Risk of Infections Associated with Improperly Reprocessed Transrectal Ultrasound–Guided Prostate Biopsy Equipment

Objective.

A hospital discovered a lapse in the reprocessing procedures for transrectal ultrasound-guided prostate biopsy equipment. An investigation was initiated to assess the risks of transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and bacteria during prostate biopsies.

Methods.

We offered testing for HBV, HCV, and HIV infection to patients who had undergone prostate biopsies from January 30, 2003, through January 27, 2006. We reviewed their medical records and obtained information on the reprocessing procedures that were in use at the time for the prostate biopsy equipment.

Setting.

A healthcare facility in Maine.

Results.

Of the 528 patients exposed to improperly reprocessed prostate biopsy equipment, none tested positive for HIV or HCV. Sixteen patients (3%) tested positive for past HBV infection but had no prebiopsy HBV serologic test results available (ie, transmission from improperly reprocessed biopsy equipment was possible), and 11 (2%) had evidence of postbiopsy bacterial infections. The number of cases of HBV and bacterial infections were within reported ranges for this population and were not clustered in time. Review of the reprocessing procedures in use at the time revealed that the manufacturer-recommended brushes for cleaning the reusable biopsy needle guide were never used. Brushes did not come with the equipment and had to be ordered separately.

Conclusions.

Despite the lack of evidence of pathogen transmission in this investigation, it is critical to review the manufacturer's reprocessing recommendations and to establish appropriate procedures to avert potential pathogen transmission and subsequent patient concerns. This investigation provides a better understanding of the risks associated with improperly reprocessed transrectal ultrasound prostate biopsy equipment and serves as a methodologic tool for future investigations.

Pandemic influenza planning, United States, 1978-2008

During the past century, 4 influenza pandemics occurred. After the emergence of a novel influenza virus of swine origin in 1976, national, state, and local US public health authorities began planning efforts to respond to future pandemics. Several events have since stimulated progress in public health emergency planning: the 1997 avian influenza A(H5N1) outbreak in Hong Kong, China; the 2001 anthrax attacks in the United States; the 2003 outbreak of severe acute respiratory syndrome; and the 2003 reemergence of influenza A(H5N1) virus infection in humans. We outline the evolution of US pandemic planning since the late 1970s, summarize planning accomplishments, and explain their ongoing importance. The public health community's response to the 2009 influenza A(H1N1)pdm09 pandemic demonstrated the value of planning and provided insights into improving future plans and response efforts. Preparedness planning will enhance the collective, multilevel response to future public health crises.

Arsenic poisoning caused by intentional contamination of coffee at a church gathering--an epidemiological approach to a forensic investigation

An outbreak of apparent food-borne illness following a church gathering was promptly reported to the Maine Bureau of Health. Gastrointestinal symptoms among church attendees were initially attributed to consumption of leftover sandwiches that had been served the previous day. However, a rapid epidemiological and laboratory assessment revealed the etiology of illness, including the death of an elderly gentleman, was not food-borne in origin. A criminal investigation determined that deliberate arsenic contamination of the brewed coffee by one of the church members was the source of the outbreak. Public health officials and criminal investigators must be aware that intentional biologic aggression can initially present as typical unintentional disease outbreaks. Practitioners must also consider the need to properly maintain and preserve potential forensic evidence. This case demonstrates the key role public health practitioners may play in criminal investigations.

Pandemic influenza: implications for programs controlling for HIV infection, tuberculosis, and chronic viral hepatitis

Among vulnerable populations during an influenza pandemic are persons with or at risk for HIV infection, tuberculosis, or chronic viral hepatitis. HIV-infected persons have higher rates of hospitalization, prolonged illness, and increased mortality from influenza compared with the general population. Persons with tuberculosis and chronic viral hepatitis may also be at increased risk of morbidity and mortality from influenza because of altered immunity and chronic illness. These populations also face social and structural barriers that will be exacerbated by a pandemic. Existing infrastructure should be expanded and pandemic planning should include preparations to reduce the risks for these populations.

Increased recognition of Powassan encephalitis in the United States, 1999-2005

Powassan virus (POWV) disease is a rare human disease caused by a tick-borne encephalitis group flavivirus maintained in a transmission cycle between Ixodes cookei and other ixodid ticks and small and medium-sized mammals. During 1958-1998, only 27 POWV disease cases (mostly Powassan encephalitis) were reported from eastern Canada and the northeastern United States (average, 0.7 cases per year). During 1999-2005, nine cases (described herein) of serologically confirmed POWV disease were reported in the United States (average, 1.3 cases per year): four from Maine, two from New York, and one each from Michigan, Vermont, and Wisconsin. The Michigan and Wisconsin cases are the first ever reported from the north-central United States. Of these nine patients, 5 (56%) were men, the median age was 69 years (range: 25-91 years), and 6 (67%) had onset during May-July. All but one patient developed encephalitis with acute onset of profound muscle weakness, confusion, and other severe neurologic signs. In one case, no neurologic symptoms were present but the presence of pleocytosis, an elevated cerebrospinal fluid (CSF) protein concentration, and POWV-specific immunoglobulin M in CSF suggested neuroinvasion. All patients recovered from their acute disease, but most had long-term neurologic sequelae. Periresidential ecologic investigations were performed in three cases, including tests of local mammals and ticks for evidence of POWV infection. Woodchucks (Marmota monax), striped skunks (Mephitis mephitis), and a raccoon (Procyon lotor) collected at two of the Maine case-patients' residences had neutralizing antibody titers to POWV. I. cookei were found on woodchucks and skunks and questing in grassy areas of one of these residences; all were negative for POWV. Although POWV disease is rare, it is probably under-recognized, and it causes significant morbidity, and thus is an additional tick-borne emerging infectious disease entity. Because no vaccine or specific therapy is available, the basis of prevention is personal protection from ticks (or "tick hygiene") and reduced exposure to peridomestic wild mammals.

Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and other mass-casualty events--United States, 2008: recommendations of the Centers for Disease Control and Prevention (CDC)

This report outlines recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings or other events resulting in mass casualties. Persons wounded during such events or in conjunction with the resulting emergency response might be exposed to blood, body fluids, or tissue from other injured persons and thus be at risk for bloodborne infections. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass-casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be implemented effectively, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma and emergency response medical communities participating in CDC's Terrorism Injuries: Information, Dissemination and Exchange (TIIDE) project. The recommendations contained in this report represent the consensus of U.S. federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community.

Challenges to implementing second-dose varicella vaccination during an outbreak in the absence of a routine 2-dose vaccination requirement--Maine, 2006

In June 2005, the Advisory Committee on Immunization Practices (ACIP) recommended administering a second dose of varicella vaccine during outbreaks, supplementing the routine 1-dose requirement. From October 2005 to January 2006, a varicella outbreak occurred in Maine in a highly vaccinated elementary school population. We investigated the outbreak, held a school-based vaccination clinic, and assessed costs in implementing ACIP's outbreak-response recommendation. Parents completed questionnaires and case investigation interviews. Personnel at the Maine Center for Disease Control and Prevention, the school in which the outbreak occurred ("school A"), and physician offices completed economic surveys. Forty-eight cases occurred, with no hospitalizations or deaths. Vaccine effectiveness was 86.6% (95% confidence interval, 82.0%-90.1%). Of 240 eligible students, 132 (55.0%) received second-dose vaccination. Implementing ACIP's outbreak-response recommendation was challenging and cost approximately $26,875. Additionally, the routine 1-dose varicella vaccination policy did not confer adequate population immunity to prevent this outbreak. These findings support ACIP's June 2007 recommendation for a routine 2-dose varicella vaccination program.

Importance of catch-up vaccination: experience from a varicella outbreak, Maine, 2002-2003

OBJECTIVE

During December 2002 to January 2003, a varicella outbreak occurred in an elementary school in Maine. Just 1 month before detecting the outbreak, Maine implemented varicella vaccine requirements for child care but did not require vaccination for school entry. We investigated this outbreak to examine reasons for its occurrence, including vaccine failure.

METHODS

A self-administered questionnaire was sent to all students' parents to determine student disease status, medical conditions, and vaccination status, which was further confirmed by review of medical records. Parental reporting of chickenpox/varicella that occurred since September 1, 2002, in a student who attended the school was used to define a case. Parents of cases were interviewed by telephone about disease characteristics. Disease severity was classified on the basis of the number of skin lesions and the occurrence of complications. Vaccine effectiveness was calculated by comparing varicella attack rates for any disease, for moderate to severe disease, and for severe disease among vaccinated and unvaccinated students.

RESULTS

We obtained complete information for 296 (81%) of 364 students. Varicella vaccine coverage was 74% overall and decreased by grade, from 90% in kindergarten to 60% in third grade. Attack rates increased significantly from 14% in kindergarten to 37% in third grade. Of the 53 varicella cases, 36 (68%) were unvaccinated, 12 (22%) were vaccinated, and 5 (10%) had previous disease history. Vaccine effectiveness was 89% (95% confidence interval [CI]: 79-94%) against disease of any severity, 96% (95% CI: 88-99%) against moderate to severe disease, and 100% (95% CI: undefined) against severe disease. Twenty-two percent of unvaccinated students had severe disease and 1 was hospitalized for a skin infection, whereas none of the vaccinated cases reported severe disease.

CONCLUSION

This outbreak was attributable primarily to failure to vaccinate, especially among children in grades 1 through 3. Catch-up vaccination of susceptible older children and adolescents is especially important to prevent accumulation of susceptibility in these groups, in which the natural disease is more severe. School entry requirements will contribute to a more rapid implementation of the existing recommendations for vaccination.

Challenges and opportunities in pandemic influenza planning: lessons learned from recent infectious disease preparedness and response efforts

The impact of the next pandemic influenza is likely to be far greater, by orders of magnitude, than most bioterrorism (BT) scenarios. A written pandemic emergency plan and establishment of emergency management teams are critical to mounting a coordinated and effective response to what will be a catastrophic event. Members of these teams should include public health, medical, emergency response and public safety officials, organized at each local, state and federal level. The tragic events of September 11, 2001 and the subsequent anthrax attacks have substantially increased funding and support for bioterrorism planning in the United States. Thus, public health officials have an unprecedented opportunity to strengthen current systems' planning efforts by promoting dual use bioterrorism/pandemic influenza plans. Combining lessons learned from the 2001 terrorist incidents, recent preevent smallpox vaccine programs and the history of past influenza pandemics, more effective strategies can be developed. For example, enhanced influenza surveillance systems can provide data that will not only provide early identification of a novel influenza strain, but will provide more timely recognition of other outbreaks of infectious diseases, including public health threats that may initially present as an influenza-like illness (ILI). In recent years, we have witnessed emerging and reemerging infectious disease threats that have presented us with challenges similar to those posed by an influenza pandemic. Such events highlight the need for advance planning to ensure an optimal response to a health emergency that is certain to be unpredictable, complex, rapidly evolving and accompanied by considerable public alarm. While advance warning for a terrorist attack is unlikely, the warning already exists for a possible new influenza strain, as evidenced by the recent cases of H5N1 in Hong Kong and the rapid global spread of cases of Severe Acute Respiratory Syndrome.

Preparing for pandemic influenza: the need for enhanced surveillance

In the US, planning for the next influenza pandemic is occurring in parallel at the national, state and local levels. Certain issues, such as conducting surveillance and purchasing pandemic vaccine, require co-ordination at the national level. However, most prevention and control actions will be implemented at the state and local levels, which vary widely in terms of population demographics, culture (e.g. rural versus urban) and available resources. In 1995, a survey by the Council of State and Territorial Epidemiologists (CSTE) found that only 29 (59%) states perceived a need to develop a specific influenza pandemic plan for their jurisdiction. Since then, the process of developing state and local plans has gained considerable momentum. Integration of these efforts with the national planning process has been facilitated by: (1) the mutual involvement of state and federal staff in both processes; (2) the sharing of draft documents; (3) the ongoing occurrence of local and national co-ordinating meetings; (4) the provision of financial resources by the federal government. So far, approximately 12 states either have drafted or begun drafting a state and local influenza pandemic plan. One of the benefits of the collaborative planning process has been the development of new working relationships and partnerships among several agencies at the state, local and national levels. Such efforts will improve our collective ability to rapidly investigate and control other emerging or re-emerging public health threats in the 21st century, be it a bioterrorist event, pandemic influenza, or any other catastrophic health event.

A multistate, foodborne outbreak of hepatitis A. National Hepatitis A Investigation Team

BACKGROUND

We investigated a large, foodborne outbreak of hepatitis A that occurred in February and March 1997 in Michigan and then extended the investigation to determine whether it was related to sporadic cases reported in other states among persons who had consumed frozen strawberries, the food suspected of causing the outbreak.

METHODS

The cases of hepatitis A were serologically confirmed. Epidemiologic studies were conducted in the two states with sufficient numbers of cases, Michigan and Maine. Hepatitis A virus RNA detected in clinical specimens was sequenced to determine the relatedness of the virus from outbreak-related cases and other cases.

RESULTS

A total of 213 cases of hepatitis A were reported from 23 schools in Michigan and 29 cases from 13 schools in Maine, with the median rate of attack ranging from 0.2 to 14 percent. Hepatitis A was associated with the consumption of frozen strawberries in a case-control study (odds ratio for the disease, 8.3; 95 percent confidence interval, 2.1 to 33) and a cohort study (relative risk of infection, 7.5; 95 percent confidence interval, 1.1 to 53) in Michigan and in a case-control study in Maine (odds ratio for infection, 3.4; 95 percent confidence interval, 1.0 to 14). The genetic sequences of viruses from 126 patients in Michigan and Maine were identical to one another and to those from 5 patients in Wisconsin and 7 patients in Arizona, all of whom attended schools where frozen strawberries from the same processor had been served, and to those in 2 patients from Louisiana, both of whom had consumed commercially prepared products containing frozen strawberries from the same processor.

CONCLUSIONS

We describe a large outbreak of hepatitis A in Michigan that was associated with the consumption of frozen strawberries. We found apparently sporadic cases in other states that could be linked to the same source by viral genetic analysis.

Predisposing factors for individuals' Lyme disease prevention practices: Connecticut, Maine, and Montana

OBJECTIVES

This study examined factors that predispose individuals to protect against Lyme disease.

METHODS

Knowledge, attitude, and practice questions concerning Lyme disease prevention were included in the Behavioral Risk Factor Surveillance surveys in Connecticut, Maine, and Montana. A total of 4246 persons were interviewed.

RESULTS

Perceived risk of acquiring Lyme disease, knowing anyone with Lyme disease, knowledge about Lyme disease, and believing Lyme disease to be a common problem were significantly associated with prevention practices.

CONCLUSIONS

Predisposing factors differ substantially between states and appear related to disease incidence. Personal risk, knowing someone with Lyme disease, and cognizance about Lyme disease and acting on this information are consistent with social learning theories.

An outbreak of cryptosporidiosis from fresh-pressed apple cider

BACKGROUND

Recent waterborne outbreaks have established Cryptosporidium as an emerging enteric pathogen, but foodborne transmission has rarely been reported. In October 1993, an outbreak of cryptosporidiosis occurred among students and staff attending a 1-day school agricultural fair in central Maine.

DESIGN

Environmental/laboratory investigation and cohort study.

PARTICIPANTS

Attendees of the fair and their household members.

MAIN OUTCOME MEASURES

Clinical or laboratory-confirmed cryptosporidiosis. Clinical cryptosporidiosis was defined as 3 days of either diarrhea (three loose stools in a 24-hour period) or vomiting.

RESULTS

Surveys were completed for 611 (81%) of the estimated 759 fair attendees. Among attendees who completed the survey, there were 160 (26%) primary cases. Cryptosporidium oocysts were detected in the stools of 50 (89%) of 56 primary and secondary case patients tested. The median incubation period was 6 days (range, 10 hours to 13 days); the median duration of illness was 6 days (range, 1 to 16 days). Eighty-four percent of primary case patients had diarrhea and 82% had vomiting. Persons drinking apple cider that was hand pressed in the afternoon were at increased risk for cryptosporidiosis (154 [54%] of 284 exposed vs six [2%] of 292 unexposed; relative risk, 26; 95% confidence interval, 12 to 59). Cryptosporidium oocysts were detected in the apple cider, on the cider press, and in the stool specimen of a calf on the farm that supplied the apples. The secondary household transmission rate was 15% (53/353).

CONCLUSIONS

This is the first large cryptosporidiosis outbreak in which foodborne transmission has been documented. It underscores the need for agricultural producers to take measures to avoid contamination of foodstuffs with infectious agents common to the farm environment.

Physicians and medical students: factors affecting entry into public health

We surveyed members of a recent master of public health (MPH) degree program to learn more about how, when, and why physicians and medical students decided to seek formal training in public health. We interviewed physicians and medical students to determine how and why these MPH students became involved in what they considered public health work; how and why they decided to attend public health school; and what their career plans were following completion of the degree program. All 47 medical students and physicians responded to the survey. Sixty-six percent described previous public health-related work experience. Only 5% decided prior to or during college to attend public health school. A personal contact directed 62% towards public health school. Those with previous public health work experience were more likely to pursue what they considered public health careers after completion of public health school than those without such previous work experience. The continuing need for qualified practitioners and leaders in public health challenges the medical community to characterize further those factors motivating medical students and physicians to formalize their training in public health.

An outbreak of cat-associated Q fever in the United States

Q fever is usually acquired by contact with aerosols generated during parturition of domestic ungulates (e.g., sheep, cows, goats). In the maritime provinces of Canada, parturient cats have also been implicated in its transmission. A 66-year-old woman from eastern Maine developed high fever, rigors, headache, myalgias, pulmonary infiltrates, and elevated hepatocellular enzymes, and the diagnosis of acute Q fever was confirmed serologically. She and 14 other family members had attended a family reunion in Maine 2 weeks earlier, when they were exposed to a parturient cat. All 11 adults and older children attending the reunion developed symptoms consistent with acute Q fever. Serum samples were obtained from 10 who attended the reunion and 8 who did not attend. Titers greater than or equal to 1:64 to Coxiella burnetii were present in all who attended the reunion but in none of those who did not. Cat-associated Q fever should be considered when sporadic cases of the disease occur in the United States.

Hepatitis B virus transmission between children in day care

We investigated two situations involving hepatitis B virus exposure among children in day care. In the first a 4-year-old boy who attended a day care center developed acute hepatitis B; another child at the center, who had a history of aggressive behavior (biting/scratching), was subsequently found to be a hepatitis B carrier. No other source of infection among family and other contacts was identified and no other persons at the center became infected. In the second situation a 4-year-old boy with frequently bleeding eczematous lesions was discovered to be a hepatitis B carrier after having attended a day care center for 17 months. Testing of contacts at the center revealed no transmission to other children or staff (representing 887 person months of exposure). Nationwide surveillance data showed that for the period 1983 to 1987, 161 children 1 to 4 years of age were reported with acute hepatitis B. After children with known hepatitis B risk factors were excluded, 25% (7 of 28) of children with known day care status were reported as day care attendees, a percentage comparable to national estimates of day care attendance by this age group. This is the first reported case of hepatitis B virus transmission between children in day care in the United States. Although it appears that day care transmission of hepatitis B is infrequent, further studies are needed to define the risk more accurately.