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Laws RL, Jain S, Cooksey GS, Mohle-Boetani J, McNary J, Wilken J, Harrison R, Leistikow B, Vugia DJ, Windham GC, Materna BL. Coccidioidomycosis outbreak among inmate wildland firefighters: California, 2017. Am J Ind Med 2021; 64:266-273. [PMID: 33484179 PMCID: PMC8935635 DOI: 10.1002/ajim.23218] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/05/2020] [Accepted: 11/08/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND In California, state prison inmates are employed to fight wildfires, which involves performing soil-disrupting work. Wildfires have become more common, including areas where Coccidioides, the soil-dwelling fungus that causes coccidioidomycosis, proliferates. However, work practices that place wildland firefighters at risk for coccidioidomycosis have not been investigated. METHODS On August 17, 2017, the California Department of Public Health was notified of a cluster of coccidioidomycosis cases among Wildfire A inmate wildland firefighters. We collected data through medical record abstraction from suspected case-patients and mailed a survey assessing potential job task risk factors to Wildfire A inmate firefighters. We described respondent characteristics and conducted a retrospective case-control investigation to assess coccidioidomycosis risk factors. RESULTS Among 198 inmate firefighters who worked on Wildfire A, 112 (57%) completed the survey. Of 10 case-patients (four clinical and six laboratory-confirmed), two were hospitalized. In the case-control analysis of 71 inmate firefighters, frequently cutting fire lines with a McLeod tool (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 1.1-37.2) and being in a dust cloud or storm (OR: 4.3; 95% CI: 1.1-17.4) were associated with illness. Two of 112 inmate firefighters reported receiving coccidioidomycosis training; none reported wearing respiratory protection on this wildfire. CONCLUSIONS Wildland firefighters who use hand tools and work in dusty conditions where Coccidioides proliferates are at risk for coccidioidomycosis. Agencies that employ them should provide training about coccidioidomycosis and risk reduction, limit dust exposure, and implement respiratory protection programs that specify where respirator use is feasible and appropriate.
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Affiliation(s)
- Rebecca L. Laws
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- California Department of Public Health, Richmond, California, USA
| | - Seema Jain
- California Department of Public Health, Richmond, California, USA
| | | | | | - Jennifer McNary
- California Department of Public Health, Richmond, California, USA
| | - Jason Wilken
- California Department of Public Health, Richmond, California, USA
- Office of Public Health Preparedness and Response, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service Commissioned Corps, Rockville, Maryland, USA
| | - Robert Harrison
- California Department of Public Health, Richmond, California, USA
| | - Bruce Leistikow
- California Correctional Health Care Services, Elk Grove, California, USA
| | - Duc J. Vugia
- California Department of Public Health, Richmond, California, USA
| | - Gayle C. Windham
- California Department of Public Health, Richmond, California, USA
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2
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Wheeler C, Mohle-Boetani J. Completion Rates, Adverse Effects, and Costs of a 3-Month and 9-Month Treatment Regimen for Latent Tuberculosis Infection in California Inmates, 2011-2014. Public Health Rep 2019; 134:71S-79S. [PMID: 31059418 DOI: 10.1177/0033354919826557] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES In California, about 80% of tuberculosis disease is caused by untreated latent tuberculosis infection (LTBI), and the rate of LTBI is higher among incarcerated persons (16%) than among nonincarcerated persons (6%). We compared 2 regimens to treat LTBI in an adult prison population in California: 9 months of twice-weekly isoniazid (9H; previous standard of care) and 12 once-weekly doses of isoniazid and rifapentine (3HP; introduced in 2011). METHODS We evaluated the rates of completion and discontinuation caused by hepatotoxicity among randomly selected patients with LTBI prescribed the 9H regimen in 2011 and among patients with LTBI prescribed the 3HP regimen who entered California prisons during September 2013-March 2014. We compared the cost per fully treated patient for the 2 regimens. RESULTS Of 92 patients treated with the 9H regimen, the treatment completion rate was 42% and discontinuation due to hepatotoxicity was 14%. Of 122 patients who accepted the 3HP regimen, the completion rate was 90% and discontinuation due to hepatotoxicity was 2%. The cost per fully treated patient for the 9H regimen was $981 and for 3HP was $652. CONCLUSIONS In an incarcerated population, the 3HP regimen had a higher completion rate, lower hepatotoxicity, and lower cost per fully treated patient than the 9H regimen. If coupled with a high treatment initiation rate, the high rate of LTBI treatment completion with 3HP may contribute to reducing tuberculosis morbidity in California.
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Affiliation(s)
- Charlotte Wheeler
- 1 Medical Services Division, Public Health Branch, California Correctional Health Care Services, Elk Grove, CA, USA
| | - Janet Mohle-Boetani
- 1 Medical Services Division, Public Health Branch, California Correctional Health Care Services, Elk Grove, CA, USA
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3
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Lee LA, Yuan J, Vugia D, Wheeler C, Chapnick R, Mohle-Boetani J. Increased Coccidioidomycosis Among Inmates at a California Prison: Initial Investigation in 2005 to 2006. J Correct Health Care 2017; 23:347-352. [PMID: 28656821 DOI: 10.1177/1078345817716451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since 2005, coccidioidomycosis has increased among inmates at a California prison. Our initial investigation found an incidence of 3,323 cases/100,000 persons. Black race, age ≥41 years, and residence on Yard C were significantly associated with coccidioidomycosis ( p < .05). Inmates at this prison have continued to be at risk for coccidioidomycosis.
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Affiliation(s)
- Lauren A Lee
- 1 California Department of Public Health, Richmond, CA, USA
| | - Jean Yuan
- 1 California Department of Public Health, Richmond, CA, USA.,2 Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Duc Vugia
- 1 California Department of Public Health, Richmond, CA, USA
| | - Charlotte Wheeler
- 1 California Department of Public Health, Richmond, CA, USA.,3 California Correctional Health Care Services, Elk Grove, CA, USA
| | - Robert Chapnick
- 3 California Correctional Health Care Services, Elk Grove, CA, USA
| | - Janet Mohle-Boetani
- 1 California Department of Public Health, Richmond, CA, USA.,3 California Correctional Health Care Services, Elk Grove, CA, USA
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4
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Benedict K, Purfield AE, Mohle-Boetani J, Wheeler C, Park BJ. Awareness and Environmental Exposures Related to Coccidioidomycosis Among Inmates at Two California Prisons, 2013. J Correct Health Care 2017; 22:157-63. [PMID: 26984139 DOI: 10.1177/1078345816635577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coccidioidomycosis (Valley fever) is a major cause of illness in inmates in some California prisons. This article discusses an investigation conducted at two prisons to describe potential environmental exposures. The study did not identify modifiable risk factors; limiting the type or duration of outdoor activity in these prisons may not decrease coccidioidomycosis morbidity.
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Affiliation(s)
| | - Anne E Purfield
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Janet Mohle-Boetani
- California Correctional Health Care Services, Public Health Branch, Elk Grove, CA, USA
| | - Charlotte Wheeler
- California Correctional Health Care Services, Public Health Branch, Elk Grove, CA, USA
| | - Benjamin J Park
- California Correctional Health Care Services, Public Health Branch, Elk Grove, CA, USA
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5
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Leung J, Lopez AS, Tootell E, Baumrind N, Mohle-Boetani J, Leistikow B, Harriman KH, Preas CP, Cosentino G, Bialek SR, Marin M. Challenges with controlling varicella in prison settings: experience of California, 2010 to 2011. J Correct Health Care 2014; 20:292-301. [PMID: 25201912 DOI: 10.1177/1078345814541535] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article describes the epidemiology of varicella in one state prison in California during 2010 and 2011, control measures implemented, and associated costs. Eleven varicella cases were reported, of which nine were associated with two outbreaks. One outbreak consisted of three cases and the second consisted of six cases with two generations of spread. Among exposed inmates serologically tested, 98% (643/656) were varicella-zoster virus seropositive. The outbreaks resulted in > 1,000 inmates exposed, 444 staff exposures, and > $160,000 in costs. The authors documented the challenges and costs associated with controlling and managing varicella in a prison setting. A screening policy for evidence of varicella immunity for incoming inmates and staff and vaccination of susceptible persons has the potential to mitigate the impact of future outbreaks and reduce resources necessary to manage cases and outbreaks.
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Affiliation(s)
- Jessica Leung
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Adriana S Lopez
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elena Tootell
- California Correctional Health Care Services, Elk Grove, CA, USA
| | - Nikki Baumrind
- California Correctional Health Care Services, Elk Grove, CA, USA
| | | | - Bruce Leistikow
- California Correctional Health Care Services, Elk Grove, CA, USA
| | | | | | | | - Stephanie R Bialek
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mona Marin
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Schneider JL, White PL, Weiss J, Norton D, Lidgard J, Gould LH, Yee B, Vugia DJ, Mohle-Boetani J. Multistate outbreak of multidrug-resistant Salmonella newport infections associated with ground beef, October to December 2007. J Food Prot 2011; 74:1315-9. [PMID: 21819658 DOI: 10.4315/0362-028x.jfp-11-046] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In late October 2007, an outbreak of multidrug-resistant Salmonella Newport infections affected 42 case patients in California, Arizona, Idaho, and Nevada. A case-control study implicated ground beef from one chain store. Despite detailed ground beef purchase histories--including shopper card information for several case patients--traceback efforts by both the U.S. Department of Agriculture, Food Safety and Inspection Service and the California Department of Public Health were unable to identify the source of contamination. Case patients consumed multiple types of ground beef products purchased at numerous chain store A retail locations. These stores had received beef products for grinding from multiple beef slaughter-processing establishments. Detailed retail grinding logs and grinding policies that prevent cross-contamination between batches of ground beef products are crucial in the identification of contaminated beef products associated with foodborne illness.
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Affiliation(s)
- J L Schneider
- California Department of Public Health, Division of Communicable Disease Control, Infectious Diseases Branch, Richmond, California 94804, USA.
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Abstract
BACKGROUND Botulism is an acute neurologic illness characterized by cranial nerve palsies and descending flaccid paralysis. Botulism is a rare disease and recurrent botulism even more rare. We review cases of recurrent wound botulism (WB) among injection drug users (IDUs) in California from 1993 through 2006 and describe 2 case patients. METHODS From botulism surveillance data for 1993-2006, we identified patients with >1 episode of clinical WB, defined as acute descending paralysis with a visible wound or recent history of injection drug use. For each patient, ≥1 of their WB episodes was laboratory confirmed. We extracted demographic, clinical, and laboratory information from case and laboratory reports and compared clinical characteristic frequency of initial and second WB episodes. RESULTS During 1993-2006, 17 IDUs had recurrent WB, 14 with 1 recurrence and 3 with 2 recurrences. Of 25 laboratory-confirmed episodes, 22 were confirmed through serum testing and 3 through wound testing. Patients were 32-61 years old, and 94% were male. All patients reported heroin injections; 88% specified black tar heroin use and 76% reported subcutaneous injection. The most common presentations were having a visible wound, speech difficulty, double vision, respiratory difficulty, and trouble swallowing. There were no significant differences in clinical presentation between initial and second episodes. CONCLUSIONS As the California epidemic of WB among IDUs continues, WB episodes are recurring. Both clinicians and IDUs should be aware of the potential for WB to recur among IDUs to enable timely diagnosis and early botulinum antitoxin administration and supportive care.
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Affiliation(s)
- Jean Yuan
- Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California 94804, USA
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8
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Skoff TH, Farley MM, Petit S, Craig AS, Schaffner W, Gershman K, Harrison LH, Lynfield R, Mohle-Boetani J, Zansky S, Albanese BA, Stefonek K, Zell ER, Jackson D, Thompson T, Schrag SJ. Increasing burden of invasive group B streptococcal disease in nonpregnant adults, 1990-2007. Clin Infect Dis 2009; 49:85-92. [PMID: 19480572 DOI: 10.1086/599369] [Citation(s) in RCA: 321] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Group B Streptococcus (GBS), traditionally considered to be a neonatal pathogen, is an important cause of morbidity and mortality among older adults and among those with underlying medical conditions. We used population-based surveillance to examine trends in adult GBS disease during the period 1990-2007 and to describe the epidemiology of adult GBS disease to guide prevention efforts. METHODS Active Bacterial Core surveillance was conducted in selected counties in 10 US states. A case was defined as isolation of GBS from a normally sterile site in a nonpregnant resident of a surveillance area who was 18 years of age. Rates were calculated using US Census data. Demographic and clinical information was abstracted from medical records. Serotyping and susceptibility testing were performed on isolates collected from a subset of case patients. RESULTS A total of 19,512 GBS cases were identified in nonpregnant adults during 1990-2007 (median patient age, 63 years); the incidence of adult GBS disease doubled from 3.6 cases per 100,000 persons during 1990 to 7.3 cases per 100,000 persons during 2007 (P < .001). The mean difference in incidence between black and white persons was 4.6 cases per 100,000 persons (range, 3.1 cases per 100,000 persons during 1991 to 5.8 cases per 100,000 persons during 1999). Common clinical syndromes in 2007 included bacteremia without focus (39.3%), skin and/or soft-tissue infection (25.6%), and pneumonia (12.6%). Most (88.0%) GBS cases in adults had 1 underlying condition; diabetes was present in 44.4% of cases. Serotypes V, Ia, II, and III accounted for 80.8% of infections during 1998-1999 and 78.5% of infections during 2005-2006. CONCLUSIONS Invasive GBS disease in nonpregnant adults represents a substantial and increasing burden, particularly among older persons, black persons, and adults with diabetes. Prevention strategies are needed.
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Affiliation(s)
- Tami H Skoff
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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9
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Abstract
BACKGROUND California has an ongoing epidemic of wound botulism (WB) among injection drug users (IDUs). We retrospectively studied a cohort of patients with WB and determined the sensitivity of the mouse bioassay-the gold standard laboratory test for confirmation of botulism-in verifying WB. METHODS We defined a clinical case of WB as an acute, bilateral, descending, flaccid paralysis starting with 1 cranial nerve palsies in an IDU with no other explainable diagnosis. We calculated the sensitivity of the mouse bioassay as the proportion of clinical WB cases that had positive serum toxin test results by mouse bioassay. We compared serum toxin-positive with serum toxin-negative patients. RESULTS Of 73 patients with WB, 50 tested serum toxin positive, yielding a sensitivity of 68%. Serum toxin-positive patients did not differ significantly from serum toxin-negative patients with respect to demographic characteristics or injection drug use practices or in days from patient symptom onset to collection of specimens for testing. Patients did not differ significantly by clinical characteristics, except that serum toxin-positive patients were more likely than serum toxin-negative patients to have required mechanical ventilation during their hospital courses (74% vs. 43%; P = .01). CONCLUSIONS In this study, the mouse bioassay failed to detect botulinum toxin in the serum samples of nearly one-third of IDUs with characteristic WB. Such patients should be considered to have probable WB. Physicians should be aware of the test's limitations and base their final diagnosis of suspected WB on clinical criteria when the mouse bioassay produces negative results.
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Affiliation(s)
- Charlotte Wheeler
- Infectious Diseases Branch, Div. of Communicable Disease Control, Center for Infectious Diseases, California Dept. of Public Health, 850 Marina Bay Pkwy., Bldg. P, Richmond, CA 94804-6403, USA.
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10
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Van Dyke MK, Phares CR, Lynfield R, Thomas AR, Arnold KE, Craig AS, Mohle-Boetani J, Gershman K, Schaffner W, Petit S, Zansky SM, Morin CA, Spina NL, Wymore K, Harrison LH, Shutt KA, Bareta J, Bulens SN, Zell ER, Schuchat A, Schrag SJ. Evaluation of universal antenatal screening for group B streptococcus. N Engl J Med 2009; 360:2626-36. [PMID: 19535801 DOI: 10.1056/nejmoa0806820] [Citation(s) in RCA: 295] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Group B streptococcal disease is one of the most common infections in the first week after birth. In 2002, national guidelines recommended universal late antenatal screening of pregnant women for colonization with group B streptococcus to identify candidates for intrapartum chemoprophylaxis. METHODS We evaluated the implementation of the guidelines in a multistate, retrospective cohort selected from the Active Bacterial Core surveillance, a 10-state, population-based system that monitors invasive group B streptococcal disease. We abstracted data from the labor and delivery records of a stratified random sample of live births and of all cases in which the newborn had early-onset group B streptococcal disease (i.e., disease in infants <7 days of age) in 2003 and 2004. We compared our results with those from a study with a similar design that evaluated screening practices in 1998 and 1999. RESULTS We abstracted records of 254 births in which the infant had group B streptococcal disease and 7437 births in which the infant did not. The rate of screening for group B streptococcus before delivery increased from 48.1% in 1998-1999 to 85.0% in 2003-2004; the percentage of infants exposed to intrapartum antibiotics increased from 26.8% to 31.7%. Chemoprophylaxis was administered in 87.0% of the women who were positive for group B streptococcus and who delivered at term, but in only 63.4% of women with unknown colonization status who delivered preterm. The overall incidence of early-onset group B streptococcal disease was 0.32 cases per 1000 live births. Preterm infants had a higher incidence of early-onset group B streptococcal disease than did term infants (0.73 vs. 0.26 cases per 1000 live births); however, 74.4% of the cases of group B streptococcal disease (189 of 254) occurred in term infants. Missed screening among mothers who delivered at term accounted for 34 of the 254 cases of group B streptococcal disease (13.4%). A total of 61.4% of the term infants with group B streptococcal disease were born to women who had tested negative for group B streptococcus before delivery. CONCLUSIONS Recommendations for universal screening were rapidly adopted. Improved management of preterm deliveries and improved collection, processing, and reporting of culture results may prevent additional cases of early-onset group B streptococcal disease.
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Affiliation(s)
- Melissa K Van Dyke
- Epidemic Intelligence Service Program, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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11
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Phares CR, Lynfield R, Farley MM, Mohle-Boetani J, Harrison LH, Petit S, Craig AS, Schaffner W, Zansky SM, Gershman K, Stefonek KR, Albanese BA, Zell ER, Schuchat A, Schrag SJ. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA 2008; 299:2056-65. [PMID: 18460666 DOI: 10.1001/jama.299.17.2056] [Citation(s) in RCA: 619] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Group B streptococcus is a leading infectious cause of morbidity in newborns and causes substantial disease in elderly individuals. Guidelines for prevention of perinatal disease through intrapartum chemoprophylaxis were revised in 2002. Candidate vaccines are under development. OBJECTIVE To describe disease trends among populations that might benefit from vaccination and among newborns during a period of evolving prevention strategies. DESIGN AND SETTING Analysis of active, population-based surveillance in 10 states participating in the Active Bacterial Core surveillance/Emerging Infections Program Network. MAIN OUTCOME MEASURES Age- and race-specific incidence of invasive group B streptococcal disease. RESULTS There were 14,573 cases of invasive group B streptococcal disease during 1999-2005, including 1348 deaths. The incidence of invasive group B streptococcal disease among infants from birth through 6 days decreased from 0.47 per 1000 live births in 1999-2001 to 0.34 per 1000 live births in 2003-2005 (P < .001), a relative reduction of 27% (95% confidence interval [CI], 16%-37%). Incidence remained stable among infants aged 7 through 89 days (mean, 0.34 per 1000 live births) and pregnant women (mean, 0.12 per 1000 live births). Among persons aged 15 through 64 years, disease incidence increased from 3.4 per 100,000 population in 1999 to 5.0 per 100,000 in 2005 (chi2(1) for trend, 57; P < .001), a relative increase of 48% (95% CI, 32%-65%). Among adults 65 years or older, incidence increased from 21.5 per 100,000 to 26.0 per 100,000 (chi2(1) for trend, 15; P < .001), a relative increase of 20% (95% CI, 8%-35%). All 4882 isolates tested were susceptible to penicillin, ampicillin, and vancomycin, but 32% and 15% were resistant to erythromycin and clindamycin, respectively. Serotypes Ia, Ib, II, III, and V accounted for 96% of neonatal cases and 88% of adult cases. CONCLUSIONS Among infants from birth through 6 days, the incidence of group B streptococcal disease was lower in 2003-2005 relative to 1999-2001. This reduction coincided with the release of revised disease prevention guidelines in 2002. However, the disease burden in adults is substantial and increased significantly during the study period.
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Affiliation(s)
- Christina R Phares
- Epidemic Intelligence Service Program, Office of Workforce and Career Development, Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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12
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Voetsch AC, Kennedy MH, Keene WE, Smith KE, Rabatsky-Ehr T, Zansky S, Thomas SM, Mohle-Boetani J, Sparling PH, McGavern MB, Mead PS. Risk factors for sporadic Shiga toxin-producing Escherichia coli O157 infections in FoodNet sites, 1999-2000. Epidemiol Infect 2006; 135:993-1000. [PMID: 17147834 PMCID: PMC2870643 DOI: 10.1017/s0950268806007564] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
To monitor risk factors for illness, we conducted a case-control study of sporadic Shiga toxin-producing Escherichia coli O157 (STEC O157) infections in 1999-2000. Laboratory-confirmed cases of STEC O157 infection were identified through active laboratory surveillance in all or part of seven states. Patients and age-matched controls were interviewed by telephone using a standard questionnaire. Information was collected on demographics, clinical illness, and exposures to food, water, and animals in the 7 days before the patient's illness onset. During the 12-month study, 283 patients and 534 controls were enrolled. STEC O157 infection was associated with eating pink hamburgers, drinking untreated surface water, and contact with cattle. Eating produce was inversely associated with infection. Direct or indirect contact with cattle waste continues to be a leading identified source of sporadic STEC O157 infections.
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Affiliation(s)
- A C Voetsch
- Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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13
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Hennessy TW, Cheng LH, Kassenborg H, Ahuja SD, Mohle-Boetani J, Marcus R, Shiferaw B, Angulo FJ. Egg consumption is the principal risk factor for sporadic Salmonella serotype Heidelberg infections: a case-control study in FoodNet sites. Clin Infect Dis 2004; 38 Suppl 3:S237-43. [PMID: 15095195 DOI: 10.1086/381593] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
To determine risk factors for sporadic Salmonella serotype Heidelberg diarrheal disease, we conducted a population-based case-control study in 5 Foodborne Diseases Active Surveillance Network (FoodNet) surveillance areas in 1996-1997. Forty-four case patients and 83 control subjects matched by age and telephone exchange were asked about exposures during the 5-day period before onset of illness in the case patient. Risk factors for infection were evaluated using conditional logistic regression analysis. Eating eggs prepared outside the home remained the only significant risk factor for illness (matched odds ratio [MOR], 6.0; 95% confidence interval [CI], 1.2-29.6). The population-attributable fraction of S. Heidelberg infections associated with eating eggs prepared outside the home was 37%. Eliminating the risk associated with out-of-home egg consumption could substantially reduce the incidence of S. Heidelberg infections. Control measures to prevent S. Heidelberg infection should include advising consumers to avoid eating undercooked eggs and educating food handlers about proper egg handling and cooking.
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Affiliation(s)
- Thomas W Hennessy
- Foodborne and Diarrheal Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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14
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Campbell JV, Mohle-Boetani J, Reporter R, Abbott S, Farrar J, Brandl M, Mandrell R, Werner SB. An outbreak of Salmonella serotype Thompson associated with fresh cilantro. J Infect Dis 2001; 183:984-7. [PMID: 11237818 DOI: 10.1086/319254] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2000] [Revised: 12/08/2000] [Indexed: 11/03/2022] Open
Abstract
An outbreak of Salmonella serotype Thompson in California was identified through laboratory-based surveillance and investigated with case-control, traceback, and laboratory studies. There were 35 "sporadic" cases and a restaurant-associated outbreak of 41 cases with onset between 6 March and 31 March 1999. Three case patients were hospitalized. A case-control study found a significant association between illness and eating cilantro at a restaurant (63% of case patients vs. 34% of control subjects; odds ratio, 3.5; 95% confidence interval, 1.1-11.4). Although common distributors of cilantro were identified, inadequate records prohibited the identification of a single farm supplying cilantro. At room temperature, Salmonella Thompson grew more rapidly and to a higher concentration on chopped cilantro, compared with whole-leaf cilantro. Freshly made salsa (pH 3.4) supported growth of Salmonella Thompson. Cilantro should be served promptly after chopping. Accurate records of the distribution of produce should be available, and bacterial contamination of produce should be prevented in retail and wholesale establishments, in packing sheds, and on farms.
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Affiliation(s)
- J V Campbell
- Disease Investigations and Surveillance Branch, California Department of Health Services (CDHS), Berkeley, CA, USA
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Sciortino S, Mohle-Boetani J, Royce SE, Will D, Chin DP. B notifications and the detection of tuberculosis among foreign-born recent arrivals in California. Int J Tuberc Lung Dis 1999; 3:778-85. [PMID: 10488885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
OBJECTIVE To evaluate the effectiveness and limitations of the B notification program for detecting tuberculosis among recent foreign-born arrivals in California. DESIGN Retrospective cohort study. All foreign-born visa holders with a B notification who arrived in California from January 1992 through September 1995 (n = 27 412) were matched with a listing of foreign-born persons who arrived in the US during the same time period and who were reported to have active tuberculosis in California within one year of their arrival from January 1992 through September 1996 (n = 2547). RESULTS Overall, 3.5% (95% confidence interval 3.3%, 3.8%) of all persons with a B notification were reported to have active tuberculosis within a year of arrival. Recent arrivals with a B notification and tuberculosis accounted for 38% of all foreign-born cases of tuberculosis reported within one year of arrival. Compared to recent arrivals without a B notification, those with a B notification were more likely to have pulmonary tuberculosis, less likely to have smear-positive pulmonary disease and reported with tuberculosis sooner after their arrival in the US. The B notification program was not able to identify 87% of the smear-positive pulmonary tuberculosis cases in adults, and did not identify 99% of these highly infectious cases among Latin Americans. CONCLUSIONS Although the evaluation of persons who enter the US with B notifications has a high yield for identifying active tuberculosis cases, it was not able to identify the majority of recent arrivals with the most infectious form of tuberculosis.
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Affiliation(s)
- S Sciortino
- California Department of Health Services, Tuberculosis Control Branch, Berkeley, USA
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Yamada EG, Mohle-Boetani J, Olson KR, Werner SB. Mushroom poisoning due to amatoxin. Northern California, Winter 1996-1997. West J Med 1998; 169:380-4. [PMID: 9866444 PMCID: PMC1305415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- E G Yamada
- California Department of Health Services, Chronic Disease Control Branch, Sacramento, CA 94234-7320, USA.
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Cummings KC, Mohle-Boetani J, Royce SE, Chin DP. Movement of tuberculosis patients and the failure to complete antituberculosis treatment. Am J Respir Crit Care Med 1998; 157:1249-52. [PMID: 9563747 DOI: 10.1164/ajrccm.157.4.9708058] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The outcomes of tuberculosis (TB) patients who move before completing antituberculosis treatment have not been described. We studied a population-based cohort of 2,576 adult patients reported as having TB in California during 1993, including 147 patients who moved from one local health jurisdiction to another within California. We determined treatment outcomes (completed, defaulted, died, other) for 131 (89%) of these 147 patients. Patients who moved defaulted more often (relative risk [RR] = 5.5, 95% confidence interval [CI] = 4.1 to 7.4) than patients who did not move. Including these patients' treatment outcomes increased the known number of defaulters by 30%, from 141 to 183 persons. Additionally, diagnosis of TB in a state prison emerged as the strongest risk factor for defaulting from treatment. Patients who moved or defaulted were more likely to abuse drugs or alcohol, to be homeless or to be associated with congregate settings such as jails and prisons. On average, patients who defaulted after moving received less than three-quarters of their recommended treatment regimens. These patients may remain infectious or become infectious again. Our findings highlight the importance of ensuring complete treatment for TB patients who move; failure to do so will adversely affect patient health and TB control, especially in many high-risk populations and settings.
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Affiliation(s)
- K C Cummings
- Tuberculosis Control Branch, California Department of Health Services, Berkeley 94704, USA
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Cummings K, Mohle-Boetani J, Catlos E, Fenstersheib M, Royce S. An investigation of increased tuberculosis case reports in Santa Clara County, California, 1993-1994. Am J Public Health 1997; 87:1721. [PMID: 9357365 PMCID: PMC1381146 DOI: 10.2105/ajph.87.10.1721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
The importance of group B streptococcus (GBS) as a cause of serious infectious disease among adults is not widely appreciated. In adults, the modes of acquisition and transmission are unknown. Since most hospital-based studies of GBS bacteremia in adults consist of small numbers of patients, the clinical spectrum of disease is not well described. Our retrospective study reviews the clinical features, antimicrobial therapy, and risk factors for mortality of 32 adult patients (18 women and 14 men) with GBS bacteremia and compares the proportion of isolates from the different beta-hemolytic streptococci sero-groups. We found that 39% of isolates from adult blood cultures were group B, a frequency nearly identical to that of group A streptococcal bacteremia. Most (66%) adult patients were more than 50 years old. Primary bacteremia was the most frequent clinical diagnosis, occurring in 7 (22%) of 32 patients. Nonhematologic cancer was the most frequently associated condition (25%). Nineteen percent of the patients had diabetes mellitus. The overall mortality rate was 31% and was significantly associated with increasing age. Our results are compared to those obtained by a review of all 5 previous comparable studies and demonstrate that GBS bacteremia is a serious infection in adults with increased mortality related to advancing age.
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Affiliation(s)
- J M Colford
- Department of Medicine, Stanford University Medical Center, California 94305, USA
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20
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Schuchat A, Deaver-Robinson K, Plikaytis BD, Zangwill KM, Mohle-Boetani J, Wenger JD. Multistate case-control study of maternal risk factors for neonatal group B streptococcal disease. The Active Surveillance Study Group. Pediatr Infect Dis J 1994; 13:623-9. [PMID: 7970951 DOI: 10.1097/00006454-199407000-00008] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Risk factors for early onset disease (EOD) caused by Group B streptococci (GBS) that are the foundation of prevention guidelines were identified in studies conducted in a few hospital centers. We investigated cases of EOD identified through laboratory-based active surveillance during 1991 and 1992 in a multistate population of 17 million. Ninety-nine cases were compared with 253 controls matched for hospital, date of birth and birth weight. Prematurity (< 37 weeks of gestation) was present in 28% of cases; 53% of case mothers had rupture of membranes > 12 hours; and 48% reported intrapartum fever. The incidence of EOD in each surveillance area was higher among blacks. By multivariate analysis, case mothers were more likely than controls to have rupture of membranes before labor onset (adjusted odds ratio 8.7, P < 0.001), intrapartum fever (adjusted odds ratio 11.9, P < 0.001), and history of urinary infection during pregnancy (adjusted odds ratio 4.3, P < 0.05). Young maternal age was also associated with risk of disease. Three-fourths of case mothers had intrapartum fever, < 37 weeks of gestation and/or prolonged rupture of membranes, indicators previously used to select high risk women for intrapartum chemoprophylaxis. Our findings extend data from single hospitals and suggest prenatal screening and selective intrapartum chemoprophylaxis of high-risk mothers could potentially prevent the majority of EOD in the United States.
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Affiliation(s)
- A Schuchat
- Childhood and Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333
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21
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Tappero JW, Koehler JE, Berger TG, Cockerell CJ, Lee TH, Busch MP, Stites DP, Mohle-Boetani J, Reingold AL, LeBoit PE. Bacillary angiomatosis and bacillary splenitis in immunocompetent adults. Ann Intern Med 1993; 118:363-5. [PMID: 8430982 DOI: 10.7326/0003-4819-118-5-199303010-00007] [Citation(s) in RCA: 114] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Tappero JW, Mohle-Boetani J, Koehler JE, Swaminathan B, Berger TG, LeBoit PE, Smith LL, Wenger JD, Pinner RW, Kemper CA. The epidemiology of bacillary angiomatosis and bacillary peliosis. JAMA 1993; 269:770-5. [PMID: 8423659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine environmental risk factors for bacillary angiomatosis-bacillary peliosis (BAP), and to confirm infection with Rochalimaea species. DESIGN Case-control study. SETTING Community and university hospitals and clinics. PATIENTS Case patients (N = 48) had biopsy-confirmed BAP. Controls (N = 94) were matched to patients by institution and by human immunodeficiency virus (HIV) serological status. MAIN OUTCOME MEASURES Clinical information was obtained from medical records. Subjects were queried about environmental exposures. Univariate odds ratios (ORs) with 95% confidence intervals (CIs) were determined. Bivariate analyses were performed on variables associated with disease by univariate analysis. DNA from 22 available case-patient tissues and from 22 control tissues was amplified with the polymerase chain reaction (PCR) using primers designed to detect Rochalimaea species. RESULTS We identified five HIV-negative, immunocompetent case patients; one HIV-negative, immunodeficient case patient; and 42 HIV-positive case patients. There were no significant differences between case patients and controls by race, sex, age, or risk factors for HIV infection. Owning a cat (OR, 2.8; CI, 1.4 to 5.8) and history of a recent cat lick (OR, 1.95; CI, 1.0 to 3.8), cat scratch (OR, 3.7; CI, 1.7 to 8.0), or cat bite (OR, 3.9; CI, 1.8 to 8.9) were associated with disease in the univariate analysis. In bivariate analyses, only the variables representing traumatic contact with a cat (bite or scratch) remained associated with disease. No other environmental exposure was associated with disease. The PCR amplified a DNA fragment of the size expected for Rochalimaea species in all 22 case-patient tissue specimens. CONCLUSIONS These data suggest that BAP is a new zoonosis associated with both traumatic exposure to cats and infection with Rochalimaea species or a closely related organism.
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Affiliation(s)
- J W Tappero
- Department of Dermatology, University of California, San Francisco
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Tappero JW, Mohle-Boetani J, Koehler JE, Swaminathan B, Berger TG, LeBoit PE, Smith LL, Wenger JD, Pinner RW, Kemper CA. The epidemiology of bacillary angiomatosis and bacillary peliosis. JAMA 1993. [PMID: 8423659 DOI: 10.1001/jama.269.6.770] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine environmental risk factors for bacillary angiomatosis-bacillary peliosis (BAP), and to confirm infection with Rochalimaea species. DESIGN Case-control study. SETTING Community and university hospitals and clinics. PATIENTS Case patients (N = 48) had biopsy-confirmed BAP. Controls (N = 94) were matched to patients by institution and by human immunodeficiency virus (HIV) serological status. MAIN OUTCOME MEASURES Clinical information was obtained from medical records. Subjects were queried about environmental exposures. Univariate odds ratios (ORs) with 95% confidence intervals (CIs) were determined. Bivariate analyses were performed on variables associated with disease by univariate analysis. DNA from 22 available case-patient tissues and from 22 control tissues was amplified with the polymerase chain reaction (PCR) using primers designed to detect Rochalimaea species. RESULTS We identified five HIV-negative, immunocompetent case patients; one HIV-negative, immunodeficient case patient; and 42 HIV-positive case patients. There were no significant differences between case patients and controls by race, sex, age, or risk factors for HIV infection. Owning a cat (OR, 2.8; CI, 1.4 to 5.8) and history of a recent cat lick (OR, 1.95; CI, 1.0 to 3.8), cat scratch (OR, 3.7; CI, 1.7 to 8.0), or cat bite (OR, 3.9; CI, 1.8 to 8.9) were associated with disease in the univariate analysis. In bivariate analyses, only the variables representing traumatic contact with a cat (bite or scratch) remained associated with disease. No other environmental exposure was associated with disease. The PCR amplified a DNA fragment of the size expected for Rochalimaea species in all 22 case-patient tissue specimens. CONCLUSIONS These data suggest that BAP is a new zoonosis associated with both traumatic exposure to cats and infection with Rochalimaea species or a closely related organism.
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Affiliation(s)
- J W Tappero
- Department of Dermatology, University of California, San Francisco
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Mohle-Boetani J, Akula SK, Holodniy M, Katzenstein D, Garcia G. The sulfone syndrome in a patient receiving dapsone prophylaxis for Pneumocystis carinii pneumonia. West J Med 1992; 156:303-6. [PMID: 1595261 PMCID: PMC1003252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- J Mohle-Boetani
- Meningitis and Special Pathogens Branch, Centers for Disease Control, Atlanta, Georgia
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Wollner A, Mohle-Boetani J, Lambert RE, Perruquet JL, Raffin TA, McGuire JL. Pneumocystis carinii pneumonia complicating low dose methotrexate treatment for rheumatoid arthritis. Thorax 1991; 46:205-7. [PMID: 2028435 PMCID: PMC463037 DOI: 10.1136/thx.46.3.205] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Low dose methotrexate has been used effectively for various rheumatic and non-rheumatic diseases. Three cases of Pneumocystis carinii pneumonia occurring during treatment of rheumatoid arthritis with low dose methotrexate are presented. Several mechanisms might contribute to impaired immunity and the rare development of opportunist lung infection with methotrexate. A high degree of suspicion may result in earlier diagnosis and treatment.
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Affiliation(s)
- A Wollner
- Respiratory Medicine Division, Stanford University Medical Center, California 94305-5236
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Whittemore AS, Wu ML, Paffenbarger RS, Sarles DL, Kampert JB, Grosser S, Jung DL, Ballon S, Hendrickson M, Mohle-Boetani J. Epithelial ovarian cancer and the ability to conceive. Cancer Res 1989; 49:4047-52. [PMID: 2736545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Relationships between ovarian cancer and ability to conceive were explored in a case-control study of 188 women with histologically confirmed epithelial ovarian cancer and 539 control women in the San Francisco Bay Area. Control women consisted of two groups: those hospitalized without cancer, matched to cases by age, race, and hospital of diagnosis (n = 280); and those selected from the general population by random digital dialing, matched to cases by age, race, and telephone prefix (n = 259). Ovarian cancer risk among nulliparous (but not parous) women was positively associated with a history of unsuccessful attempts to conceive, of physician-diagnosed infertility, and of doubts about ability to conceive. Among all women, risk increased with increasing years of unprotected intercourse (P value for trend = 0.02). Risk among women having 10 or more yr of unprotected intercourse was 1.8 relative to that among women having less than 2 such yr (P = 0.01). This association was independent of parity, oral contraceptive use, and estimated years of ovulation, each associated with ovarian cancer. Further, duration of unprotected intercourse combined multiplicatively with each of these latter characteristics in increasing ovarian cancer risk. For example, while cancer risk exhibited a 2-fold range from lowest to highest years of unprotected intercourse and a 4-fold range from lowest to highest years of ovulation, risk among women in the highest joint category of these characteristics was 8 times that of women in the lowest category. We believe that some abnormality of ovulation that reduces the likelihood of conception plays a role in epithelial ovarian cancer.
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Affiliation(s)
- A S Whittemore
- Department of Health Research and Policy, Stanford University School of Medicine, California 94305-5092
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Wu ML, Whittemore AS, Paffenbarger RS, Sarles DL, Kampert JB, Grosser S, Jung DL, Ballon S, Hendrickson M, Mohle-Boetani J. Personal and environmental characteristics related to epithelial ovarian cancer. I. Reproductive and menstrual events and oral contraceptive use. Am J Epidemiol 1988; 128:1216-27. [PMID: 3195563 DOI: 10.1093/oxfordjournals.aje.a115076] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In two case-control studies conducted in the six-county San Francisco Bay Area, 111 women diagnosed with epithelial ovarian carcinoma in 1974-1977 and 188 women diagnosed in 1983-1985 were interviewed concerning their menstrual, sexual, and reproductive histories. For comparison, interviews were conducted with 752 control women admitted to the same hospitals within six months of the cases; for cases diagnosed in the later period, interviews were also conducted with an additional 259 population-based controls selected by random digit dialing. Controls were matched to cases by age and race. Qualitative and quantitative findings were similar for the two studies. In the combined data, cases were more likely than their matched controls to have been nulliparous, to have undergone menarche at an early age, and to have refrained from using oral contraceptives. Menopause occurred slightly later for cases than for controls, but the differences were not statistically significant. Neither age at first term pregnancy (20 or more weeks gestation) nor number of term pregnancies was predictive of ovarian cancer risk. The protection afforded by oral contraceptive use was independent of parity, and it increased with increasing duration of use. There were no trends in risk with time since last oral contraceptive use or with time since first use, after adjustment for duration of use. These observations suggest that oral contraceptive use decreases risk for ovarian cancer, rather than merely indicates fertility, which may itself decrease risk of developing the disease. The authors combined reproductive characteristics and oral contraceptive use to estimate a woman's total duration of ovulation, which was positively associated with ovarian cancer risk (p less than 0.001 for trend). These observations support the concept that the greater the duration of ovulation or accompanying endocrinologic phenomena, the greater a woman's risk for ovarian cancer.
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Affiliation(s)
- M L Wu
- Department of Health Research and Policy, Stanford University School of Medicine, CA
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