A research and development (R&D) roadmap for broadly protective coronavirus vaccines: A pandemic preparedness strategy

Broadly protective coronavirus vaccines are an important tool for protecting against future SARS-CoV-2 variants and could play a critical role in mitigating the impact of future outbreaks or pandemics caused by novel coronaviruses. The Coronavirus Vaccines Research and Development (R&D) Roadmap (CVR) is aimed at promoting the development of such vaccines. The CVR, funded by the Bill & Melinda Gates Foundation and The Rockefeller Foundation, was generated through a collaborative and iterative process, which was led by the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota and involved 50 international subject matter experts and recognized leaders in the field. This report summarizes the major issues and areas of research outlined in the CVR and identifies high-priority milestones. The CVR covers a 6-year timeframe and is organized into five topic areas: virology, immunology, vaccinology, animal and human infection models, and policy and finance. Included in each topic area are key barriers, gaps, strategic goals, milestones, and additional R&D priorities. The roadmap includes 20 goals and 86 R&D milestones, 26 of which are ranked as high priority. By identifying key issues, and milestones for addressing them, the CVR provides a framework to guide funding and research campaigns that promote the development of broadly protective coronavirus vaccines.

Multistate analysis of prospective Legionnaires' disease cluster detection using SaTScan, 2011-2015

Detection of clusters of Legionnaires’ disease, a leading waterborne cause of pneumonia, is challenging. Clusters vary in size and scope, are associated with a diverse range of aerosol-producing devices, including exposures such as whirlpool spas and hotel water systems typically associated with travel, and can occur without an easily identified exposure source. Recently, jurisdictions have begun to use SaTScan spatio-temporal analysis software prospectively as part of routine cluster surveillance. We used data collected by the Active Bacterial Core surveillance platform to assess the ability of SaTScan to detect Legionnaires’ disease clusters. We found that SaTScan analysis using traditional surveillance data and geocoded residential addresses was unable to detect many common Legionnaires’ disease cluster types, such as those associated with travel or a prolonged time between cases. Additionally, signals from an analysis designed to simulate a real-time search for clusters did not align with clusters identified by traditional surveillance methods or a retrospective SaTScan analysis. A geospatial analysis platform better tailored to the unique characteristics of Legionnaires’ disease epidemiology would improve cluster detection and decrease time to public health action.

Public Health and Law Enforcement Joint Investigation of Unknown Suspicious Substances and Potential Threat Evaluations, Minnesota, 2007-2016

From the Field is a semi-regular column that explores what it means to be a local health professional on the front lines of an emergency. Typically, National Association of County and City Health Officials (NACCHO) members share their stories of preparing for and responding to disasters, epidemics, and other major health issues. This month's column features a submission from a state health department that describes their experience in investigating white powder incidents. Through exploring the analysis of the challenges faced and the solutions developed, readers can learn how these public health champions keep their communities safe even in extreme situations. Readers may submit topics of interest to the column's editor, Meghan McGinty, PhD, MPH, MBA, at mmcginty@naccho.org.

Training in Infectious Disease Epidemiology through the Emerging Infections Program Sites

EIP sites contribute substantially to training current and future public health professionals.

One objective of the Emerging Infections Program (EIP) of the US Centers for Disease Control and Prevention is to provide training opportunities in infectious disease epidemiology. To determine the extent of training performed since the program's inception in 1995, we reviewed training efforts at the 10 EIP sites. By 2015, all sites hosted trainees (most were graduate public health students and physicians) who worked on a variety of infectious disease surveillance and epidemiologic projects. Trainee projects at all sites were used for graduate student theses or practicums. Numerous projects resulted in conference presentations and publications in peer-reviewed journals. Local public health and health care partners have also benefitted from EIP presentations and training. Consideration should be given to standardizing and documenting EIP training and to sharing useful training initiatives with other state and local health departments and academic institutions.

Emerging Infections Program--State Health Department Perspective

The Emerging Infections Program (EIP) is a collaboration between the Centers for Disease Control and Prevention and 10 state health departments working with academic partners to conduct active population-based surveillance and special studies for several emerging infectious disease issues determined to need special attention. The Centers for Disease Control and Prevention funds the 10 EIP sites through cooperative agreements. Our objective was to highlight 1) what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. Sharing these experiences should provide constructive insight to other public health programs and other countries contemplating a collaborative federal-local approach to collective public health challenges.

Recent Outbreaks of Meningococcal Disease among Men Who Have Sex with Men

Meningococcal disease outbreaks recently have occurred in several U.S. cities among men who are HIV-infected and who have had sex with other men. This article describes the first similar case of meningococcal meningitis serogroup C in Minnesota, which was confirmed this summer. It also offers vaccination guidance for physicians who care for patients who may be at high risk for the disease.

Legal Authority for Infectious Disease Reporting in the United States: Case Study of the 2009 H1N1 Influenza Pandemic

Tracking of infectious diseases is a public health core function essential to disease prevention and control. Each state mandates reporting of certain infectious diseases to public health authorities. These laws vary by state, and the variation could affect the ability to collect critical information. The 2009 H1N1 influenza pandemic served as a case study to examine the legal authority in the 50 states; Washington, DC; and New York City for mandatory infectious disease reporting, particularly for influenza and new or emerging infectious diseases. Our study showed reporting laws to be generally present and functioning well; nevertheless, jurisdictions should be mindful of their mandated parameters and review the robustness of their laws before they face a new or emerging disease outbreak.

Two concurrent enteric disease outbreaks among men who have sex with men, minneapolis-st paul area

Between 1 November 2013 and 31 March 2014, concurrent shigellosis and cryptosporidiosis outbreaks occurred among men who have sex with men in the Minneapolis-St. Paul area, 75% of whom were HIV-infected. Current HIV/AIDS strategy emphasizing treatment as prevention may effectively decrease HIV transmission, but raises concerns about other diseases if safer sex messages are de-emphasized.

Epidemiologic investigation of immune-mediated polyradiculoneuropathy among abattoir workers exposed to porcine brain

Background

In October 2007, a cluster of patients experiencing a novel polyradiculoneuropathy was identified at a pork abattoir (Plant A). Patients worked in the primary carcass processing area (warm room); the majority processed severed heads (head-table). An investigation was initiated to determine risk factors for illness.

Methods and Results

Symptoms of the reported patients were unlike previously described occupational associated illnesses. A case-control study was conducted at Plant A. A case was defined as evidence of symptoms of peripheral neuropathy and compatible electrodiagnostic testing in a pork abattoir worker. Two control groups were used - randomly selected non-ill warm-room workers (n = 49), and all non-ill head-table workers (n = 56). Consenting cases and controls were interviewed and blood and throat swabs were collected. The 26 largest U.S. pork abattoirs were surveyed to identify additional cases. Fifteen cases were identified at Plant A; illness onsets occurred during May 2004–November 2007. Median age was 32 years (range, 21–55 years). Cases were more likely than warm-room controls to have ever worked at the head-table (adjusted odds ratio [AOR], 6.6; 95% confidence interval [CI], 1.6–26.7), removed brains or removed muscle from the backs of heads (AOR, 10.3; 95% CI, 1.5–68.5), and worked within 0–10 feet of the brain removal operation (AOR, 9.9; 95% CI, 1.2–80.0). Associations remained when comparing head-table cases and head-table controls. Workers removed brains by using compressed air that liquefied brain and generated aerosolized droplets, exposing themselves and nearby workers. Eight additional cases were identified in the only two other abattoirs using this technique. The three abattoirs that used this technique have stopped brain removal, and no new cases have been reported after 24 months of follow up. Cases compared to controls had higher median interferon-gamma (IFNγ) levels (21.7 pg/ml; vs 14.8 pg/ml, P<0.001).

Discussion

This novel polyradiculoneuropathy was associated with removing porcine brains with compressed air. An autoimmune mechanism is supported by higher levels of IFNγ in cases than in controls consistent with other immune mediated illnesses occurring in association with neural tissue exposure. Abattoirs should not use compressed air to remove brains and should avoid procedures that aerosolize CNS tissue. This outbreak highlights the potential for respiratory or mucosal exposure to cause an immune-mediated illness in an occupational setting.

Outbreaks of salmonellosis in Minnesota (1998 through 2006) associated with frozen, microwaveable, breaded, stuffed chicken products

From 1998 through 2006, four outbreaks of salmonellosis associated with raw, frozen, microwaveable, breaded, prebrowned, stuffed chicken products were identified in Minnesota. In 1998, 33 Salmonella Typhimurium cases were associated with a single brand of Chicken Kiev. In 2005, four Salmonella Heidelberg cases were associated with a different brand and variety (Chicken Broccoli and Cheese). From 2005 to 2006, 27 Salmonella Enteritidis cases were associated with multiple varieties of product, predominately of the same brand involved in the 1998 outbreak. In 2006, three Salmonella Typhimurium cases were associated with the same brand of product involved in the 2005 Salmonella Heidelberg outbreak. The outbreak serotype and pulsed-field gel electrophoresis subtype of Salmonella were isolated from product in each outbreak. In these outbreaks, most individuals affected thought that the product was precooked due to its breaded and prebrowned nature, most used a microwave oven, most did not follow package cooking instructions, and none took the internal temperature of the cooked product. Similar to previous salmonellosis outbreaks associated with raw, breaded chicken nuggets or strips in Canada and Australia, inadequate labeling, consumer responses to labeling, and microwave cooking were the key factors in the occurrence of these outbreaks. Modification of labels, verification of cooking instructions by the manufacturer, and notifications to alert the public that these products contain raw poultry, implemented because of the first two outbreaks, did not prevent the other outbreaks. Microwave cooking is not recommended as a preparation method for these types of products, unless they are precooked or irradiated prior to sale.

Invasive group a streptococcal disease in nursing homes, Minnesota, 1995-2006

Nursing home residents are at high risk for invasive GAS disease; clusters are common.

Nursing home residents are at high risk for invasive group A streptococcal (GAS) disease, and clusters of cases in nursing homes are common.To characterize the epidemiologic features of invasive GAS disease in nursing homes, we conducted active, statewide, population- and laboratory-based surveillance in Minnesota from April 1995 through 2006. Of 1,858 invasive GAS disease cases, 134 (7%) occurred in nursing home residents; 34 of these cases were identified as part of 13 clusters. Recognizing cases of GAS disease in nursing homes posed challenges. Measures to ensure identification of case-patients as residents of specific nursing homes need to be included in standard guidelines for the prevention and control of invasive GAS disease in this setting.

Invasive group a streptococcal disease in nursing homes, Minnesota, 1995-2006

Nursing home residents are at high risk for invasive group A streptococcal (GAS) disease, and clusters of cases in nursing homes are common.To characterize the epidemiologic features of invasive GAS disease in nursing homes, we conducted active, statewide, population- and laboratory-based surveillance in Minnesota from April 1995 through 2006. Of 1,858 invasive GAS disease cases, 134 (7%) occurred in nursing home residents; 34 of these cases were identified as part of 13 clusters. Recognizing cases of GAS disease in nursing homes posed challenges. Measures to ensure identification of case-patients as residents of specific nursing homes need to be included in standard guidelines for the prevention and control of invasive GAS disease in this setting.

Circumstances of Bat Encounters and Knowledge of Rabies among Minnesota Residents Submitting Bats for Rabies Testing

Minnesota residents who submitted a bat to the Minnesota Department of Health for rabies testing in 2003 were surveyed by telephone regarding the circumstances of the bat encounter and their knowledge of bats and rabies. Of 442 bats submitted for testing, 12 (3%) tested positive for rabies, and 410 (93%) tested negative; 17 (4%) bats were unsuitable for testing, and three (1%) had equivocal results. A case-control study found that rabid bats were more likely than non-rabid bats to be found in September, found outside, found in a wooded area, unable to fly, acting ill, or acting aggressively. Rabid bats were not more likely than non-rabid bats to be found during the day or to have bitten someone. While most persons submitting bats for rabies testing were aware that bats can carry rabies, few knew they should submit the bat for testing until they sought the advice of an animal control officer, veterinarian, or healthcare provider.

Community-associated methicillin-resistant Staphylococcus aureus, Minnesota, 2000-2003

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) invasive disease resembled healthcare-associated MRSA disease.

We compared characteristics of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections (SSTIs) and CA-MRSA invasive disease identified in Minnesota from 2000 through 2003. A total of 586 patients with SSTIs and 65 patients with invasive disease were identified. Patients with invasive disease were more likely to be smokers (p = 0.03), and report a history of immunosuppressive therapy (p = 0.03), emphysema (p = 0.011), or injection drug use (p = 0.020) than were SSTI patients. Invasive disease isolates were less likely to be susceptible to ciprofloxacin (p = 0.002) and clindamycin (p = 0.001) and more likely to have healthcare-associated pulsed-field gel electrophoresis subtypes than SSTI isolates (p<0.001). Patients with invasive disease may have had healthcare exposures that put them at risk of acquiring healthcare-associated MRSA and which were not exclusion criteria in the CA-MRSA case definition. Continued surveillance of MRSA is needed to better characterize CA-MRSA infections.

Perinatal group B streptococcal disease prevention, Minnesota

In 2002, revised guidelines for preventing perinatal group B streptococcal disease were published. In 2002, all Minnesota providers surveyed reported using a prevention policy. Most screen vaginal and rectal specimens at 34–37 weeks of gestation. The use of screening-based methods has increased dramatically since 1998.

Outbreak of Escherichia coli O157:H7 infections associated with nonintact blade-tenderized frozen steaks sold by door-to-door vendors

Steaks have not been recognized as an important vehicle of Escherichia coli O157:H7 infection. During 11 to 27 June 2003, the Minnesota Department of Health (MDH) identified four O157 infection cases with the same pulsed-field gel electrophoresis (PFGE) subtype. All four case patients consumed brand A vacuum packed frozen steaks sold by door-to-door vendors. The steaks were blade tenderized and injected with marinade (i.e., nonintact). Information from single case patients in Michigan and Kansas identified through PulseNet confirmed the outbreak. The MDH issued a press release on 27 June to warn consumers, prompting a nationwide recall of 739,000 lb (335,506 kg) of frozen beef products. The outbreak resulted in six culture-confirmed cases (including one with hemolytic uremic syndrome) and two probable cases in Minnesota and single confirmed cases in four other states. The outbreak PFGE subtype of O157 was isolated from unopened brand A bacon-wrapped fillets from five affected Minnesota households. A fillet from one affected household was partially cooked in the laboratory, and the same O157 subtype was isolated from the uncooked interior. The tenderizing and injection processes likely transferred O157 from the surface to the interior of the steaks. These processing methods create new challenges for prevention of O157 infection. Food regulatory officials should reevaluate safety issues presented by nonintact steak products, such as microbiologic hazards of processing methods, possible labeling to distinguish intact from nonintact steaks, and education of the public and commercial food establishments on the increased risk associated with undercooked nonintact steaks. Information on single cases of O157 infection in individual states identified through PulseNet can be critical in solving multistate outbreaks in a timely manner.

An Outbreak of Pontiac Fever with Respiratory Distress among Workers Performing High‐Pressure Cleaning at a Sugar‐Beet Processing Plant

BACKGROUND

In August 2000, the Minnesota Department of Health was notified of and investigated an outbreak of febrile respiratory illness among workers at a sugar-beet processing plant.

METHODS

A case was defined as fever and respiratory symptoms occurring in a worker at the sugar-beet plant on or after 31 July 2000. Case patients were interviewed, medical and work records were reviewed, and clinical samples were obtained. The plant was inspected, and environmental samples were collected.

RESULTS

Fourteen of 15 case patients performed high-pressure water cleaning in the confined space of an evaporator vessel. Symptoms included fever and chills (100%), chest tightness (93%), cough (80%), and shortness of breath (73%). In case patients, median temperature was 39.4 degrees C, median oxygen saturation was 93%, and median white blood cell count was 12x10(3) cells/ mu L. Four (29%) of 14 case patients showed evidence of Legionella pneumophila exposure, according to serologic testing. Water sources contained up to 10(5) cfu/mL of L. pneumophila and 22,200 endotoxin units/mL.

CONCLUSIONS

Outbreak features were consistent with Pontiac fever. Respiratory symptoms, which are atypical for Pontiac fever, could be attributed to a high exposure dose of L. pneumophila from confined-space aerosolization or to endotoxin exposure. This outbreak demonstrates the potential occupational hazards for those performing high-pressure cleaning in confined spaces.

Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection

CONTEXT

Methicillin-resistant Staphylococcus aureus (MRSA) has traditionally been considered a health care-associated pathogen in patients with established risk factors. However, MRSA has emerged in patients without established risk factors (community-associated MRSA).

OBJECTIVE

To characterize epidemiological and microbiological characteristics of community-associated MRSA cases compared with health care-associated MRSA cases.

DESIGN, SETTING, AND PATIENTS

Prospective cohort study of patients with MRSA infection identified at 12 Minnesota laboratory facilities from January 1 through December 31, 2000, comparing community-associated (median age, 23 years) with health care-associated (median age, 68 years) MRSA cases.

MAIN OUTCOME MEASURES

Clinical infections associated with either community-associated or health care-associated MRSA, microbiological characteristics of the MRSA isolates including susceptibility testing, pulsed-field gel electrophoresis, and staphylococcal exotoxin gene testing.

RESULTS

Of 1100 MRSA infections, 131 (12%) were community-associated and 937 (85%) were health care-associated; 32 (3%) could not be classified due to lack of information. Skin and soft tissue infections were more common among community-associated cases (75%) than among health care-associated cases (37%) (odds ratio [OR], 4.25; 95% confidence interval [CI], 2.97-5.90). Although community-associated MRSA isolates were more likely to be susceptible to 4 antimicrobial classes (adjusted OR, 2.44; 95% CI, 1.35-3.86), most community-associated infections were initially treated with antimicrobials to which the isolate was nonsusceptible. Community-associated isolates were also more likely to belong to 1 of 2 pulsed-field gel electrophoresis clonal groups in both univariate and multivariate analysis. Community-associated isolates typically possessed different exotoxin gene profiles (eg, Panton Valentine leukocidin genes) compared with health care-associated isolates.

CONCLUSIONS

Community-associated and health care-associated MRSA cases differ demographically and clinically, and their respective isolates are microbiologically distinct. This suggests that most community-associated MRSA strains did not originate in health care settings, and that their microbiological features may have contributed to their emergence in the community. Clinicians should be aware that therapy with beta-lactam antimicrobials can no longer be relied on as the sole empiric therapy for severely ill outpatients whose infections may be staphylococcal in origin.

Epidemiology and clonality of community-acquired methicillin-resistant Staphylococcus aureus in Minnesota, 1996-1998

Methicillin-resistant Staphylococcus aureus (MRSA) has emerged among patients in the general population who do not have established risk factors for MRSA. Records from 10 Minnesota health facilities were reviewed to identify cases of MRSA infection that occurred during 1996-1998 and to identify which cases were community acquired. Susceptibility testing and pulsed-field gel electrophoresis (PFGE) subtyping were performed on available isolates. A total of 354 patients (median age, 16 years) with community-acquired MRSA (CAMRSA) infection were identified. Most case patients (299 [84%]) had skin infections, and 103 (29%) were hospitalized. More than 90% of isolates were susceptible to all antimicrobial agents tested, with the exception of beta-lactams and erythromycin. Of 334 patients treated with antimicrobial agents, 282 (84%) initially were treated with agents to which their isolates were nonsusceptible. Of 174 Minnesota isolates tested, 150 (86%) belonged to 1 PFGE clonal group. CAMRSA infections were identified throughout Minnesota; although most isolates were genetically related and susceptible to multiple antimicrobials, they were generally nonsusceptible to initial empirical therapy.

Addressing emerging infections. The partnership between public health and primary care physicians

In response to concerns about emerging infections, the Minnesota Department of Health, in conjunction with the Centers for Disease Control and Prevention, developed a model emerging infections program in 1995. The authors' experience with the program has demonstrated the key role clinicians have as partners with public health agencies in identifying and reporting disease cases, educating patients about infectious risks, and preventing emerging infections. This partnership is well illustrated by two examples from Minnesota: a recent outbreak of Neisseria meningitidis infection in a rural area and a laboratory surveillance study of invasive and drug-resistant Streptococcus pneumoniae infections in a metropolitan area.

Recommendations for chemoprophylaxis after occupational exposure to human immunodeficiency virus: a public health agency perspective

Public health agencies across the country uniformly retain three core functions, as identified in a 1988 Institute of Medicine report: assessment, assurance, and planning and policy development. The conduct of these functions will influence the ways the Public Health Service recommendations for postexposure prophylaxis are implemented locally. State, territorial, and local health departments play a key role in the monitoring and prevention of occupationally acquired human immunodeficiency virus (HIV) infections. Through assessment, public health agencies often are responsible for investigating healthcare workers who apparently have contracted HIV infection through an occupational exposure. In their function of providing assurance, public health agencies disseminate the national recommendations and may provide expert consultation taking into consideration local conditions. Specific healthcare worker exposure situations may pose complex medical and legal challenges best handled by public health agencies. In their role of providing policy development, public health agencies may convene an expert panel to review local data that affect postexposure prophylaxis, such as antiretroviral drug resistance and drug availability. The recommendations may result in legislative action in the form of mandatory testing of patients or other groups, and public health agencies must be wary of such attempts that are of unproven efficacy. Public health agencies nationwide must see that exposed healthcare workers and the clinicians counseling them are adequately informed about the risks of HIV transmission and the options available for prophylaxis.

A population-based study of sexually transmitted disease incidence and risk factors in human immunodeficiency virus-infected people

BACKGROUND AND OBJECTIVES

The Minnesota Department of Health conducts active surveillance for cases of human immunodeficiency virus (HIV) infection and passive surveillance for gonorrhea, Chlamydia trachomatis infection, and syphilis. The authors linked two computerized surveillance databases to assess gonorrhea incidence and risk factors for sexually transmitted disease (STD) acquisition among people with known HIV infection.

STUDY DESIGN

People diagnosed with adolescent/adult HIV infection before 1993 and still alive as of December 31, 1994 were compared to people diagnosed with gonorrhea, chlamydial infection, or primary/secondary syphilis in 1993 or 1994. Records were matched on name, date of birth, and gender. The incidence of reported gonorrhea was calculated and risk factors for STD acquisition were examined.

RESULTS

Thirty (1.3%) of 2,315 HIV-infected people were diagnosed with one or more STDs after HIV diagnosis (median interval: 3 years). There were 31 episodes of gonorrhea, seven episodes of chlamydial infection, and one episode of secondary syphilis. The gonorrhea incidence among HIV-infected people was high compared to the general population in Minnesota, even after stratifying by gender, age, and county of residence. STD acquisition was independently associated with female gender (odds ratio [OR] = 3.8; 95% confidence interval [CI] = 1.7, 8.3) and residence in Hennepin County (OR = 2.9; 95% CI = 1.2, 7.1), the most populous county in Minnesota.

CONCLUSIONS

Linkage of STD and HIV surveillance data is useful as a sentinel for high-risk sexual behavior among HIV-infected people, and it can help identify individuals who require additional interventions to prevent HIV transmission. State and local health departments should consider linking these data sources to assess trends and allocate resources.

Dental health care workers' response to the HIV epidemic

Random samples of Minnesota DHCWs were surveyed in late 1989 regarding HIV-related and infection control KAPs. Response rates were: dentists 69% (438/631); hygienists 73% (439/603); and assistants 56% (384/691). More than 50% of DHCWs said they did not have sufficient information to safely and effectively provide care for HIV-infected patients. Use of infection control techniques varied considerably. Parenteral injuries were relatively high, but only 5% of DHCWs believed they could have been exposed to HIV from these occurrences, and few DHCWs sought medical evaluation. Less than 45% of offices had a blood/body fluid exposure staff protocol, and few offices had a policy for HIV-infected staff. Nearly twice as many DHCWs said offices have an ethical versus a legal duty to treat HIV-infected persons. Low percentages of DHCWs believed the private practice dental office is the best place to treat HIV-infected patients, but approximately 50% said they would provide care. Twenty percent indicated that a diagnosed HIV-infected person had been seen at their office. Seventy-six percent said staff had been uncomfortable treating HIV-infected patients, 14% said staff had refused to treat, and 10% said referrals were difficult. DHCWs exhibited substantial improvements in their HIV-related KAPs compared to previous surveys. Nevertheless, additional cognitive and behavioral changes are necessary to ensure that all DHCWs provide care with the highest technical, legal, and ethical standards for all patients.

A look-back investigation of patients of an HIV-infected physician. Public health implications

BACKGROUND

Transmission of the human immunodeficiency virus (HIV) to five patients receiving care from an HIV-infected dentist in Florida has recently been reported. Current data indicate that the risk of HIV transmission from health care workers to patients is low. Despite this low risk, programs to notify patients of past exposure to an HIV-infected health care worker are being conducted with increasing frequency.

METHODS

We recently conducted an investigation of all the patients cared for by an HIV-infected family physician during a period when he had severe dermatitis caused by Mycobacterium marinum on his hands and forearms. After reviewing the patients' records, we notified 336 patients who had undergone one or more procedures (digital examination of a body cavity or vaginal delivery) placing them at potentially increased risk of HIV infection. The patients were offered tests for HIV infection and counseling.

RESULTS

Of the 336 patients, 325 (97 percent) had negative tests for HIV antibody, 3 (1 percent) refused testing, 1 (less than 1 percent) died of a cause unrelated to HIV infection before notification, and the HIV-antibody status of 7 (2 percent) remained unknown. The direct and indirect public health costs of this investigation were approximately $130,000.

CONCLUSIONS

The results of this investigation raise important questions about the risk of HIV transmission from health care workers to patients and the usefulness of HIV look-back programs, particularly in the light of recently published recommendations from the Centers for Disease Control. We propose that before a look-back investigation is undertaken, there should be a clearly identifiable risk of transmission of the infection, substantially higher than the risk requiring limitation of an HIV-infected health care worker's practice prospectively.

Infection control practices and beliefs of Minnesota dental hygienists and dental assistants

To obtain comprehensive information about the knowledge, attitudes, and practices of Minnesota dental hygienists and registered dental assistants, a questionnaire was mailed to random samples of both groups in the fall of 1988. Most assistants and hygienists claimed to always wear gloves, but substantially fewer indicated always wearing a mask. Use of eye protection showed even lower compliance, with less than half of either group routinely using protective eyewear or a face shield. Assistants and hygienists reported incurring numerous needlesticks and instrument injuries. A contributing factor may be that many staff were still recapping needles with an unprotected hand. Most people who had not been vaccinated against hepatitis B said that they would be immunized if their employer or health insurance paid for it. Less than one-half of either group felt knowledgeable about infection control. Only one-third of assistants and less than one-half of hygienists claimed to be familiar with the Centers for Disease Control's "Recommended Infection Control Practices for Dentistry." This is consistent with assistants' and hygienists' reported infection control related behaviors. Other than gloving, many recommended infection control measures--masking, wearing protective eyewear and uniforms, hepatitis B immunization, and proper handling of sharps--were not employed by a substantial number of respondents. Many respondents indicated insufficient knowledge to safely and effectively care for patients with hepatitis B, hepatitis B carriers, or individuals infected with the human immunodeficiency virus (HIV). This is reflected in the relatively small percentages of respondents who indicated willingness to treat these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV-1 counseling and testing sites, Minnesota: analysis of trends in client characteristics

We report here a summary of the data obtained from two HIV-1 antibody counseling and testing sites in Minneapolis-St. Paul for the first 48 months of operation (24,911 persons tested). The HIV-1 antibody seroprevalence rate for all persons tested was 5 percent. The highest seroprevalence rates were in male homosexual/bisexual intravenous drug users (23 percent) and homosexual/bisexual men (13 percent). There was a significant decrease in the HIV-1 antibody seroprevalence rate among clients during the 48-month period from 14 percent in the first six months to 3 percent in the last six months. This decrease coincided with an increase in the number of low-risk female clients and low-risk heterosexual male clients, and a decrease in the number of homosexual/bisexual males participating in the programs. These findings suggest the need for development and implementation of other strategies to identify and reach persons at highest risk for HIV-1 infection.

Infection with human T-lymphotropic virus type III/lymphadenopathy-associated virus: considerations for transmission in the child day care setting

Many public health and social issues relate to infection with the human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV)-the virus that causes the acquired immunodeficiency syndrome. One such issue is the care and education of infected children, both in schools and in day care facilities. To date, transmission of HTLV-III/LAV in either the school or the day care setting has not been documented. However, because the virus has been isolated from a variety of body fluids, contact with such fluids from an infected child poses at least a theoretical risk of transmission. Past experience with transmission of hepatitis B virus provides a possible model to aid in understanding the epidemiology of HTLV-III/LAV infection. The risk of transmission of HTLV-III/LAV in day care settings is not known, and infection with this virus carries serious public health and clinical implications.