Occupational exposure to body fluids among health care workers in Georgia

BACKGROUND

Health care workers (HCWs) are at increased risk of being infected with blood-borne pathogens.

AIMS

To evaluate risk of occupational exposure to blood-borne viruses and determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among HCWs in Georgia.

METHODS

The sample included HCWs from seven medical institutions in five cities in Georgia. A self-administered questionnaire was used to collect information on demographic, occupational and personal risk factors for blood-borne viruses. After obtaining informed consent, blood was drawn from the study participants for a seroprevalence study of HBV, HCV and HIV infections.

RESULTS

There were 1386 participating HCWs from a number of departments, including surgery (29%), internal medicine (19%) and intensive care (19%). Nosocomial risk events were reported by the majority of HCWs, including accidental needlestick injury (45%), cuts with contaminated instruments (38%) and blood splashes (46%). The most frequent risk for receiving a cut was related to a false move during a procedure, reassembling devices and handing devices to a colleague. The highest proportion of needlestick injuries among physicians (22%) and nurses (39%) was related to recapping of used needles. No HIV-infected HCW was identified. Prevalence of HCV infection was 5%, anti-HBc was present among 29% with 2% being HBsAg carriers.

CONCLUSIONS

Data from this study can be utilized in educational programs and implementation of universal safety precautions for HCWs in Georgia to help achieve similar reductions in blood-borne infection transmission to those achieved in developed countries.

A mammaglobin-A targeting agent for noninvasive detection of breast cancer metastasis in lymph nodes

Pathologic axillary lymph node (ALN) status is an important prognostic factor for staging breast cancer. Currently, status is determined by histopathology following surgical excision of sentinel lymph node(s), which is an invasive, time consuming, and costly procedure with potential morbidity to the patient. Here, we describe an imaging platform for noninvasive assessment of ALN status, eliminating the need for surgical examination of patients to rule out nodal involvement. A targeted imaging probe (MamAb-680) was developed by conjugation of a mammaglobin-A-specific monoclonal antibody to a near-infrared fluorescent dye. Using DNA and tissue microarray, mammaglobin-A was validated as a cell-surface target that is expressed in ALN-positive patient samples but is not expressed in normal lymph nodes. In vivo selectivity was determined by i.v. injection of MamAb-680 into mice with mammaglobin-A-positive and -negative mammary fat pad (MFP) tumors; and by peritumoral MFP injection of the targeted imaging probe in mice with spontaneous ALN metastases. Fluorescence imaging showed that probe was only retained in positive tumors and metastases. As few as 1,000 cells that endogenously express mammaglobin-A were detected in ALN, indicating high sensitivity of this method. Translation of this approach offers considerable potential as a noninvasive clinical strategy to stage breast cancer.

The biology underlying molecular imaging in oncology: from genome to anatome and back again

Cancers are complex, evolving, multiscale ecosystems that are characterized by profound spatial and temporal heterogeneity. The interactions in cancer are non-linear in that small changes in one variable can have large changes on another. These multiple interacting phenotypes and spatial scales can best be understood with appropriate mathematical and computational models. Imaging is central to this investigation because it can non-destructively and longitudinally characterize spatial variations in the tumour phenotype and environment so that the system dynamics over time can be captured quantitatively.

Photoassisted electrolysis of water by irradiation of a titanium dioxide electrode

Ultraviolet irradiation (351, 364 nm) of the n-type semiconductor TiO(2) as the single crystal electrode of an aqueous electrochemical cell evolves O(2) at the TiO(2) electrode and H(2) at the Pt electrode. The gases are typically evolved in a two: one (H(2):O(2)) volume ratio. The photoassisted reaction seems to require applied voltages, but values as low as 0.25 V do allow the photoassisted electrolysis to proceed. Prolonged irradiation in either acid or base evolves the gaseous products in amounts which clearly demonstrate that the reaction is catalytic with respect to the TiO(2). The wavelength response of the TiO(2) and the correlation of product yield and current are reported. The results support the claim that TiO(2) is a true photoassistance agent for the electrolysis of water. Minimum optical storage efficiencies of the order of 1% can be achieved by the production of H(2).

Evaluation of tickborne encephalitis case classification in Poland

Central European tickborne encephalitis (TBE) is a viral disease of the central nervous system. Despite a surveillance system for TBE existing in Poland since 1970, there are no standardised case definitions and different diagnostic tests are used in various regions. The purpose of this study was to summarise four years of surveillance data using standardised case definitions. From 1999 to 2002, 607 cases of TBE were reported to Poland’s national surveillance system: 386 (63.6%) were males, 331 (54.5%) lived in rural areas, and 186 (30.6%) were between 30 and 50 years old. Of 606 diagnosed cases, 453 (74.7%) had aseptic meningitis, 109 (18.0%) had meningoencephalitis, and 44 (7.3%) had meningoencephalomyelitis. Of the 607 reported cases, 602 (99.2%) could be classified: 153 (25.4%) as confirmed, 343 (57.0%) as probable, and 106 (17.6%) as possible cases. There was a significant difference in classified cases by gender: 28.6% of male cases were classified as confirmed, compared with 19.7% of female cases (chi2= 10.48, p=0.0053). There was a significant difference in case classification by clinical diagnosis: 32.4% of cases with meningoencephalitis were classified as confirmed cases, compared with 24.7% of cases with aseptic meningitis (chi2=11.79, p=0.019). There were also significant differences in the distribution by case definition group across geographical regions. For appropriate monitoring of TBE, a uniform and valid case definition should be used in European countries. With only 25% of reported cases meeting the definition for confirmed cases, there is a need for more complete follow-up and standardised testing of suspect cases.

Evaluation of tickborne encephalitis case classification in Poland

Central European tickborne encephalitis (TBE) is a viral disease of the central nervous system. Despite a surveillance system for TBE existing in Poland since 1970, there are no standardised case definitions and different diagnostic tests are used in various regions. The purpose of this study was to summarise four years of surveillance data using standardised case definitions. From 1999 to 2002, 607 cases of TBE were reported to Poland's national surveillance system: 386 (63.6%) were males, 331 (54.5%) lived in rural areas, and 186 (30.6%) were between 30 and 50 years old. Of 606 diagnosed cases, 453 (74.7%) had aseptic meningitis, 109 (18.0%) had meningoencephalitis, and 44 (7.3%) had meningoencephalomyelitis. Of the 607 reported cases, 602 (99.2%) could be classified: 153 (25.4%) as confirmed, 343 (57.0%) as probable, and 106 (17.6%) as possible cases. There was a significant difference in classified cases by gender: 28.6% of male cases were classified as confirmed, compared with 19.7% of female cases (chi2= 10.48, p=0.0053). There was a significant difference in case classification by clinical diagnosis: 32.4% of cases with meningoencephalitis were classified as confirmed cases, compared with 24.7% of cases with aseptic meningitis (chi2=11.79, p=0.019). There were also significant differences in the distribution by case definition group across geographical regions. For appropriate monitoring of TBE, a uniform and valid case definition should be used in European countries. With only 25% of reported cases meeting the definition for confirmed cases, there is a need for more complete follow-up and standardised testing of suspect cases.

Evaluation of hepatitis C surveillance in Poland in 1998

The aim was to evaluate hepatitis C surveillance in Poland during 1998. Hepatitis C reports were obtained from epidemiology offices. Public health staff were interviewed to collect information on surveillance operations. To estimate the proportion of acute cases among the total reported, a study was conducted in the Warsaw district to validate case reports. A total of 1661 (97.2%) hepatitis C cases were studied. Hepatitis C surveillance was timely and acceptable to the user, but did not provide a number of information elements required to differentiate acute from chronic cases of infection. Of the 268 case reports available in the Warsaw district, only 15 (5.6%) met the acute hepatitis C case definition. It is concluded that hepatitis C surveillance in Poland cannot provide useful incidence estimates and information regarding risk factors for acute infection. A strict case definition and a modified case form with specific questions for HCV transmission routes should be applied.

Sexual activity and condom use among Eastern European adolescents--the Study of Hungarian Adolescent Risk Behaviours

While rates of HIV and STD infection in Eastern Europe are increasing rapidly, little is known about sexual behaviour, including condom use, among Eastern European youths. The Study of Hungarian Adolescent Risk Behaviours was designed to assess the knowledge, attitudes, and behaviours of adolescents studying in secondary schools in Budapest, Hungary. Students (n =3486) in a random sample of public secondary schools completed a self-administered questionnaire, including measures of sexual activity and condom use. Thirty-eight percent of students reported ever having had vaginal intercourse. Condom use by those reporting having had sex in the past five weeks was classified as consistent/every time (40%); irregular (25.6%); and none (34.3%). Multivariate analysis revealed positive opinions about condoms, fear of AIDS, and initiation of condom use by both partners to predict more frequent condom use. Implications for targeted AIDS/STD education and prevention among adolescents are discussed.

Subglacial volcanic features beneath the West Antarctic Ice Sheet interpreted from aeromagnetic and radar ice sounding

The West Antarctic Ice Sheet (WAIS) flows through the volcanically active, late Cenozoic West Antarctic rift system. Active subglacial volcanism and a vast (> 106 km3) extent of subglacial volcanic structures have been interpreted from aerogeophysical surveys over central West Antarctica in the past decade, combined with results from 1960s and 1970s aeromagnetic profiles over the WAIS. Modelling of magnetic anomalies constrained by radar ice sounding shows volcanic sources at the base of the ice throughout large areas, whose subglacially erupted hyaloclastite edifices have been eroded by moving ice, as in Iceland. The 1800 m-high divide of the WAIS is underlain by the 400 km-long volcanic Sinuous Ridge, which rises above sea level; most hyaloclastite edifices there have also been glacially removed, indicating migration of the ice divide through time. Northeast of the divide of the WAIS there is a 400-nT positive magnetic anomaly over the shallowest, most rugged bedrock topography (elevation +380m above sea level), probably comprising subaerially erupted flows erupted when the Sinuous Ridge area was deglaciated. Uplift of the Sinuous Ridge may have forced the advance of the WAIS. Other aspects of the subglacial volcanism in Antarctica can be observed in Iceland and have a direct bearing on our understanding of the subglacial conditions of the WAIS and its dynamics.

West Nile virus: a case study in how NY State Health Information infrastructure facilitates preparation and response to disease outbreaks

New York's (NY) Health Information Network (HIN) provided timely access to West Nile Virus (WNV) data during the initial outbreak in the late Summer 1999. In December 1999, NY developed a plan to deal with WNV in 2000 that required an integrated surveillance system for humans, birds, mammals, and mosquitoes. The HIN infrastructure allowed NY to deploy this system statewide in three months. Local health departments throughout NY used the system to report, track, and retrieve surveillance data as WNV spread throughout NY in 2000. The HIN infrastructure includes partnerships, training/support, technical capacity and architecture similar to NEDSS as proposed by the US CDC.

Recurrent Listeria monocytogenes infection: relapse or reinfection with a unique strain confirmed by molecular subtyping

We report a case of recurrent listeriosis for which molecular subtyping by automated ribotyping and pulsed-field gel electrophoresis confirmed either relapse of infection or reinfection due to a common source almost 9 months after initial infection due to a unique Listeria monocytogenes strain in a patient with colorectal cancer. This case report illustrates the potential use of molecular subtyping to further understand the pathogenesis and epidemiology of listeriosis and the potential for relapse of Listeria infections in humans.

Intussusception, rotavirus diarrhea, and rotavirus vaccine use among children in New York state

OBJECTIVE

To describe epidemiologic features of intussusception and rotavirus diarrhea in New York, to examine the baseline incidence and trends over time, and to ascertain whether an excess of cases occurred in the 9 months of vaccination with the newly licensed rotavirus vaccine.

METHODS

Hospital discharge data from 1989 through 1998 were reviewed for children (<1 year old) whose primary or secondary diagnosis was coded as intussusception or rotavirus diarrhea. Characteristics of patients admitted for intussusception and rotavirus diarrhea were compared, and trends over time were examined. For a subset of patients, medical records and vaccine histories for intussusception hospitalizations from October 1998 through June 1999 were analyzed. The number of intussusception cases attributable to rotavirus vaccine was calculated based on the penetration of the vaccine (21%) and a range of excess risks of intussusception among vaccinated children as estimated by the National Immunization Program (NIP).

RESULTS

From 1989 through 1998, 1450 intussusception-associated hospitalizations were reported in children <1 year old (average annual incidence 5.4/10 000). Among these children, 47% were treated medically and 53% had surgery, with 9% needing surgical resection. The incidence of intussusception declined over time from 6.1 per 10 000 in 1989 to 3.9 per 10 000 in 1998. Intussusception hospitalizations occurred throughout the year, whereas rotavirus-associated hospitalizations peaked from February to April. Of 20 patients with intussusception whose hospitalization charts were reviewed, 5 had received rotavirus vaccine. All 5 were hospitalized after their first dose of vaccine, were admitted before 7 months of age, were white, and had private insurance. A total of 81 cases of intussusception occurred during the 9-month period of rotavirus vaccination, compared with 78 during the same period in the prevaccination year. The number of excess intussusception cases observed (n = 3) was lower than expected using the NIP estimate of excess risk (1.8) among rotavirus vaccinated children (n = 12) but not significantly different from the risks identified in the NIP cohort studies (1 in 12 000).

CONCLUSION

Our data suggest that in New York the rate of intussusception has declined, and approximately 1 child in 2600 develops intussusception before 1 year of age. The different seasonality between intussusception and rotavirus-related hospitalizations suggests that if any causal association exists, it must be small. Unlike other studies, analysis of New York hospitalized discharge data failed to show an appreciable increase in the incidence of intussusception after introduction of the rotavirus vaccine.

Folding a fish, making a mushroom: the role of diagrams in executing assembly procedures

Three experiments examined the role of step-by-step and final-state diagrams in supporting object assembly. A total of 180 college students made origami objects from instructions consisting of text only, text plus a final-state (completed-object) diagram, or text plus step-by-step and final-state diagrams. In Experiments 1 and 2, construction accuracy in the final-diagram condition was comparable to that in the step-by-step condition when the objects required few assembly steps, but it was comparable to that in the text-only condition when many steps were required. Experiment 3 independently manipulated the number of assembly steps and the ease of seeing the steps in, or inferring them from, the final diagram. The results indicated that the case of extracting the steps from the final diagram was the primary causal variable in the interaction with instructional condition. We interpret these results in terms of mental model construction and working memory load.

Coccidioidomycosis in New York State

Coccidioidomycosis, a systemic fungal disease caused by Coccidioides immitis, is endemic in the southwestern United States and in parts of Mexico and Central and South America. Only sporadic cases have been reported in areas (including New York) where the disease is not endemic. We used hospital discharge records and state mycology laboratory data to investigate the characteristics of C. immitis infections among New York State residents. From 1992 to 1997, 161 persons had hospital discharge diagnoses of coccidioidomycosis (ICD9 Code 114.0 - 114.5, 114.9). From 1989 to 1997, 49 cultures from patients were confirmed as C. immitis; 26 of these patients had traveled to disease-endemic areas. Fourteen of 16 isolates had multilocus genotypes similar to those of Arizona isolates, which corroborates the travel-related acquisition of the disease. Our results indicate that coccidioidomycosis may be more common in New York residents than previously recognized. Increased awareness among health-care providers should improve timely diagnosis of coccidioidomycosis and prevention of associated illnesses and deaths among patients in nondisease-endemic areas.

Seafood-associated disease outbreaks in New York, 1980-1994

BACKGROUND

Seafood-associated disease outbreaks in New York were examined to describe their epidemiology and to identify areas for prevention and control efforts.

METHODS

We reviewed reports submitted to the New York State Department of Health (NYSDOH) of seafood-associated outbreaks occurring from January 1, 1980, through December 31, 1994.

RESULTS

During 1980-1994, 339 seafood-associated outbreaks were reported, resulting in 3959 illnesses, 76 hospitalizations, and 4 deaths. During this period, seafood-associated outbreaks accounted for 19% of all reported foodborne outbreaks and 10% of foodborne illnesses. Shellfish, the most frequently implicated seafood item, accounted for 64% of seafood outbreaks, followed by finfish (31% of outbreaks). Of the 148 seafood-associated outbreaks with a confirmed etiologic agent, Norwalk virus and scombrotoxin were the most frequently identified agents: Norwalk virus accounted for 42% of outbreaks and 42% of illnesses, and scombrotoxin accounted for 44% of outbreaks and 19% of illnesses. Three of the 4 seafood-associated deaths were caused by Clostridium botulinum; the remaining death was caused by Vibrio vulnificus.

CONCLUSIONS

Reducing the number of seafood outbreaks will require continued and coordinated efforts by many different agencies, including those involved with water quality; disease surveillance; consumer education; and seafood harvesting, processing, and marketing. New York's foodborne disease surveillance data highlight potential areas on which to focus prevention efforts, including: (1) commodities and associated pathogens causing the largest number of seafood-associated outbreaks and illnesses, namely shellfish-associated viral gastroenteritis and finfish-associated scombroid fish poisoning, and (2) venues at which seafood were most frequently consumed in reported outbreaks, such as commercial food establishments and catered events.

The 1996 New York blizzard: impact on noninjury emergency visits

The purpose of this study was to investigate the impact of the January 1996 New York blizzard on emergency visits to 12 Suffolk County hospitals for 10 noninjury health conditions. Emergency charts from the blizzard week (January 7-11) and a nonblizzard week (January 21-25) were reviewed and information was abstracted from the records meeting the criteria. Blizzard conditions were associated with increased visits for myocardial infarction/angina, primarily shoveling-related, and with decreased visits for asthma. Diagnoses for the other noninjury conditions did not differ significantly between time periods. The decrease in asthma visits possibly resulted from asthmatics avoiding exposure to blizzard conditions. An unexpected finding was that most patients with shoveling-related myocardial infarction/angina did not report pre-existing heart disease. Also of interest was that one quarter of myocardial infarction/angina visits by women were reportedly shoveling-related. This suggests that health warnings may be less effective at decreasing shoveling-induced myocardial infarction if they are directed primarily at men and at people with heart disease.

A nosocomial outbreak of malaria associated with contaminated catheters and contrast medium of a computed tomographic scanner

OBJECTIVE

To identify the risk factors associated with an unexpected outbreak of malaria that occurred among seven patients in a general teaching hospital in Taipei in October 1995.

DESIGN

A three-stage case-control study was conducted to identify risk factors.

PATIENTS

We identified all 7 patients who were diagnosed as malaria cases and 69 controls from those undergoing computed tomography (CT) examination.

METHODS

Malaria was diagnosed by demonstrating the presence of Plasmodium falciparum on either thick or thin blood smears. Clinical characteristics and exposure information were collected from medical records and patient interviews.

RESULTS

The index case was infected by malaria when he visited Nigeria in early September and was diagnosed when he was hospitalized in hospital A in October. Among 10 patients examined with the Imatron scanner after the index case, all 6 who were injected with contrast medium were infected, but none of 4 examined without contrast medium were infected (P=.005).

CONCLUSIONS

This nosocomial outbreak of malaria was most likely due to transmission via a contaminated catheter and contrast medium used for CT scanning. Use of disposable catheters may avoid such nosocomial outbreaks in the future.

Human babesiosis in New York State: Review of 139 hospitalized cases and analysis of prognostic factors

BACKGROUND

Babesiosis infections are infrequent, occur in limited geographic locations, and range from asymptomatic infection to severe illness and death.

METHODS

Descriptive clinical and epidemiological information on human babesiosis cases was collated from state communicable disease reports and medical records of patients hospitalized from 1982 to 1993. Univariate and multivariate analyses were performed to determine prognostic factors associated with severe disease outcome (hospitalization ending in death, duration of hospitalization > 14 days, or intensive care unit stay > 2 days).

RESULTS

Between 1982 and 1993, 139 patients were hospitalized with babesiosis in New York State. Nine patients (6.5%) died, 35 (25.2%) were admitted to the intensive care unit, and 35 (25.2%) required hospitalization for more than 14 days. Mean age at first hospitalization was 62.5 years. Sixty-two percent were male, and 91% resided in Suffolk County, Long Island. The most common symptoms were fatigue/malaise/weakness (91%), fever (91%), shaking chills (77%), and diaphoresis (69%). Past medical records showed that 52% of patients had a history of chronic disease; 12% had a history of Lyme disease; 12% had undergone a splenectomy; and 2% had undergone a blood transfusion. There was a 12- to 14-day delay between onset of symptoms and initiation of appropriate antibiotic treatment. Univariate analyses showed alkaline phosphatase levels greater than 125 U/L, white blood cell counts greater than 5 x 10(9)/L, history of cardiac abnormality, history of splenectomy, presence of heart murmur, and parasitemia values of 0.04 or higher to be significantly associated with disease severity. Multiple logistic regression analyses indicated that male sex, alkaline phosphatase values greater than 125 U/L, and white blood cell counts greater than 5 x 10(9)/L remained strong predictors of severe outcome.

CONCLUSIONS

Human babesiosis is a rare but debilitating and potentially fatal illness, especially in the elderly. Prompt disease diagnosis and treatment are essential but are often delayed, as seen in our series. This delay reinforces the need for enhanced public and physician education targeted toward residents and visitors to the few high-risk geographic areas where disease and Ixodes scapularis ticks are endemic. Patients presenting with certain prognostic indicators (male sex, alkaline phosphatase values > 125 U/L, and white blood cell counts >5 x 10(9)/L) require comprehensive and aggressive medical care to prevent further deterioration. Since babesiosis is only 1 of 3 currently recognized diseases transmitted by I scapularis ticks, primary prevention recommendations will also reduce human exposure to Lyme disease and human granulocytic ehrlichiosis.

Synchronous climate changes in antarctica and the north atlantic

Central Greenland ice cores provide evidence of abrupt changes in climate over the past 100,000 years. Many of these changes have also been identified in sedimentary and geochemical signatures in deep-sea sediment cores from the North Atlantic, confirming the link between millennial-scale climate variability and ocean thermohaline circulation. It is shown here that two of the most prominent North Atlantic events-the rapid warming that marks the end of the last glacial period and the Bolling/Allerod-Younger Dryas oscillation-are also recorded in an ice core from Taylor Dome, in the western Ross Sea sector of Antarctica. This result contrasts with evidence from ice cores in other regions of Antarctica, which show an asynchronous response between the Northern and Southern Hemispheres.

The role of young children in a community-wide outbreak of hepatitis A

An Hasidic Jewish community has experienced recurrent hepatitis A outbreaks since 1980. To assess risk factors for illness during a 1985-6 outbreak, the authors reviewed case records and randomly selected 93 households for an interview and serologic survey. In the outbreak, 117 cases of hepatitis A were identified, with the highest attack rate (4.2%) among 3-5 year olds. Among the survey households, the presence of 3-5 year olds was the only risk factor that increased a household's risk of hepatitis A (indeterminant relative risk, P = 0.02). Furthermore, case households from the outbreak were more likely to have 3-5 years olds than were control households from the survey (odds ratio = 16.4, P < 0.001). Children 3-5 years old were more likely to have hepatitis A and may have been the most frequent transmitters of hepatitis A in this community. Hepatitis A vaccination of 3-5 year olds can protect this age group and might prevent future outbreaks in the community.

Climate Change During the Last Deglaciation in Antarctica

Greenland ice core records provide clear evidence of rapid changes in climate in a variety of climate indicators. In this work, rapid climate change events in the Northern and Southern hemispheres are compared on the basis of an examination of changes in atmospheric circulation developed from two ice cores. High-resolution glaciochemical series, covering the period 10,000 to 16,000 years ago, from a central Greenland ice core and a new site in east Antarctica display similar variability. These findings suggest that rapid climate change events occur more frequently in Antarctica than previously demonstrated.

Human and rodent hantavirus infection in New York State: public health significance of an emerging infectious disease

BACKGROUND

A case of hantavirus pulmonary syndrome with possible exposure in New York and/or Rhode Island was confirmed in February 1994.

OBJECTIVE

To conduct four studies to determine the historical and geographic distribution of human and small-mammal infection with hantaviruses in New York State.

METHODS

Enzyme-linked immunosorbent assays were performed on serum samples obtained from 130 humans during a 1978 babesiosis survey, 907 small mammals collected in New York State since 1984, 12 rodents collected in 1994 near the residences of the patients with hantavirus pulmonary syndrome, and 76 New York patients with acute respiratory distress syndrome-like illness (as suspected cases of hantavirus pulmonary syndrome).

RESULTS

None of the human serum samples from the 1978 serosurvey showed evidence of hantavirus exposure by enzyme-linked immunosorbent assay. Statewide historical serum samples from white-footed mice showed evidence of Sin Nombre virus infection in 12.0% (97/809) and Seoul-like virus infection in 9.6% (78/809). Site-specific seropositivity rates were as high as 48.5% with Sin Nombre virus during 1 year (1984). Two of 12 mice captured near the residences of a human patient were positive for Sin Nombre virus by enzyme-linked immunosorbent assay, yet were negative for viral RNA by polymerase chain reaction. None of the patients with suspected hantavirus pulmonary syndrome was serologically reactive for Sin Nombre virus.

CONCLUSIONS

We provide serologic evidence of small-mammal infection with hantaviruses in New York State as long ago as 1984. Human cases of hantavirus pulmonary syndrome are rare in New York, and data indicate that transmission to humans is probably infrequent. A unique set of host, agent, and environmental factors may be necessary to cause hantavirus pulmonary syndrome in humans.

Use of multiple reporting sources for perinatal hepatitis B surveillance and follow-up

The New York State Perinatal Hepatitis B Prevention Program was implemented in New York State (excluding New York City) as a surveillance and control program in 1988. This report describes and evaluates the program and provides data from 1991 regarding hepatitis B surface antigen (HBsAg)-positive mothers and their infants' subsequent hepatitis B vaccination. The program was created using multiple existing surveillance and data collection systems. Completeness of case-ascertainment was estimated by means of the Chandra Sekar-Deming method (J Am Stat Assoc 1949; 44:101-15). An audit of hospital medical records and follow-up by local health departments were used to validate reporting accuracy. Of 158,273 live births in 1991, 363 (0.2%) were born to confirmed HBsAg-positive mothers. Estimated completeness of case-ascertainment was 96%. Thirty-five percent of HBsAg-positive mothers did not report risk factors for hepatitis B, confirming the need for universal testing. Of the infants, 83% received hepatitis B immune globulin and three doses of vaccine within one year of birth. By using existing data collection systems, the program was established quickly, and start-up funding and training requirements were simplified. Multiple reporting increased case-ascertainment to almost 100%. The program effectively identifies and ensures prompt vaccination of infants born to HBsAg-positive mothers.

Nosocomial tuberculosis: an outbreak of a strain resistant to seven drugs

OBJECTIVE

To evaluate nosocomial transmission of multidrug-resistant (MDR) tuberculosis (TB).

DESIGN

Outbreak investigation: review of infection control practices and skin test results of healthcare workers (HCWs); medical records of hospitalized TB patients and mycobacteriology reports; submission of specimens for restriction fragment length polymorphism (RFLP) typing; and an assessment of the air-handling system.

SETTING

A teaching hospital in upstate New York.

RESULTS

Skin-test conversions occurred among 46 (6.6%) of 696 HCWs tested from August through October 1991. Rates were highest on two units (29% and 20%); HCWs primarily assigned to these units had a higher risk for conversion compared with HCWs tested following previous incidents of exposure to TB (relative risk [RR] = 53.4, 95% confidence interval [CI95] = 6.9 to 411.1; and RR = 37.4, CI95 = 5.0 to 277.3, respectively). The likely source patient was the only TB patient hospitalized on both units during the probable exposure period. This patient appeared clinically infectious, was associated with a higher risk of conversion among HCWs providing direct care (RR = 2.37; CI95 = 1.05 to 5.34), and was a prison inmate with TB resistant to seven antituberculosis agents. The MDR-TB strain isolated from this patient also was isolated from other inmate and noninmate patients, and a prison correctional officer exposed in the hospital. Mycobacterium tuberculosis isolates from all of these patients had matching RFLP patterns. Infection control practices closely followed established guidelines; however, several rooms housing TB patients had marginal negative pressure with variable numbers of air changes per hour, and directional airflow was disrupted easily.

CONCLUSIONS

These data strongly suggest nosocomial transmission of MDR-TB to HCWs, patients, and a prison correctional officer working in the hospital. Factors contributing to transmission apparently included prolonged infectiousness of the likely source patient and inadequate environmental controls. Continued urgent attention to TB infection control is needed.

Neonatal meningitis in England and Wales: a review of routine national data

The objective of this study was to describe trends in neonatal meningitis in England and Wales during the years 1975-91. Laboratory reports and, for the years 1983-91, data on statutory notifications and deaths from neonatal meningitis were reviewed. The mean annual total of laboratory reports of neonatal bacterial meningitis 1975-91 was 109 cases (range 69-133) with a slight upward trend apparent in the latter half of the study period. The mean annual number of reports of neonatal viral meningitis was only 14 cases with no trend apparent. The leading bacteria isolated were group B streptococci, Escherichia coli, and Listeria monocytogenes accounting for 34.1%, 28.5%, and 6.8% of reports, respectively. There was a change in the pattern of causative bacteria from 1981 onwards with the group B streptococcus displacing E coli as the leading cause. With respect to neonatal viral meningitis, echoviruses and coxsackie viruses accounted for 55.4% and 38.6% of cases, respectively. Neonatal meningitis was seriously undernotified; the ratio of laboratory reported cases to cases notified ranged from 12:1 in 1985 to 4:1 in 1989. The annual numbers of deaths ranged from 18 to 39. The laboratory reporting system provided the most useful data on secular trends and causative organisms for neonatal meningitis. The slight upward trend in the number of reports of bacterial meningitis merits continued surveillance.

Impact of regulation on benzodiazepine prescribing to a low income elderly population, New York State

On 1 January 1989, in an effort to reduce diversion of benzodiazepines for illicit use and reduce inappropriate prescribing, a regulation was implemented requiring the reporting of all benzodiazepine prescriptions to the New York State Department of Health. To assess the impact of the regulation on prescribing practices to the elderly, we followed the number of benzodiazepines and other central nervous system medications prescribed to a cohort of participants in an elderly pharmaceutical insurance program. Benzodiazepines were prescribed for 4652 (22%) of the 20,944 patients studied. By the last quarter of 1989, benzodiazepines were prescribed for 3120 (15%) patients, a decrease of 33%. The number of prescriptions of benzodiazepines decreased by 5010 (45%), from 11,123 to 6113. Decreases in the number of prescriptions were similar across benzodiazepine brands (range 40-56%). Statistically significant (p < 0.05) decreases were seen in all sex, age, race and marital status groups. Increases in number (and percent increases) of prescriptions for miscellaneous anxiolytics (i.e. hydroxyzine (399, 69%), meprobamate (299, 149%), buspirone (263, 111%), chloral hydrate (138, 265%), antidepressants (658, 19%), barbiturates (150, 29%), and tranquilizers (198, 19%), some of which may be more toxic or less effective, were noted. New York State's reporting regulation was effective in reducing both the number of patients being prescribed benzodiazepines and the number of prescriptions given to those who remain on benzodiazepines in the elderly population studies.

Outbreak and sporadic egg-associated cases of Salmonella enteritidis: New York's experience

Since 1985, egg-associated Salmonella enteritidis has emerged as a major cause of foodborne disease. New York State has been especially affected, with 47 documented egg-associated S enteritidis outbreaks involving 2279 cases and 10 deaths. Individual case reports of salmonella have also increased 56%, and sporadic cases of S enteritidis have been shown to be associated with egg consumption. Further educational and regulatory activities are needed to control this continuing public health problem.

Implementation of a proficiency testing program for Lyme disease in New York State

Nine proficiency test events for Lyme disease (Borrelia burgdorferi) antibody were carried out from October 1988 to January 1992 by the New York State Department of Health, Albany, Overall sensitivity for the 846 participants averaged 95.4%, with varying sensitivities of 98.7% for users (71 laboratories) of immunofluorescence assays, 97.4% for users (144 laboratories) of solid-phase fluorescence immunoassays, and 94.6% for users (631 laboratories) of enzyme immunoassays. Thirty percent of the enzyme immunoassay laboratories tested at greater than or equal to 98.4% sensitivity by the DiaMedix test kit (DiaMedix Corp, Miami, Fla) and MarDx test kit (MarDx Diagnostics Inc, Scotch Plains, NJ), while 7% tested at less than or equal to 83% by the Access test kit (Access Medical Systems Inc, Branford, Conn) and the Cambridge BioScience test kit (Cambridge BioScience, Worcester, Mass). Overall specificity was 98.8%, with specificities greater than 99% for both solid-phase fluorescence immunoassay and enzyme immunoassay users and 92.9% for immunofluorescence assay users. Cross-reactivity with Treponema pallidum antibody was high for the Hillcrest (Hillcrest Biologicals, Cypress, Calif) (30%) and Wampole (Wampole Laboratories, Cranbury, NJ) (25%) immunofluorescence assay test kit users and for the MarDx (30%) and 3M (3M Diagnostics Systems Inc, Santa Clara, Calif) (24%) enzyme immunoassay test kit users. Laboratories that tested by the Wampole immunofluorescence assay test kit had also high cross-reactivity (25%) against heterophile antibody.

An outbreak of Salmonella mikawasima associated with doner kebabs

During October 1992 an increase in the number of isolates of Salmonella mikawasima, a rare serotype, was noted including a cluster of nine cases in the South West Thames region. A case control study was conducted and univariate analysis showed a statistical association between illness and eating at take-away A for cases compared with household controls (P = 0.003) and with neighbourhood controls (P = 0.0245). Cases were also more likely to have eaten kebabs than were controls or average take-away A customers, implicating doner kebabs as the most likely vehicle of infection. Plasmid profile analysis of the nine cases' isolates showed them to be indistinguishable and to be characterized by a single plasmid of approximately 60 MDa. The original source of the Salmonella mikawasima contamination was not determined, but food preparation practices for kebabs at take-away A were insufficient to protect against illness if contaminated. This outbreak was only recognized because of the unusual serotype, but could be an indication of a more widespread problem with doner kebabs.

Pleurodynia among football players at a high school. An outbreak associated with coxsackievirus B1

OBJECTIVE

Enteroviral outbreaks involving athletic teams have been described, although the mode of transmission has been unclear. In September 1991, an outbreak of pleurodynia among high school football players provided an opportunity to identify possible modes of transmission.

DESIGN

Retrospective cohort outbreak investigation.

SETTING

Public high school in upstate New York.

RESULTS

Illness was reported by 17 (20%) of the football players. Behaviors involving contact with common water containers were associated with illness, including eating ice cubes from the team ice chest (relative risk [RR], 9.2; 95% confidence interval [CI], 1.3 to 65.5) and drinking water from the team cooler (RR, 6.3; 95% CI, 1.5 to 25.7). Coxsackievirus B1 was isolated in four (50%) of the eight stool specimens collected.

CONCLUSIONS

Contamination of common water containers by an infected player may have contributed to or initiated the outbreak. In addition to discouraging direct oral contact with common drinking containers, use of individual water containers and ice packs for injuries was recommended.

Survival and mortality patterns of an acquired immunodeficiency syndrome (AIDS) cohort in New York State

The survival experience and causes of death of acquired immunodeficiency syndrome (AIDS) patients were studied using a cohort of 3,699 AIDS patients in New York State, excluding New York City, whose illness was diagnosed before January 1990 at age 13 years or older. The median length of survival for all cases was 11.5 months, and survival increased over time from 5.3 months pre-1984 to 9.3 months in 1984-1986 and to 13.2 months in 1987-1989. In a Cox proportional hazards model, risk of dying was higher for persons aged 35 years or more at diagnosis and for persons with a diagnosis other than Pneumocystis carinii pneumonia or Kaposi's sarcoma whose illness was diagnosed before 1986. In this AIDS cohort, 2,834 (77 percent) persons died before 1991; 87 percent of the death certificates listed human immunodeficiency virus (HIV)/AIDS or an AIDS indicator disease as one of the multiple causes of death. The finding that 13 percent of the death certificates did not mention AIDS/HIV suggests that use of death certificates alone to count HIV-related deaths would result in an undercount. The recent expansion of the federal AIDS case definition is expected to add HIV-infected persons who die from conditions, such as recurrent pneumonia, that were not included in the earlier definition.

High prevalence of syphilis detected through a jail screening program. A potential public health measure to address the syphilis epidemic

BACKGROUND

In June 1990, a syphilis initiative was undertaken to help control New York's most extensive syphilis epidemic since the 1940s.

METHODS

To evaluate the usefulness of syphilis screening in local jails, were reviewed demographic and syphilis screening data from a county jail in an area with a high prevalence of syphilis that has routinely tested incoming inmates.

RESULTS

Of 12,685 inmates, 9797 (77%) were screened for syphilis, and 321 (3.3%) had a positive test result; 258 (80%) of the positive results were confirmed. Data were available for 244 of the inmates with a confirmed positive result: 162 (67%) had newly diagnosed syphilis (overall rate, 1.6%), 112 of whom had early syphilis; 50 (20%) had been previously treated for syphilis; and 32 (13%) were unavailable for follow-up. Of 162 inmates with newly diagnosed syphilis, 122 (75%) were treated in jail, and 40 were treated after their release from jail. The median time from screening to treatment was 17 days. The median jail stay was 45 days for inmates who were evaluated for treatment vs 5 days for those who were unavailable for follow-up.

CONCLUSIONS

Screening inmates for syphilis was a productive public health measure, as inmates accounted for 20% of the county's syphilis morbidity. Given the high prevalence of syphilis among inmates and the inability to reach them for treatment after release, strategies are needed to rapidly screen and treat inmates before their release from jail.

Typhoid fever at a resort hotel in New York: a large outbreak with an unusual vehicle

The largest outbreak of typhoid fever in the United States since 1981 occurred in 1989 among guests and staff at a New York hotel. There were 43 culture-confirmed and 24 probable cases among guests, 1 culture-confirmed case and 1 asymptomatic culture-positive case among hotel employees, and 1 culture-confirmed secondary case. Twenty-one persons were hospitalized and 2 had bowel perforation. Breakfast on 13 June was the only meal consumed by all ill persons (relative risk, infinite; P = .004). In a case-control study, case-patients were more likely than controls to have consumed orange juice (odds ratio, 5.6; 95% confidence interval, 1.1-54.7), which had been prepared in a 208-L container with ample opportunity for hand contact. No other food was associated with illness. S. typhi was isolated from the stool of an asymptomatic food worker who handled orange juice but who was not known to be a typhoid carrier. S. typhi is a foodborne pathogen with continuing potential to cause large outbreaks in the United States.

Risk profile for Chlamydia infection in women from public health clinics in New York State

The prevalence of chlamydial infection and associated risk factors were studied in 1531 women from ten clinics in New York State excluding New York City. Overall Chlamydia infection rates were 13.6%; 17.6% in eight high risk family planning and STD clinics, and 5.7% in two low risk college and private clinics. Risk factors for Chlamydia infection included: age < 20 years (odds ratio 1.6), use of oral contraceptives (odds ratio 2.0), a history of having more than one sexual partner (odds ratio 1.7) and, in one clinic where data was available, inflammation on Papanicolaou smears (odds ratio 2.1). These data helped secure funding for Chlamydia preventive services and permitted development of a risk profile (score card) of Chlamydia for each age group. Use of such a score card can be most helpful in assigning which patients could benefit most from Chlamydia cultures, especially in those areas where testing is unavailable or too costly to screen all patients.

The resurgence of scabies

The prevalence of scabies infection shows a cyclical pattern with a periodicity of 10-30 years. Various sources indicate that a major increase has been underway since 1991 and CDSC has received several reports of outbreaks in schools, hospitals and nursing homes in recent months. This brief review outlines the clinical features, diagnosis, epidemiology and management of this time-honoured infection.

Human babesiosis in New York State: an epidemiological description of 136 cases

Epidemiological data on 136 cases of human babesiosis reported from laboratories and clinicians in the state of New York from 1982 to 1991 were reviewed. All but two patients, who had traveled to Nantucket Island in Massachusetts, acquired disease in Suffolk County, Long Island. The highest average age-group-specific annual incidence rates occurred among men > or = 80 years of age (7.72 per 100,000) and among women 70-79 years of age (3.61 per 100,000). Seven patients (5%) had previously undergone splenectomy, and 31 (23%) had evidence of concurrent Lyme disease. One hundred three patients (76%) were hospitalized, and seven (5%) died. Although the geographic distribution of this disease has remained constant, the recent introduction of babesiosis in mainland Connecticut and the spread of Lyme disease in New York suggest that the geographic distribution of babesiosis could also spread in New York.

A multistate outbreak of sporotrichosis associated with sphagnum moss

In the spring of 1988, the largest documented US outbreak of cutaneous sporotrichosis to date occurred, with 84 cases among persons from 15 states who were exposed to Wisconsin-grown sphagnum moss used in packing evergreen tree seedlings. In New York State, 13 cases occurred among 109 forestry workers. All 13 cases occurred among 76 workers who had handled evergreen seedlings and moss (attack rate = 17%). For those exposed to evergreens and moss, the risk of infection increased as worktime exposure to moss increased (attack rates: less than 10 hours, 8%; 10-19 hours, 12%; greater than 19 hours, 33%). While environmental samples of moss from the Wisconsin supplier were negative, Sporothrix schenckii was cultured from multiple samples of the sphagnum moss obtained from one of six Pennsylvania tree nurseries, representing the nursery that was identified as the source for 79 (94%) of the moss-associated cases. Differences in tree-handling procedures at this nursery--including the use of 1- to 3-year-old moss to pack seedlings, use of a pond water source to wet the moss, use of an organic polymer gel on the seedling root system, and underground storage and longer storage of moss-packed seedlings before shipping--suggested possible explanations for the association. Efforts to prevent sporotrichosis among persons handling evergreen seedlings should include the use of alternate types of packing material (e.g., cedar wood chips or shredded paper) and protective clothing such as gloves and long-sleeved shirts.

An outbreak of influenza A (H3N2) in a well immunized nursing home population

OBJECTIVE

To describe the epidemiologic features of an outbreak of influenza A that occurred in a skilled nursing home although over 90 percent of the resident population had previously received influenza vaccine.

DESIGN

Retrospective cohort study.

SETTING

Skilled nursing home facility in western New York State.

PATIENTS

Nursing home residents and patient-care staff.

MAIN OUTCOME MEASURE

Incidence of influenza-like illness among vaccinated versus unvaccinated nursing home residents and staff.

RESULTS

Thirty-seven of 124 residents (attack rate = 30%) and 18 of 146 staff (attack rate = 12%) had an influenza-like illness. Staff illness began 16 days prior to onset among residents. Six cases of pneumonia and three influenza-related deaths occurred, all among the vaccinated residents. Ninety percent of the nursing home residents and 10% of the staff received the influenza vaccine prior to the outbreak. The calculated vaccine efficacies were minus 21% and plus 45% for residents and staff, respectively.

CONCLUSION

While antigenic drift of the circulating influenza virus was the major factor in the apparent vaccine failure, the observed poor staff immunization rate (10%) and absence of surveillance which precluded the use of amantadine chemoprophylaxis suggest that the use of these strategies may be of importance in controlling influenza outbreaks in nursing homes.

The geographic spread and temporal increase of the Lyme disease epidemic

OBJECTIVE

To describe the temporal and geographic progression of the Lyme disease epidemic in New York State from 1977 through 1989.

DESIGN

Communicable disease surveillance system.

SETTING

Statewide.

MAIN OUTCOME MEASURES

The progression of the epidemic was examined by analyzing trends in Lyme disease cases reported to the state surveillance system, town and county Lyme disease incidence rates, Lyme disease hospital discharge rates, and the distribution of Ixodes dammini ticks obtained from surveillance efforts and submitted for identification.

MAIN RESULTS

The number of confirmed Lyme disease cases in New York has increased with concurrent increases in the number of hospital discharges. The number of counties endemic for Lyme disease increased from four to eight between 1985 and 1989. The number of counties with documented I dammini ticks increased from four in 1985 to 22 in 1989. Incidence of the disease also increased within known endemic counties.

CONCLUSIONS

Tick surveillance indicated that the range of I dammini has expanded annually into areas up to 384 km from the original known endemic areas of Long Island, NY, and Connecticut. Cumulative data from human surveillance resources document both temporal increases and geographic expansion of the Lyme disease epidemic in New York.

Geographic distribution of newborn HIV seroprevalence in relation to four sociodemographic variables

The geographic distribution of newborn human immunodeficiency virus seroprevalence at zip code level was compared with the distribution of four sociodemographic variables. For New York City significant univariate correlations were found between HIV and low birthweight, drug use (as measured by hospital discharges), maternal education less than 12 years, and race/ethnicity. Less significant correlations were found for New York State exclusive of New York City. For New York City a model comprising low birthweight and all drug discharges was shown by multiple regression analysis to be most strongly associated with HIV status (r2 = .77). Elsewhere a model comprising race/ethnicity (percent Black, percent Hispanic) and cocaine drug discharges had the best, but less strong association (r2 = .39). However, because of intercorrelations, race/ethnicity added little when the other variables were included first. Knowledge of the geographic association between HIV seroprevalence and sociodemographic status can be useful in designing and focusing prevention efforts in areas at highest risk for future HIV/AIDS activity.