Tetanus antibody protection among HIV-infected US-born patients and immigrants

INTRODUCTION

Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the Third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% nonprotective anti-tetanus antibody (ATA) level. Less work has been conducted among other vulnerable populations such as human immunodeficiency virus (HIV)-infected patients. The objective of this study was to measure ATA levels among the HIV immigrant population compared with US-born HIV-infected patients.

METHODS

A convenience sample of 158 HIV-infected individuals was recruited to determine the levels of ATA. A nonprotective level of ATA was defined as below 0.15 IU/ml.

RESULTS

Among the HIV-infected patients, 72% (114/158) were born in the USA. A total of 17% (27/158) lacked protective levels of ATA. A total of 6.1% (7/114) of those born in the USA lacked protection, compared to 45% (20/44) born outside the USA (p < 0.0001).

CONCLUSION

The results illustrate that the country of birth is an important predictor of ATA protection, even among HIV-infected patients.

Seroprevalence of hepatitis A among hospital dietary workers: implications for screening and immunization

Hepatitis A is a self-limited, virally mediated infection of the liver. The usual mode of transmission is by the fecal-oral route. Employees of food-service establishments who are infected with the hepititus A virus can transmit the disease when handling food products. The Centers for Disease Control and Prevention recommends the use of the hepatitis A vaccine among dietary workers who may be at risk for contracting and spreading the disease. Because hepatitis A infection can often be a subclinical disease, the incidence of cases reported is not indicative of its true prevalence. The objective of this study was to document the seroprevalence of hepatitis A among hospital dietary workers. Dietary workers at a suburban hospital were interviewed to determine if they had been exposed to hepatitis A and if they had a history of hepatitis A infection. Serum was obtained from each subject and tested for the presence of hepatitis A antibodies. The Abbott HAVAB EIA kit was used for the detection of immunoglobulin G (IgG) and IgM hepatitis A antibodies. Of 119 subjects, 56 (47%) were women, and 63 (53%) were men; the subjects had a mean age of 42 years (range, 20-66). Fifty-one subjects (43%) were born in the United States, and 68 subjects (57%) were born outside of the United States. Of the 119 subjects, only 2 (2%) had a known history of hepatitis A infection, yet 67 (56%) had hepatitis A titers; 52 (44%) were susceptible to the disease. One subject had received the hepatitis A vaccine. Fifty-five of 68 foreign-born subjects (81%; 95% confidence interval, 71-91%) had hepatitis A antibodies versus 12 of 51 US-born subjects (24%; 95% confidence interval, 12-36%). The foreign-born subjects had a mean age of 28 years at the time of their arrival in the United States. In conclusion, a large number of foreign-born hospital dietary workers have hepatitis A antibodies without a history of disease. Immunization of this group of dietary workers may not have any beneficial effects, nor is it cost-effective.

Psychological impact on house staff of an initial versus subsequent emergency medicine rotation

The objective of this study was to assess the psychological impact of a 4-week emergency medicine (EM) rotation on residents undergoing their first EM experience. These findings were compared to the psychological impact the rotation had on residents with prior EM experience. Data were obtained from a post hoc analysis of a previous study. Prerotation and postrotation psychological distress levels were assessed over a 4-week EM rotation. Anxiety and depressive symptoms were evaluated by the Brief Symptom Inventory and the Dissociative Experience Scale that together comprise a total of 14 psychometric scales. All scales were given at the beginning and end of the initial EM rotation for the academic year of 1994-1995. All information was coded and confidential. Eighteen junior residents (9/18 EM [50%]) were analyzed as a group and compared to 53 residents (34/51 EM [66%]) with prior exposure to the authors' emergency department. Residents doing their first EM rotation (N = 18) showed improvement in 13 of 14 scales (P = .002). Of the 13 scales that improved, 3 improved significantly: Brief Symptom Inventory = anxiety (P = .002) and Dissociative Experience Scale = absorption (P = .001) and other (P = .001). Residents with prior EM experience (N = 53) displayed worsening in 9 of 13 scales (P = not significant) and no change in 1. Residents undergoing their first EM rotation showed a significant decrease in psychological distress over the 4-week period. Residents with prior EM experience did not show a similar change.

Overlooked sources of ethanol

The case of a 55-year-old female who presented to the emergency department with acute ethanol intoxication and suicidal ideation is reported. After initiating routine management, we discovered that her serum ethanol levels remained persistently elevated as a result of the patient's secretly ingesting mouthwash. This occurred after she was searched and allowed to retain personal hygiene products. Alcohol-dependent patients may consume ethanol products that are not manufactured for ingestion. These products include cosmetics, cough and cold remedies, and personal hygiene products. The ethanol content of these nonbeverage ethanol (NBE) products exceeds that of many conventional alcoholic beverages. Financial constraints and ease of availability are factors leading to their consumption. This report serves as a reminder to be aware of the existence and popularity of NBE in order to avoid potential morbidity and even mortality associated with its use.

Seroprevalence of varicella antibodies among new house officers

STUDY OBJECTIVE

Varicella, an illness common to children, can occur in nonimmune adults, often causing serious morbidity and mortality. House officers without protective titers to varicella are at risk of contracting the disease and may spread it to the patients they serve. They are also subject to significant losses in work time and wages. Accordingly, in August 1996, the Centers for Disease Control and Prevention recommended vaccinating nonimmune health care providers with the varicella vaccine. We also sought to document the seroprevalence of varicella antibodies among new house officers and to determine the association of self-reported history of infection with varicella antibody levels.

METHODS

This study was conducted at a university-affiliated teaching hospital. Serology testing was performed on house officers beginning their residencies in July 1997. Subjects provided information regarding demographics, medical history, previous varicella exposure, and previous administration of varicella vaccine. Serum was tested using the FIAX test kit, (Biowhitaker, Walkersville, MD).

RESULTS

One hundred fifty-four house officers participated. The mean age was 30 (range, 24 to 50+/-SD 5.5 years). History of varicella infection was given by 119 (77%) of the 154 subjects, whereas 15 (10%) reported no history of infection, and 20 (13%) were uncertain. Ten (7%) of the participants had received varicella vaccine previously. Overall, 6 (4%) had nonprotective titers to varicella. Of the 119 house officers who reported a history of varicella, only 2 (1.7%) had nonprotective titers, and 4 (27%) who reported no history of varicella infection had nonprotective titers. Of the 10 house officers who had previously received varicella vaccine, 1 (10%) had nonprotective titers.

CONCLUSION

Although most house officers had protective titers, a reported history of varicella or the administration of varicella vaccine did not assure the presence of protective titers. House officers should be tested for varicella immunity regardless of a history of previous infection or the administration of varicella vaccine.

Early development of emergency medicine in Chennai (Madras), India

India is the second most populous country in the world, with a population approaching 1 billion people. The development of emergency medicine is still in its earliest stages because the Medical Council of India (MCI) does not yet recogonize the specialty. Recent developments may cause the MCI to reconsider specialty status for emergency medicine as an academic discipline.

Immunologic response to tetanus toxoid in the elderly: one-year follow-up

STUDY OBJECTIVE

To determine whether elderly patients documented to have nonprotective titers of anti-tetanus antibodies (ATA) are able to achieve and maintain protective ATA titers for at least 1 year after tetanus immunization.

METHODS

Thirty-five outpatients aged 65 or older with documented inadequate ATA titers were given 1 tetanus immunization. Repeat titers were obtained 2 months and 12 months after immunization. Titers were measured with an enzyme-linked immunoassay kit (Bindazyme kit). ATA titers in excess of .17 IU were considered protective. The study was conducted at a large urban geriatric center.

RESULTS

The mean age of participants was 78.7 years; 86% (24/28) were women. Repeat ATA titers were obtained an average of 122 days and 493 days after immunization. The mean preimmunization ATA titer was .1 IU, (range .04 to .16 IU). After immunization, the 2-month ATA titer rose a mean of .61 (95% confidence interval [CI] .35 to .87) IU, with 86% (30/35) achieving protective titers. After 1 year only 28 of 35 patients were available for follow-up. Protective titers had been present in all 7 patients lost to follow-up. After 1 year, 82% (23/28) patients had protective titers. The mean ATA titer for the 28 patients was .54 (95% CI -.78 to 1.86) IU, a significant increase from preimmunization levels (P=.002). However, ATA titers changed -.18 (95% CI -.98 to .62) IU between 2 months and 1 year (P=.02). There was no correlation between gender, country of birth, and medical history with development or maintenance of protective titers.

CONCLUSION

Administration of 1 tetanus toxoid affords protective immunization to a large portion of the elderly population after 1 year.

Immunologic response to tetanus toxoid in geriatric patients

STUDY OBJECTIVE

Tetanus antibody levels have been shown to be inadequate in 50% of patients older than 65 years. Although immunization recommendations have been made for this age group, the efficacy of this intervention has not been well documented. We sought to determine the difference in tetanus antibody levels after the administration of one tetanus toxoid immunization to geriatric patients without adequate titers.

METHODS

Thirty-five patients older than 65 years at a large urban comprehensive care geriatric center who were documented to have inadequate tetanus antibody titers were each given one tetanus toxoid immunization. Repeat titers were obtained at least 2 months after the immunization with the use of enzyme-linked immunosorbent assay (Bindazyme kit; the Binding Site Corporation, Birmingham, England). We considered tetanus antibody levels greater than .17 IU/mL protective.

RESULTS

The mean age was 79.4 years; 30 of 35 (86%) were female. Repeat tetanus antibody titers were obtained an average of 123 days (range, 63 to 204 days) after immunization with tetanus toxoid. The mean preimmunization antibody titer was .1 IU/mL (range, .04 to .16 IU/mL). After immunization, antibody titers increased a mean of .61 IU/mL (range, -.01 to 2.23 IU/mL; 95% confidence interval, .35 to .87 IU/mL). Thirty of the 35 patients who received a single injection of tetanus toxoid (86%) developed protective titers. We found no relationship between seroconversion and age, sex, or medical history; nor did we find a relationship between antibody level and time elapsed since immunization when repeat titers were obtained.

CONCLUSION

Administration of one tetanus toxoid injection affords protective immunity in many geriatric patients.

Antibody protection to diphtheria in geriatric patients: need for ED compliance with immunization guidelines

STUDY OBJECTIVE

Because 50% to 70% of geriatric patients have been shown to have nonproductive levels of tetanus antibodies, we postulated that this population might also have inadequate levels of diphtheria antibodies. Emergency physicians have the opportunity to immunize patients against tetanus and diphtheria. We sought to determine the seroprevalence of diphtheria antibodies in patients older than 65 years and to assess compliance with immunization guidelines in EDs.

METHODS

Enzyme-linked immunosorbent assay for diphtheria antibodies was conducted in 58 outpatients of geriatric medical facility aged 65 years or older. We considered titers greater than .1 IU/mL protective. Eighteen ED personnel, ages 25 to 40 years, served as comparison subjects. The preparation used for immunization of injured patients--tetanus toxoid or tetanus and diphtheria toxoids adsorbed for adult use--was determined by means of a telephone survey of 64 New York City EDs.

RESULTS

The mean age of our patients was 80 years (range, 65 to 95 years). Their mean diphtheria antibody titer was .17 IU/mL (range, .04 to .54 IU/mL). Thirty-three percent (19 of 58; 95% confidence interval [Cl], 21% to 54%) of patients had inadequate levels of diphtheria antibodies. We found no significant differences between protected and nonprotected patients with respect to age, sex, medical history, or military service. Patients with nonprotective levels of diphtheria antibodies were more likely to have inadequate tetanus antibody titers. Sixty-eight percent of patients without protection from diphtheria (13 of 19; 95% Cl, 48% to 88%) were also unprotected from tetanus, and 33% (13 of 39; 95% Cl, 19% to 47%) o those with adequate diphtheria antibodies had nonprotective levels of tetanus antibodies (P = .012). All 18 ED personnel had adequate diphtheria and tetanus antibodies. The telephone survey revealed that 30% (19 of 64) of EDs use only tetanus toxoid for immunization of injured patients.

CONCLUSION

A significant percentage of geriatric patients have inadequate diphtheria antibodies. Emergency physicians must comply with immunization guidelines for injured patients to assure adequate protection from both tetanus and diphtheria.

The psychological effects of a four-week emergency medicine rotation on residents in training

OBJECTIVE

To prospectively evaluate psychological stress reactions among residents in an emergency medicine (EM) rotation during a 4-week period.

METHODS

Pre- and postrotation psychological distress levels were assessed over a 4-week EM rotation. Subjects were evaluated by several psychometric measures. These included the assessment of anxiety, depressive, and other psychological symptoms by the Brief Symptom Inventory (BSI), and the occurrence of traumatic anxiety via the Dissociative Experience Scale (DES). Also assessed were the Impact of Events Scale and the Holmes Social Readjustment Ratings Scale (Holmes), a baseline life-change measure. Demographic data were obtained. The study occurred in a university-affiliated teaching hospital ED. The 45 EM residents and 27 non-EM residents were analyzed as a group, followed by subgroup analysis comparing EM vs non-EM residents.

RESULTS

An increase in psychological distress over the 4-week rotation was found in the non-EM group, but not in the EM group. For the non-EM residents, all 10 BSI scales worsened and 3 of 4 DES scales worsened (p = 0.002), indicative of increased psychological distress. In contrast, analysis of the 45 EM residents showed improvement in 8 of 10 BSI scales and 3 of 4 DES scales (p = 0.057).

CONCLUSION

A significant increase in psychologic distress was found among the non-EM residents during an EM rotation. The EM residents showed a trend for a decrease in psychological distress over the same 4-week period.

Seroprevalence of tetanus antibodies among adults older than 65 years

STUDY OBJECTIVE

To define the extent of immunity against tetanus among patients older than 65 years of age by measuring antitetanus antibody levels.

METHODS

A convenience sample of 129 patients from an urban comprehensive care geriatric center was studied. Serum was obtained and enzyme-linked immunosorbent assay (ELISA) testing performed. Twenty health care providers, aged 25 to 40 years, were tested for comparison.

RESULTS

In 64 (50%) of 129 study patients, antitetanus antibody levels did not reach protective levels. Fifty-four (59%) of 92 women and 10 (27%) of 37 men did not have adequate titers. All 20 health care workers had protective titers.

CONCLUSION

Elderly patients are substantially less likely than young individuals to have adequate immunity against tetanus. Emergency physicians must take this into consideration when evaluating tetanus immunization status in injured elderly patients.

Impact of Yankee Stadium Bat Day on blunt trauma in northern New York City

STUDY OBJECTIVE

To determine the incidence of blunt trauma in northern New York City before and after the distribution of 25,000 baseball bats at Yankee Stadium.

DESIGN

Prospective multicenter study, including ten days before and ten days after Bat Day (June 3, 1990).

SETTING

Ten emergency departments in the Bronx and northern Manhattan.

TYPE OF PARTICIPANT

All patients presenting to the ED with baseball bat injuries.

INTERVENTIONS

Each hospital collected the following data for each subject: date and time of injury, patient's age and sex, extent of injury, whether a Yankee bat was used, presence of loss of consciousness, results of computed tomography scan of the brain (if performed), history source, and disposition of the patient. Average daily atmospheric temperature was recorded for each day of the study.

MEASUREMENTS AND MAIN RESULTS

Seventy-seven patients sustained bat injuries, 38 (49%) before and 36 (47%) after Bat Day. There were no significant differences between the two groups with respect to age, sex, time of injury, number and distribution of fractures and lacerations, incidence of loss of consciousness, source of history, or dispostion. There was a positive association between the number of cases on a given day and the average temperature that day (r = .5; P < .01).

CONCLUSION

The distribution of 25,000 wooden baseball bats to attendees at Yankee Stadium did not increase the incidence of bat-related trauma in the Bronx and northern Manhattan. There was a positive correlation between daily temperature and the incidence of bat injury. The informal but common impressions of emergency clinicians about the cause-and-effect relationship between Bat Day and bat trauma were unfounded.