as metals, solvents, paint thinners, or pesticides.
5. Obtain early consultation with and/or referral to a gastroenterologist or infectious disease specialist for medical workup and management of patients with signs and symptoms of acute hepatitis.
6. Contact your local health authority to report cases of acute non-viral hepatitis of unknown etiology.
7. Contact your local poison center (1-800-222-1222) for information on chemical or drug-induced liver toxicity and report any cases.

For Public Health

1. Please contact CDC via email (NCEHOutbreak@cdc.gov) for case classification criteria, suggested reporting guidelines, case investigation forms, and other questions. Acute non-viral hepatitis is currently not a nationally notifiable disease. Case findings may be mainly from clinicians reporting who may recognize these illnesses in their patients. The forms provided by CDC will help prepare public health agencies to receive these reports from clinicians.
2. Consider conducting case-finding activities that leverage existing data sources such as hospital discharge data, electronic syndromic surveillance systems, your local poison center, and other applicable surveillance systems. Contact CDC at NCEHOutbreak@cdc.gov for guidance on search criteria.

For More Information

• FDA Investigation
• FDA Case Reporting:
• MedWatch
• Online
• Paper
• FDA Consumer Complaints
• Southern Nevada Health District FAQ
• American Association of Poison Control Centers

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.

____________________________________________________________________________________

Categories of Health Alert Network messages:

Health Alert          Requires immediate action or attention, highest level of importance

Health Advisory   May not require immediate action; provides important information for a specific incident or situation

Health Update      Unlikely to require immediate action; provides updated information regarding an incident or situation

HAN Info Service Does not require immediate action; provides general public health information

Important Reminder about NCCPA Certification

Please keep in mind that NCCPA extended the December 31, 2020 deadline for maintaining certification to March 31, 2021. If you've earned and/or logged CME with the AAPA or PAEA , you must log those credits with NCCPA in order to maintain your certification.  Since you typically take care of certification maintenance at the end of the year, we wanted to make sure you aren't missing important deadlines with NCCPA.

For more information, log onto your NCCPA record at www.nccpa.net.

NCCPA understands that things can happen and have policies in place to help in specific situations. If you need to request an exception to policy (ETP) or extension of certification maintenance requirements, you can sign in to your online record to submit an ETP. For more information visit:  www.nccpa.net/Legal

Outbreaks of Ebola virus disease (EVD) are ongoing in the Democratic Republic of the Congo (DRC) and Guinea. Please share this information with all personnel who might conduct screening and triage activities or be responsible for initial clinical management of patients (e.g., including Emergency Medical Services, outpatient, and Emergency Department personnel).  

Recommendations for Healthcare Facilities:

• Continue to screen and triage everyone entering the facility for signs and symptoms of COVID-19.
• Screen for international travel histories to alert healthcare personnel to the possibility of other communicable infections, such as viral hemorrhagic fevers, that need specific infection control precautions and/or treatment.
• Post contact information for infection control personnel and your local public health agency for reporting of communicable diseases, including EVD, in easily visible locations.
• Understand your role in the tiered network as a Frontline facility.  The State-designated Assessment Hospital is Banner University Medical Center – Tucson.  ADHS, BUMC-T and Pima County Health Department would coordinate transfer to a Treatment Center if needed.
• Have established plans for how suspected EVD patients are to be managed and referred.
• Contact your local public health agency if EVD testing is needed.

Resources:

• CDC Ebola website for clinicians
• Clinically Stable PUIs: Guidance on PPE including donning and doffing procedures
• Confirmed Ebola Patients or Clinically Unstable PUI: Guidance on PPE including donning and doffing procedures
• PPE Calculator Tool 
• National Emerging Special Pathogens Training and Education Center maintains online resources and remains available to provide consultation to hospitals for managing patients with EVD.
• Interim Guidance on Risk Assessment and Management of Persons with Potential EVD Exposure

Thank you,
Arizona Health Alert Network

On December 18, 2020 the CDC published updated guidance entitled ‘Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020’ in the MMWR.

Key points:

1. Treat gonorrhea infections with a single 500 mg injection of ceftriaxone for persons who weigh < 300lbs. For persons who weigh ≥ 300lbs, a 1g injection of ceftriaxone is recommended. 
2. Dual therapy is only recommended for persons who are coinfected with chlamydia.
3. Ceftriaxone is the only therapy recommended for pharyngeal gonorrhea; there are no recommended alternative regimens.
4. As always, facilitate partner testing and treatment.
5. Seven to fourteen (7-14) days after initial treatment, a test-of-cure is recommended for all persons  with pharyngeal gonorrhea regardless of treatment regimen, or if symptoms persist in uncomplicated urogenital or rectal gonorrhea.
6. Three (3) months after initial treatment, test for reinfection. If not possible, retest in 12 months.
7. Please review the full guidance for more information and a list of alternative therapies when ceftriaxone is unavailable or in the case of allergy.

The change from dual therapy to monotherapy was prompted by three main factors:

1. Antimicrobial stewardship and the need to minimize antibiotic exposure unless the benefit clearly outweighs the risk.
2. Further evidence and understanding of ceftriaxone’s pharmacokinetics and pharmacodynamics.
3. Notable decreases in Neisseria gonorrhoeae’s susceptibility to azithromycin.

From the new guidelines:

BOX. CDC recommended regimens for uncomplicated gonococcal infections, 2020*

*CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2015;64(No. RR-3). https://www.cdc.gov/mmwr/preview/ mmwrhtml/rr6403a1.htm.

For more information: Email us at std@azdhs.gov

Thank you,
Arizona Health Alert Network

The following is a notice on data collection requirements for healthcare providers administering the COVID-19 vaccine. 

In accordance with Arizona Executive Order 2020-57 and pursuant to the Enhanced Surveillance Advisory and A.R.S. §§ 36-782(B)(l) and (4), 36-783(A), (D) and (F), and 36-787(A), an individual or local health agency who administers COVID-19 vaccine shall report the following through the Arizona Department of Health Services (ADHS) Vaccine Management Tool or an electronic health reporting system that can report to the Arizona State Immunization Information System (ASIIS) every 24 hours:

1. The individual's name, date of birth, gender, race/ethnicity, residential address, phone number, and vaccine priority group;
2. The vaccine product information, including CVX, dose number, lot number, manufacturer, and expiration date;
3. The route of administration and administration site on the patient's body;
4. The month, day, and year of each immunization;
5. The facility administration site details including facility name, type, and address; and
6. Attest to providing the individual with follow up information if a second dose is required.

For more information and additional healthcare provider resources, please visit azhealth.gov/COVID19Vaccine.

Thank you,
Arizona Health Alert Network

We are excited to announce that COVID-19 vaccine will soon be available for Phase 1A priority populations in Arizona, including health care personnel and EMS providers on the front lines and vulnerable long-term care staff and residents.

Here are some updates as of December 14, 2020:

• On December 11, 2020, the FDA announced that the Pfizer-BioNTech COVID-19 vaccine received emergency use authorization (EUA) for ages 16 years and older.
• CDC has confirmed that a limited number of Pfizer vaccine (~58,000 first doses) will begin shipping and arriving at prepositioning sites in Tucson and Phoenix between December 14-16.
•  A FDA EUA for Moderna’s COVID-19 vaccine is expected to follow this week, with ~189,000 additional vaccine doses scheduled to ship to all Arizona counties the week of December 20.
•  Arizona’s updated COVID-19 Vaccination Plan and VAPAC recommendations will be available at www.azhealth.gov/covid19vaccine. 

While vaccine supplies are limited initially, each county health department will be responsible for implementing vaccination plans within their jurisdiction. In the next week, vaccine information will be available to share from local public health partners to let priority populations know how to determine if they are eligible for Phase 1A and where they can go to receive vaccination.

For more information about COVID-19 vaccination, please visit the following sites which include information and resources on vaccine safety, how to complete pre-screening and sign up for an appointment when vaccine is available:

• CDC: www.cdc.gov/vaccines/covid-19
• ADHS: www.azhealth.gov/covid19vaccine
• Maricopa County: https://www.maricopa.gov/5647/Phase-1A
• Pima County: https://webcms.pima.gov/cms/One.aspx?portalId=169&pageId=669257

As vaccine supplies become available over the next week, additional information about statewide vaccine availability in all Arizona counties will be added to www.azhealth.gov/covid19vaccine.

Thank you to the scientists, health care and government leaders for their tireless efforts to deliver a safe and effective vaccine to the front lines. We appreciate the ongoing efforts of local and tribal health care partners to ensure that vaccines are administered to front line responders, including the most vulnerable Arizonans that are the highest risk for COVID-19. It is important to note that while the historic announcement of COVID-19 vaccine symbolizes a light at the end of the tunnel for the pandemic, public health recommendations to limit disease spread will continue to be crucial until there is demonstrated herd immunity to protect high-risk individuals in our communities.

Thank you,
Arizona Health Alert Network

Due to the Pandemic Onboarding for COVID-19 vaccines, the Arizona Immunization Program Office would like to remind you of the storage & handling requirements for the ultra low temperature vaccine (the Pfizer vaccine that is under FDA review).

Warning: Dry ice must be handled in a ventilated space with proper protective gear. Please find more information on how to handle dry ice below.

Important Notes:

• 1 tray contains 195 vials of ultra low temperature COVID-19 vaccine (the Pfizer vaccine that is under FDA review) with each vial containing 5 doses after dilution (total of 975 doses per tray).

              ○    Sites requesting this vaccine must order a minimum of 1 tray in ASIIS.

• Each vaccine vial contains 2mL of preservative-free COVID-19 vaccine.
• When removed for use from ultra cold temperature storage, the vaccine must be thawed for either 3 hours (in the refrigerator between 2.0°C - 8.0°C) or at room temperature for 30 minutes before dilution to ensure the vaccine is fully thawed.
• Once the vaccine is at room temperature, it must be diluted within 2 hours.
• For dilution, use the 0.9% preservative-free normal saline diluent that will accompany the vaccine shipments.
• When reconstituting vaccine, please gently turn the vial in your hands. Do not shake the vial.
• Once the vaccine is diluted, it must be administered within 6 hours. Discard any unused doses after 6 hours.
• Providers do not need to buy an ultra low temperature freezer.  Please see below for the vaccine storage requirements.

*If you have an ultra low temperature freezer:

• Take out the vial tray(s)  from the thermal shipper and transfer to the ultra low temperature (ULT) freezer using hand protection such as thick gloves or oven mitts.
• Transfer must be done in less than 5 minutes (keep the tray lid closed) to prevent premature thawing of vaccines. 
• The ULT temperature unit should be between -60.0°C to -80.0°C (-76.0°F to -112.0°F).

*If you are going to keep the vaccines in the thermal shipper:

• The thermal shipper can be used to store vaccines up to 30 days (new information).
• When the vaccines are received, reset the data logger contained in the thermal shipper.  This data logger can be used to monitor temperatures for the duration that the shipper is used.
• Once the thermal shipper has been received, the container must be recharged (re-iced) with pelletized dry ice within 24 hours.

             ○    CDC will send dry ice pellets to vaccine recipients for this 1st dry ice recharge.

             ○    Recharging with pelletized dry ice will need to be done every 5 days thereafter.

             ○    To store vaccines in the shipper for up to 30 days, a maximum of 6 recharges with dry ice will be allowed (counting the first re-icing).

• Keep the tray lids closed until vaccines are accessed.  The thermal shipper can only be opened up to 2 times a day for up to 3 minutes each time (new information).
• Return the data logger and thermal shipper to the manufacturer after 30 days or as soon as you stop using the thermal shipper for vaccine storage (new information).

*When moving ultra low temperature vaccine into a refrigerator:

• The vaccines can be stored in the thermal shipper for up to 30 days (if properly re-iced) and then moved to a refrigerator for an additional 5 days (new information).
• When deciding to thaw vaccine, the vaccine vials must be moved from the thermal shipper into the refrigerator within a 5 minute time frame.
• Once thawed, the vaccine vials cannot be refrozen.
• The maximum shelf life of the thawed vials in the refrigerator is 5 days with the temperature between  2.0°C  to 8.0°C (36.0°F to 46.0°F).
• Once the thawed vials are diluted, they must be used within 6 hours.

Safe Handling of Dry Ice
**MISUSE OF DRY ICE MAY BE HARMFUL OR FATAL**

Handling:
Do not let dry ice touch bare skin.  Whenever handling dry ice, use an ice scoop or tongs, insulated (thick) gloves or thick oven mitts, and a face shield/goggles/safety glasses. When handling individual frozen vials, use protective gloves that allow for manual dexterity.
If dry ice comes in contact with the skin or the eye, it can cause an injury similar to a burn.  Prolonged contact with dry ice can cause frostbite which needs immediate medical attention.

Ventilation:
Dry ice must be handled in a well-ventilated space with proper protective gear. Do not use dry ice in confined areas or in rooms without ventilation. If you are transporting dry ice, ensure that the windows are down in the vehicle to allow for ventilation.  Try not to transport dry ice in the cab of a vehicle. Use a container such as a Styrofoam chest with a loose fitting lid for transporting dry ice.

Storage:
Dry ice must be stored in a well-ventilated space. Do notstore dry ice in a confined area, a walk-in refrigerator, or a room without ventilation.If dry ice is left in a confined space, the carbon dioxide gas will displace oxygen and may pose a suffocation hazard. If you are working with dry ice, leave the area immediately if you start to pant or have difficulty catching your breath. This is a sign that you may have inhaled too much carbon dioxide gas. Never store dry ice in an airtight container. Carbon dioxide gas from the dry Ice can build up in an airtight container until the container bursts. Dry Ice needs to be stored in a container that allows for some carbon dioxide escape.

The Immunization Program Office is here to assist you!

Pandemic Provider Training can be completed at this link here.

ASIIS Help Desk: 602-364-3899

Email: ArizonaVFC@azdhs.gov

Thank you,
Arizona Health Alert Network

In recognition of Antibiotic Awareness Week, please find the attached letter from the Arizona Department of Health Services and ASAPA.

Thank you for your continued membership and support.

Jacob Gubler, MMS, PA-C
President Arizona State Association of PAs

• Be the CHANGE Grant – Up to $2,500 Funding available now
• Mental Health Outreach Grant – Up to $1,000 Funding available now
• Oral Health Outreach Grant – Up to $1,000 Funding available now
• Oral Health Integration Grant – Up to $3,000 Funding available now
• Kathy Pedersen Grant to Promote Equitable Care – Up to $5,000 Next cycle opens in 2021

Right now, the need for innovative and creative outreach efforts are greater than ever.  Plus, we offer grant writing tips; and follow us on social media (Facebook, Twitter, Instagram, and LinkedIn) for ideas, announcements, and highlight from grantees. 

Reach out to grants@nccpahealthfoundation.net with any questions.  To date, we’ve funded >100 projects; help us get the word out to grow and showcase PA efforts to improve health in your communities!

The PA History Society continues to diligently work to preserve history.  

Please take a moment to look through the fall newsletter attached.  

MIS-C is a disease associated with COVID-19 that is under investigation by the Centers for Disease Control and Prevention (CDC). The disease causes inflammation (swelling) across multiple body systems, including the heart, lungs, kidneys, brain, skin, eyes and gastrointestinal organs. Some cases may also experience fever, abdominal pain, diarrhea, vomiting, neck pain, rash and tiredness.

Arizona providers should report all suspect cases of MIS-C to their local health department. The Arizona Department of Health Services and local health departments are coordinating surveillance and communication with CDC regarding MIS-C.

A case of MIS-C is defined as: 

• Persons < 21 years of age, AND
• Fever >38∘C for > 24 hours, or report of subjective fever lasting > 24 hours, AND
• Laboratory markers of inflammation (including, but not limited to one or more; an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase, or interleukin 6, elevated neutrophils, reduced lymphocytes and low albumin), AND
• Evidence of clinically severe illness requiring hospitalization, with multisystem (> 2) organ involvement, AND
• No alternative plausible diagnosis, AND
• Positive for current or recent SARS-COV-2 infection by: OR

o    RT-PCR

o    Serology

o    Antigen test

• COVID-19 exposure within the 4 weeks prior to the onset of symptoms 

For more information on MIS-C, please visit the CDC MIS-C website. If you have any questions, contact your local health department.

Thank you,
Arizona Health Alert Network

There is a current national shortage of STI test kits and laboratory supplies. This shortage has mainly impacted the nucleic acid amplification test (NAAT) for chlamydia and gonorrhea (CT/GC). STI screening is important as STIs have been on the rise in Arizona for over a decade and infected persons can be initially asymptomatic. 

Please see the following advised strategies for reducing the use of STI test kits during the shortage:

Strategy 1: Treat persons with any of the following conditions empirically, without testing (as recommended in CDC STD Guidelines 2015): 

• Cervicitis syndrome 
• PID 
• Proctitis
• Contacts to persons that test positive for an STI
  • Expedited partner therapy is legal in Arizona (ARS 32-1401 § (27)(tt)(v)) so partners of persons who have an STI can be offered treatment for chlamydia, gonorrhea, and/or syphilis without testing. 

Strategy 2: Reduce unnecessary screening (as recommended in CDC STD Guidelines 2015and the U.S. Preventive Services Task Force):

• Extra-genital CT/GC screening is not recommended for women
• CT/GC screening is not recommended for asymptomatic men who have sex only with women 
• Though more frequent screening intervals for specific populations (e.g. high risk MSM and MSM on PrEP) is recommended, providers may have to consider reducing the frequency of screening during severe test kit shortages. 

Strategy 3 (ONLY IF NECESSARY, and after contacting your local health department):  Prioritize certain individuals for screening, as recommended by the CDC:

• Chlamydia and gonorrhea screening of asymptomatic individuals
  • Pregnant persons
  • Asymptomatic women
  • Asymptomatic gay, bisexual, and other men who have sex with men (MSM)
    • MSM should be offered screening at all sites of exposure 
    • Consider prioritizing rectal screening above pharyngeal testing if there is a severe testing shortage
  • Persons at increased risk (e.g. those who have a new sex partner, more than one sex partner, concurrent sex partners)
  • Persons taking PrEP
  • Persons with  any of the following conditions:
    • Cervicitis syndrome
    • Pelvic inflammatory disease (PID)
    • Symptomatic urethritis 
    • Proctitis syndrome

If you are experiencing a shortage of tests or have questions, please contact us at std@azdhs.gov. 

References:

• U.S. Preventive Services Task Force 
• https://www.cdc.gov/hiv/clinicians/prevention/prep.html 
• CDC STD Guidelines 2015

Thank you,
Arizona Health Alert Network

Please take a moment to look through the summer newsletter attached.  

David Rueb - ASAPA President 1983

I have to take a minute today and think about a good friend and PA colleague who passed away yesterday from chronic disease. No services are planned. Ashes to be scattered in the Pacific Ocean. A past-President of the Arizona State Association of PAs! An exceptional orthopedic PA. We worked together in an HMO in the early 1980s and at a rural urgent care in the '90s. We worked arm in arm with ASAPA on professional and legislative issues. He was always wonderful to be around. He loved to play pool. In fact, he paid his way through PA school (Baylor) playing pool. He used to kill me at billiards. Had a nice pool table in his house. We spent many a day together at PA conferences, state and national, and he loved the profession. RIP, my friend! I will miss our all-night discussions about gold futures!

Randy Danielsen

The Arizona Department of Health Services was notified by the Food and Drug Administration (FDA) about several hand sanitizing products that have been inappropriately manufactured with methanol. Arizona Poison Control Centers have reported an increase in the number of methanol-related poisonings from hand sanitizers by ingestion and skin exposure.

Alcohol-based hand sanitizers have been marketed heavily during the COVID-19 pandemic as an alternative to washing hands with soap and water. FDA recently advised consumers not to use hand sanitizers manufactured by Eskbiochem SA de CV (made in Mexico), because even though the label may list ethanol they also can contain methanol. The FDA maintains a list of affected hand sanitizers that contain methanol.

The major toxic effects of methanol do not show until methanol is broken down in the body, which may be delayed for 12-24 hours after exposure. These effects can include: drowsiness, headache, vomiting, abdominal pain, visual disturbances, and blurred vision. Consumers who have been exposed to hand sanitizer containing methanol should seek immediate medical care.

If a patient presents with the aforementioned symptoms and has history of exposure to alcohol-based hand sanitizers, Arizona providers should:

● Provide immediate treatment, which is critical for potential reversal of toxic effects of methanol poisoning;
● Immediately call the Poison Control Center at (800) 222-1222.

Arizona providers are encouraged to educate patients on the appropriate use and storage of ABHS to avoid unintentional ingestion and exposures

The Arizona Department of Health Services and local health departments will continue to monitor developments related to this emerging issue. Please continue to check the CDC website for the newest, most reliable information. If you have any questions about reporting, please contact your local health department.

Thank you,
Arizona Health Alert Network

Nominees for PA Student of the Year are students who have demonstrated excellent academic achievement while also participating in community service projects and/or activities that promote the PA profession. Each PA program in Arizona should nominate at least one student for the award. PA students should be in their second year of PA school.

A.T. Still University - Carly "Zoe" Swett
As president of the class of 2020 ATSU physician assistant class, Ms. Carly "Zoe" Swett has dedicated hundreds of hours in addition to her studies to the betterment of her class, her future profession, and her community.  Zoe grew up in Bishop, California and graduated from San Francisco State University with a degree in Human Physiology. Prior to PA school, Zoe worked as a medical assistant for a surgical gynecologist as well as a general surgery practice. She wanted to become a physician assistant to serve to underrepresented and underserved communities.   In order to prepare herself to fulfill this goal, Zoe is completing all of her clinical year rotations this year in the underserved, rural community of Albany, Georgia at Albany Area Primary Health Care.  Prior to PA school, Zoe contributed to underserved international communities in central American providing medical, dental, and public health aid.  This past September, Zoe was selected as a Physician Assistant Education Association's Student Health Policy Fellowship recipient. Zoe was selected from many PA students across the U.S. to attend advocacy training in Washington, D.C. to enhance students' understanding of the political process and health policy with the ultimate goal to inspire and prepare fellows for lifelong grassroots advocacy, both in Washington and at home, to promote the PA profession as an integral part of the health care system.  In her spare time, Zoe enjoys snowboarding, reading, listening to live music and enjoying the outdoors.  When Zoe graduates in August 2020, she would like to work in emergency medicine, urgent care or primary care providing the best care possible to her patients.

Midwestern University - Christopher Klein
Chris has demonstrated the ability to successfully navigate a rigorous academic program as well as to participate in service projects and activities that promote the profession. He is always willing to step up and offer his help with any task. He eagerly and enthusiastically brings his classmates together in his role as class historian. He is a hard worker and has demonstrated a passion for orthopaedics.  He was selected as a finalist for the PAOS Susan Lindahl Memorial Scholarship and submitted a scholarly work for consideration. His drive and motivation are accompanied by a quiet demeanor and an ever-present smile.

Northern Arizona University - Brandon Braaksma
Brandon continuously embodies the perfect blend of superb academic success with notable professionalism. Brandon’s achievement of a 4.0 through the didactic phase of his education was impressive due to the commitment required to master the enormous volume of medical knowledge, all while he maintained his participation with the prestigious Phi Kappa Phi Honors Society. This nationally renowned society promotes academic excellence with service and respect for others, features which are second nature to Brandon. Brandon continues his exceptional performance in the clinical phase of his education. He succeeds in mastering his course of study, all while effectively communicating with faculty, preceptors, and most importantly patients. Brandon’s first rotation preceptor called the school directly to speak to the quality of Brandon’s knowledge, compassion, and professionalism. The preceptor stated that such high-level performance is usually only expected of a student at the end of the clinical year, rather than the beginning. Brandon’s other preceptors have consistently described him as hardworking, organized, and knowledgeable. The NAU PA Program has gained a solid and devoted individual by matriculating Brandon. We are confident he will represent the program, and the profession through the remainder of the curriculum and into his career.

2020 Scholarship Recipients
A.T. Still University - Kelsey Enlow
Midwestern University- Jacqueline Fernandez
Northern Arizona University - Jennifer Gabriel

AAPA and the African Heritage PA Caucus will be hosting two webinar listening sessions for all PAs to listen to and learn from Black PAs and PAs of color, including students, about how racism has impacted and continues to impact their lives and the lives of their patients. Creating shared understanding of these perspectives and experiences, as well as identifying potential solutions, will propel AAPA’s collaborative work to enhance diversity within the PA profession and promote equity and justice in healthcare.

This message is going out to all 118 constituent organizations (COs). COs are getting priority access to register for the Listening Sessions before this opens up to general membership tomorrow.  

To ensure as many people as possible can participate, the first session will be held on Wednesday, June 24 from 8 to 9:30 p.m. EDT, repeating with a second session on Friday, June 26 from 12 to 1:30 p.m. EDT. The Zoom webinars will be able to accommodate up to 5,000 attendees per session.

Susan Salahshor, PhD, PA-C, DFAAPA will facilitate both sessions. Read more about her leadership, professional accomplishments, and commitment to the PA profession.

Please register here: https://www.aapa.org/news-central/listening-sessions/ today and share with your networks before we push this out on AAPA’s social channels on Thursday. We encourage you to register early so you secure a spot.

We hope to have you on the call next week.

Warmly,
Mary Kate

Mary Kate Allee, MPH
Director, Constituent Organization Outreach & Advocacy
AAPA
mallee@aapa.org

The results are as follows:
President Elect: Sarah Bolander, PA-C
Secretary: Elias Villarreal, PA-C
Directors at Large: Amber Herrick, PA-C and Elizabeth Stearns, PA-C
AAPA House of Delegates: Sarah Bolander, PA-C, Jennifer Feirstein, PA-C and Allyson Hamacher, PA-C

Returning Board Members and House of Delegates:
President: Jacob Gubler, PA-C
Immediate Past President: Kirsten Bonnin, PA-C
Treasurer: Michelle DiBaise, PA-C
Directors at Large: Jeannette Vaughn-Dotterer, PA-C
AAPA House of Delegates: Melinda Rawcliffe, PA-C and Elicia Hunt, PA-C

A big thank you to the candidates for their time and commitment to serve in their new roles starting in July! Congrats!

Sincerely,

June 5, 2020

AAPA Supports the Black Community and Pledges to Combat Racism

We at AAPA are appalled by the killing of George Floyd and the disturbing pattern of continued violence and discrimination against the Black community. These events, along with passionate messages from PAs and PA students, have propelled us to reflect more deeply on how AAPA can better exemplify the values of the PA profession, now and in the future.

All PAs uphold as their primary responsibility the health, safety, welfare, and dignity of all human beings. This absolutely includes Black lives, which have been jeopardized for more than 400 years. Racism is fueling a public health crisis in our country. We greatly admire and respect the PAs and PA students who are bravely working to eliminate racism. Now AAPA must better support our members in achieving this goal.

AAPA will begin building a comprehensive strategy to do our part to eliminate racism and explicit and implicit bias while promoting equity and justice in healthcare. We know this endeavor deserves more time, collaboration, and attention. But to start, we feel strongly that Black PAs and PA students, and the allies that support them, must be heard.

This month, we will host professionally facilitated online sessions for all PAs and PA students, engaging our constituent organizations that represent people of color. Our goal is to listen, create shared understanding, build trust, and build respect that will make our organization and profession stronger and more effective. We will share details as soon as they are available.

Together, and in partnership with our sister PA organizations, we will identify ways in which AAPA can be of service and take action. These include, but are not limited to, advocating to eliminate health disparities, recruiting Black applicants to the PA profession and developing resources to overcome professional challenges, instituting corporate best practices to address implicit bias and racism, engaging more Black PAs and other PAs of color in volunteer leadership opportunities, and working with the PA Foundation to establish scholarship opportunities for Black PA students.

This is not the end of the conversation but the start. We pledge that AAPA’s work will better reflect the values of the PA profession and that we will move forward with openness and kindness as we seek out every opportunity to listen. This week we have heard many of your voices, and we are thankful.

Please take a moment to read their attached spring newsletter.  

A pediatric multi-system inflammatory syndrome has recently been reported in the United Kingdom and New York City that may be linked to COVID-19. Clinical features of this syndrome have been noted to include features of Kawasaki disease or shock; persistent fever and elevated inflammatory markers (CRP, troponin, etc.) have been seen among affected patients. Reportedly, many of these children have tested positive either for COVID-19 or for its antibodies.

If the above-described inflammatory syndrome is suspected, Arizona providers should immediately:

• Refer patients to a specialist. Appropriate specialties may include pediatric infectious disease, rheumatology, and/or critical care. Early diagnosis and treatment of patients meeting full or partial criteria for Kawasaki disease is critical to preventing end-organ damage and other long-term complications. Patients meeting criteria for Kawasaki disease should be treated with intravenous immunoglobulin and aspirin.
• Consider COVID-19 testing.  Many pediatric patients with this syndrome did not show respiratory symptoms, yet tested positive for COVID-19 or its antibodies.
• Report suspected cases of Kawasaki Disease-like Syndrome to local public health.  Real-time surveillance of this is critical to public health understanding and recommendations.

The Arizona Department of Health Services and local health departments will continue to monitor developments related to this potentially new syndrome. Please continue to check the ADHS website and the CDC website for the newest, most reliable information. If you have any questions about reporting, please contact your local health department.

Thank you,
Arizona Health Alert Network

The Food and Drug Administration (FDA) has reported a national shortage of azithromycin. Although supply is available from select wholesalers at this time, ADHS recommends judicious prescribing to maintain adequate supply:

• Only prescribe azithromycin for conditions that need to be treated with azithromycin. Consider alternative treatment regimens as clinically indicated.
• Notify ADHS at std@azdhs.gov  and the FDA at drugshortages@fda.hhs.gov if you experience difficulty procuring azithromycin or other drugs that impact treatment of STIs.
• If you have a patient in need of treatment for an STI but do not have the recommended therapy available, contact your local health department to arrange for treatment.
• If you have less than a three week supply of azithromycin and cannot procure more, consider using an alternative therapy for the following STIs described below and reserve azithromycin for women who are pregnant.
• Doxycycline is not a suitable alternative therapy for pregnant women.

*Additional alternative therapies can be found in the full 2015 STD treatment guidelines and the 2015 STD Treatment Summary chart

Please refer to the FDA website for the latest updates on drug supply availability.

For more information:

• 2015 STD treatment guidelines
• 2015 STD Treatment Summary
• CDC Dear Colleague Letter
• Email us at std@azdhs.gov

Thank you,
Arizona Health Alert Network

Elective Surgeries To Resume May 1 For Health Care Facilities That Meet Preparedness Standards

PHOENIX⁠ — With hospitals reporting increased availability of personal protective equipment (PPE) and bed capacity, Governor Ducey today issued an Executive Order removing restrictions on conducting elective surgeries for hospitals, health care facilities and providers that meet certain preparedness criteria.

Under the new order, hospitals, dental offices and other health facilities can resume conducting elective surgeries on May 1 if they can show they have implemented measures intended to keep health care workers and patients safe. These include:

• Demonstrating greater than a 14 day supply of PPE;
• Ensuring adequate staffing and beds;
• Testing patients prior to surgery and all at-risk health care workers;
• Ensuring appropriate discharge plans for patients being transferred to nursing care facilities, including diagnostic testing for COVID-19;
• Implementing a universal symptom screening process for staff, patients, and visitors;
• Establishing an enhanced cleaning process for waiting areas;
• And prioritizing the restart of elective surgeries based on urgency.
  

Facilities that meet the specified standards will need to receive approval from the Department of Health Services before resuming elective surgeries. The order shall be considered for repeal or revision every two weeks.

“Hospitals around the state have stepped up to provide additional protections for their staff and patients and increased bed capacity to prepare for a possible COVID-19 surge,” said Governor Ducey. “Because of these preparations, and the responsible actions of Arizonans across our state, data shows our health system continues to remain ahead of the curve. Today’s order continues to prioritize public health while improving access to care for Arizonans and the overall viability of our health care system.”

“The Arizona Department of Health Services has worked closely with our health care providers as they’ve expanded capacity and overall preparedness to prepare for a potential surge in COVID-19 cases,” said Dr. Cara Christ, Director of the Department of Health Services. “Today’s order ensures that adequate protections remain in place as health care facilities expand operations and that public health remains our top priority.”

On March 19, Governor Ducey announced new actions to help preserve hospital equipment and protective gear, including suspending elective surgeries. A week later, the Governor issued an Executive Order requiring hospitals to increase the amount of hospital bed capacity in the state, take steps to optimize staffing levels and maximize critical resources. Expanded reporting requirements have helped the Department of Health Services track capacity and availability of resources.

As hospitals and emergency departments hit a critical surge of ill patients, Emergency Medical Services (EMS) can keep medically appropriate patients at home or refer patients to alternative destinations to decrease the burden on acute care settings. On April 4, 2020, the State Disaster Medical Advisory Committee approved the implementation of the Treat and Keep Home and Treat and Refer guidelines. These strategies will reduce the number of patients seeking medical care at hospitals when hospitalization is not clinically necessary.  

The Arizona Department of Health Services recommends that healthcare providers and healthcare facilities do the following: 

• Familiarize yourself with the guidelines available under Treat & Refer Resources on the EMS and 9-1-1 Resources. 
• Share this HAN with healthcare partners across the healthcare spectrum, including hospitals, urgent care facilities, doctors’ offices, and all levels of long term care facilities.
• Partner with your local EMS agencies in implementing these guidelines, as they will help decrease the burden on the acute care settings, conserve PPE, and limit further risk of spread of COVID-19.

Please contact the Bureau of EMS & Trauma System at EMSCOVID@azdhs.gov with questions regarding Treat & Refer.

Thank you,
Arizona Health Alert Network

April 10, 2020

Arizona PAs,

As a follow-up to our last communication (3/31/20), we would like to update you on the Association’s activities as it relates to the COVID-19 public health emergency.  As previously cited, prior to COVID-19, Arizona was one of only 14 states that waived physician supervision requirements for PAs during emergencies or disasters (Arizona Revised Statues 32-2535).  ASAPA leadership has been working closely with our lobbyist team and the Arizona Regulatory Board of PAs (ARBoPA) for clarification of this statute to determine if any process needed to be followed in order for it to be enacted. 

ASAPA provided public comments during the ARBoPA teleconference meeting on April 2, as they considered recommendations to submit to the Arizona Department of Health Services (ADHS) regarding PA licensing as it relates to responding to the current COVID-19 crisis. 

ASAPA has also been in communication with both the Governor’s Office and the ADHS requesting their prompt approval of the ARBoPA request to allow PAs to practice without supervision, as provided in A.R.S 32-2535. 

We are pleased to report that as of April 10, ARBoPA has released the following statement which has been approved by the appropriate authorities:

TEMPORARY LICENSURE FOR PHYSICIAN ASSISTANTS DURING THE COVID-19 STATE OF EMERGENCY AND WAIVER OF SUPERVISION REQUIREMENT FOR LICENSED PAs

The Arizona Regulatory Board of Physician Assistants announces the following available temporary emergency licenses for Physician Assistants (PAs) to practice in Arizona and the waiver of certain requirements during the COVID-19 State of Emergency:

• PAs licensed in another state are eligible to apply for temporary licensure in the State of Arizona using the emergency temporary licensure application. The application fee is waived and, if granted, the PA licensed in another state may practice in Arizona without physician supervision for the duration of the State of Emergency.
• For PAs currently licensed in the State of Arizona, the requirement to have a written delegation agreement with a supervising physician during the State of Emergency is waived for those PAs wishing to providing care in response to the State of Emergency.
• Recently graduated PAs, who have not yet taken and passed the PANCE, may apply for a temporary emergency license; however, the requirement to practice pursuant to a signed delegation agreement with an Arizona licensed Supervising Physician remains in effect.

Additionally, we would like to commend Governor Ducey, for proactively including the PA profession in the “Good Samaritan Order” released on April 9.

We would like to thank Arizona PAs for their support and patience as we worked with the appropriate entities to address the need for PAs to practice medicine without administrative barriers during a time of emergency. 

We hope you are all staying healthy as you navigate the many demands of your personal and professional lives during these unprecedented times.  We cannot thank you enough for contributing to the health of Arizona, and the nation, as we know some of you may be redeploying to other states in response to their public health needs.

Sincerely,

Arizona State Association of Physician Assistants Leadership

Please see below the attached Arizona Vaccine News.  The intent of Arizona Vaccine News is to summarize local, national, and international vaccine information that affects Arizona.

Feel free to distribute ADHS' Arizona Vaccine News to any of your partners who may be interested. 

Past issues of Arizona Vaccine News can be found at: http://www.azdhs.gov/phs/immun/vacNews.htm

Thank you,
Arizona Health Alert Network

In response to the COVID-19 pandemic, the Arizona Department of Health Services (ADHS) has convened the State Disaster Medical Advisory Committee (SDMAC).  On April 1, 2020, guidance for crisis staffing in short-term acute care facilities, healthcare staffing, and pre-hospital triage was approved.  

These measures will ensure we provide the best possible care and preserve capacity within our hospitals.

Recommendation: Acute Care Facilities should identify Triage Officer(s) and a Clinical Care Director. 

In order to operationalize the SDMAC recommendations, short-term inpatient acute care facilities will need staff available to review, coordinate and implement the rapidly changing, crisis-level guidance.  Triage Officer(s) will also be needed, ideally at the facility level, to implement the approved triage plans. Job Action sheets in the Arizona Crisis Standards of Care Plan are available.   

Recommendation: EMS should communicate contingency status, changes in transportation, and consider changes in deployment strategies.

The Arizona Office of 9-1-1 should distribute guidance to all PSAPS on how to communicate to callers that transport decisions will be based on the EMS assessment. In mild or moderate cases, patients may be permitted to stay at home with guidance or transported to an alternative destination.

The ADHS Bureau of EMS and Trauma System should communicate to all Arizona EMS agencies that the clinical and operational status of the Arizona healthcare system is anticipated to shift from contingency to crisis status as COVID-19 continues to spread and impact hospital surge capacity. EMS agencies should implement Treat-and-Keep-Home and Treat-and-Refer-to-Alternate-Care-Site guidelines, and fire-based EMS agencies should consider deployment strategies to increase utilization of 2-person response units for the next 60 days.  EMS agencies should implement the SDMAC approved guidelines specific to the management of patients with suspected COVID-19.

Recommendation: Facilities should develop and implement expanded staffing plans.

Healthcare organizations should establish expanded staffing plans that could integrate alternative healthcare staffing resources into their current model.  In addition, healthcare organizations should develop protocols for rapid, immediate onboarding of additional healthcare staff in their facility. Healthcare organizations should also develop just-in-time training for healthcare workers to provide care in departments outside of their own, under the supervision of a clinical supervisor.

More information on the SDMAC and the guidance reported here can be found on the ADHS website for SDMAC.

Thank you,
Arizona Health Alert Network

If you are a healthcare provider with an active license, a public health professional, member of a medical disaster response team, or non-health community volunteer willing to be on-call to support Arizona in the event of a disaster - help support public health emergency preparedness and "Register Today."

Statewide registration is available for "The Arizona Emergency System for Advance Registration of Volunteer Health Professionals (AZ-ESAR-VHP)," local "Medical Reserve Corps Units," "General Volunteers," and/or additional "Specialty Teams."

For more information and to register visit: https://esar-vhp.health.azdhs.gov/

We would like to start this message with a heartfelt thank you to all of the PAs on the front lines practicing medicine during the COVID-19 public health emergency.  We also appreciate the challenging work facing PA educators in the state of Arizona, as they work toward graduating more PAs with as little disruption as possible. 

We have received many inquiries from PAs regarding how ASAPA is responding, and what efforts are being made to ensure PAs can provide medical care in response to this emergency.  We are very fortunate in Arizona to have a PA practice act with minimal restrictions, and one that largely allows for PAs to practice medicine to their full scope of training and competence.  Additionally, prior to COVID-19, we were one of only 14 states that waived physician supervision requirements for PAs during emergencies or disasters (Arizona Revised Statues 35-2535).  ASAPA leadership has reached out to the Arizona Regulatory Board of PAs (ARBoPA) for clarification on this statue, and whether any official process needs to be followed in order to practice medicine without supervision under this law.  It is our hope that ASAPA and/or ARBoPA will be providing this clarification by the end of the week.

On a federal level, many of you have probably heard that CMS has announced expanded Medicare telehealth coverage; additionally, federal COVID-19 emergency legislation (the CARES act) has passed, permanently authorizing PAs to order home healthcare services for Medicare patients.  More locally, in Arizona, Governor Ducey has passed the following executive orders, which specifically impact PA practice:

• March 25, 2020 – The Governor issued an executive order requiring health care insurance companies to expand telemedicine coverage for all services that would normally be covered for an in-person visit.
• March 26, 2020 – The Governor issued an executive order with the following provisions:
  • State agencies and boards will defer requirements to renew licenses that have an expiration date between March 1, 2020 and September 1, 2020 by six months from the expiration date;
  • State agencies and boards will suspend any rules that prevent or limit the amount of online or alternative learning hours permitted to issue or renew a license; and
  • State agencies and boards will issue provisional licenses to applicants who have met all other requirements of Arizona statute and administrative code but cannot take the exam remotely.

The American Academy of PAs has done a tremendous job keeping current, relevant resources available on their website (AAPA COVID-19 Resource Center); we encourage you to visit this site frequently.  Additionally, access to the most up-to-date recommendations regarding managing and treating COVID-19, along with recommended guidelines for health care providers, can be found on the CDC website.

Sincerely,

Arizona State Association of Physician Assistants Leadership

Dear Partner,

As you may have seen, Governor Ducey signed an executive order to issue an enhanced surveillance advisory related to COVID-19. Pursuant to  A.R.S. § 36-782(D).

Key provision of this order include the following:

• Pursuant to the Enhanced Surveillance Advisory and A.R.S. §§ 36-782(B)(1) and (4), 36-783(A), (D) and (F), and 36-787(A), a hospital, as defined in Arizona Administrative Code R9-10-101, shall report the following through EMResource or alternative form to the Arizona Department of Health Services every twenty-four hours:
• Per day staff call out;
• Number of ventilators in use;
• Number of ventilators available for use;
• Number of ICU beds in use;
• Number of ICU beds available for use;
• Number of inpatient beds in use;
• Number of inpatient beds available for use;
• Number of ED beds in use;
• Number of ED beds available for use;
• PPE shortage (N95, surgical masks, gowns, etc.);
• PPE surplus (N95, surgical masks, gowns, etc.):
• Medical supply and equipment shortage (medications, fluids, O2 tanks, sanitizer, ECMO circuits, etc.); 
• Medical supply and equipment surplus (medication, fluids, O2 tanks, sanitizer, ECMO circuits, etc.): and
• Description of triage process currently established

Please ensure you are updating EMResource daily by 12:00pm. This is a critical surveillance tool for the current response and accurate numbers are crucial for federal assistance and statewide situational awareness.  

Attached is a toolkit for your reference.  
EMResource Link: https://emresource.juvare.com/login  

For any questions or assistance, please email: Amanda.Lusk@azdhs.gov and Cody.Curl@azdhs.gov

Thank you,
Arizona Department of Health Services