Sequential administration of Prevnar 13™ and PNEUMOVAX™ 23 in healthy participants 50 years of age and older

In most countries worldwide, pneumococcal conjugate vaccines have been included in the infant immunization program, resulting in a significant reduction in the burden of pneumococcal disease in children and adults. Shifting serotype distribution due to the indirect effect of infant vaccination with the 13-valent pneumococcal conjugate vaccine (PCV13) may continue to increase the gap between 23-valent pneumococcal polysaccharide vaccine (PPSV23) and PCV13 serotype coverage for older adults in the coming years. This clinical study (V110-029; NCT02225587) evaluated the safety and immunogenicity of sequential administration of PCV13 followed approximately 8 weeks later, or approximately 26 weeks later, by PPSV23 in healthy adults ≥50 years of age. Both dosing intervals were generally well tolerated as measured by the nature, frequency, and intensity of reported adverse events (AEs) in both vaccination groups. Serotype-specific opsonophagocytic activity (OPA) geometric mean titers (GMTs) measured 30 days following receipt of PPSV23 in either group and at Week 30 were generally comparable between the 2 groups for 6 serotypes unique to PPSV23 and 12 serotypes shared between PCV13 and PPSV23, regardless of the interval between receipt of PCV13 and PPSV23. In addition, administration of PPSV23 given either 8 weeks or 26 weeks following PCV13 did not negatively impact immune responses induced by PCV13. Furthermore, administration of PPSV23 given either 8 weeks or 26 weeks after PCV13 elicited serotype-specific OPA GMTs to serotypes unique to PPSV23, which could provide earlier protection against pneumococcal disease caused by these serotypes in comparison with the current Advisory Committee on Immunization Practices recommended interval of at least 12 months.

Risk of pneumococcal diseases in adults with underlying medical conditions: a retrospective, cohort study using two Japanese healthcare databases

OBJECTIVES

To quantify the risk of pneumococcal pneumonia (PP) and invasive pneumococcal disease (IPD) in adults aged ≥19 years with underlying medical conditions compared with healthy adults of the same age in Japan.

DESIGN

An observational, retrospective, cohort study using two healthcare claims databases in Japan: Japan Medical Data Center (JMDC) and Medical Data Vision (MDV) databases.

PARTICIPANTS

A total of 10.4 million individuals, representing 9.3 million person-years of follow-up, were included in the analysis. Eleven medical conditions as well as PP and IPD were identified by the International Statistical Classification of Diseases and Related Health Problems version 10 diagnostic codes and/or local disease codes used in Japan.

PRIMARY OUTCOME MEASURES

Adjusted rate ratios (RRs) for PP and IPD in adults with a medical condition versus adults without any medical condition were calculated using multivariate Poisson regression models with age and/or sex as covariates.

RESULTS

In the JMDC and MDV databases, respectively, adults ≥19 years with a medical condition (RRs for PP: 3.3 to 13.4, 1.7 to 5.2; RRs for IPD: 12.6 to 43.3, 4.4 to 7.1), adults with two or more medical conditions (PP: 11.6, 2.8; IPD: 18.7, 5.8) and high-risk adults (PP: 12.9, 1.8; IPD: 29.7, 4.0) were at greater risk of PP and IPD compared with their healthy counterparts. Adults aged 50-64 years with an underlying medical condition (PP rate: 38.6 to 212.1 per 100 000 person-years) had a higher rate of PP than those aged ≥65 years without any condition (PP rate: 13.2 to 93.0 per 100 000 person-years).

CONCLUSIONS

Adults of all ages with an underlying medical condition are at greater risk of PP and IPD compared with adults without any medical condition. This risk increases with the number of underlying medical conditions. Our results support extending pneumococcal vaccination to younger adults with an underlying medical condition, especially those aged 50-64 years.

Paying for prevention: a critical opportunity for public health

Despite spending an increasing amount on health care and more than every other industrialized country, the U.S. ranks 37th in health outcomes. The implementation of the Patient Protection and Affordable Care Act (ACA) promises to ensure better access to health care for many Americans through expanded public and private insurance coverage, including basic preventive health care. Public health must seize this critical opportunity by taking steps to ensure that prevention, especially primary prevention, is embedded in our health system. This manuscript outlines four areas where public health officials across the U.S. can immediately capitalize on opportunities created by the ACA to ensure that prevention is a key component of health reform: (1) leading the way on community health assessments; (2) linking clinical and community prevention; (3) supporting the development of alternative payment methodologies to pay for prevention; and (4) serving as a community resource for the coordination of care and building the non-traditional health workforce.

The status of legal authority for injury prevention practice in state health departments

Despite the potential for public health strategies to decrease the substantial burden of injuries, injury prevention infrastructure in state health departments is underdeveloped. We sought to describe the legal support for injury prevention activities at state health departments. We searched the Lexis database for state laws providing authority for those activities, and categorized the scope of those laws. Only 10 states have authority that covers the full scope of injury prevention practice; in the others, legal authority is piecemeal, nonspecific, or nonexistent. More comprehensive legal authority could help health departments access data for surveillance, work with partners, address sensitive issues, and garner funding. Efforts should be undertaken to enhance legal support for injury prevention activities across the country.

Using diagnostic codes to screen for intimate partner violence in Oregon emergency departments and hospitals

OBJECTIVES

Many of the 2.5 million Americans assaulted annually by intimate partners seek medical care. This project evaluated diagnostic codes indicative of intimate partner violence (IPV) in Oregon hospital and emergency department (ED) records to determine predictive value positive (PVP), sensitivity, and usefulness in routine surveillance. Statewide incidence of care for IPV was calculated and victims and episodes characterized.

METHODS

The study was a review of medical records assigned > or = 1 diagnostic codes thought predictive of IPV. Sensitivity was estimated by comparing the number of confirmed victims identified with the number predicted by statewide telephone survey. Patients were aged > or = 12 years, treated in any of 58 EDs or hospitals in Oregon during 2000, and discharged with one of three primary or 12 provisional codes suggestive of IPV. Outcome measures were number of victims detected, PPV and sensitivity of codes for detection of IPV, and description of victims.

RESULTS

Of 58 hospitals, 52 (90%) provided records. Case finding using primary codes identified 639 victims, 23% of all estimated female victims seen in EDs or hospitalized statewide. PVP was 94% (639/677). Provisional codes increased sensitivity (51%) but reduced PVP (50%). Highest incidence occurred in women aged 20-39 years, and those who were black. Hospitalizations were highest among women aged > or = 50 years, black people, or those with comorbid illness.

CONCLUSIONS

Three diagnostic codes used for case finding detect approximately one-quarter of ED- and hospital-treated victims, complement surveys, and facilitate description of injured victims.

Translation of an effective tai chi intervention into a community-based falls-prevention program

Tai chi--moving for better balance, a falls-prevention program developed from a randomized controlled trial for community-based use, was evaluated with the re-aim framework in 6 community centers. The program had a 100% adoption rate and 87% reach into the target older adult population. All centers implemented the intervention with good fidelity, and participants showed significant improvements in health-related outcome measures. This evidence-based tai chi program is practical to disseminate and can be effectively implemented and maintained in community settings.

The effects of executive and behavioral dysfunction on the course of ALS

OBJECTIVE

To determine whether patients with ALS-frontotemporal lobar dementia (FTLD) have a shorter survival and are less compliant with recommended treatments than those with ALS who have normal executive and behavioral function (classic ALS).

METHODS

Survival analysis from ALS symptom onset to death included 81 of 100 consecutive patients who could be classified definitely as ALS with abnormal executive or behavioral function or as classic ALS. Criteria were defined for compliance with noninvasive positive-pressure ventilation (NPPV) and percutaneous endoscopic gastrostomy (PEG).

RESULTS

Median survival was 2 years 4 months for the 28 patients with FTLD and 3 years 3 months for the 53 patients with classic ALS (relative hazard for death 1.93, CI 1.09 to 3.43; p = 0.024). However, the relative hazard associated with FTLD (1.49) in the multivariate model was diminished by the association of FTLD with bulbar onset and older age and was not significant in this sample size. With bulbar onset, median survival was 2 years 0 months for the 14 with ALS-FTLD and 2 years 10 months for the 10 with classic ALS (relative hazard for death 2.78, CI 1.02 to 7.55; p = 0.045), and older age was not a significant risk. Noncompliance with NPPV and PEG were 75% and 72% in ALS-FTLD, respectively, vs 38% and 31% in classic ALS (relative risks 2.00 and 2.34; p = 0.013 and 0.022).

CONCLUSIONS

Survival is significantly shorter among patients with ALS-FTLD than with classic ALS. Furthermore, patients with ALS-FTLD are twice as likely to be noncompliant.

Investigation of an electronic emergency department information system as a data source for respiratory syndrome surveillance

Emergency department syndromic surveillance may provide early warning of disease outbreaks due to bioterrorism or natural phenomena. The purpose of this investigation was to explore how an electronic emergency department information system could be used as a data source for respiratory syndrome surveillance. The process of data collection, entry, and transmission is described, and then a subset of data elements with potential epidemiological value is selected. The quality of the data contained in the system was evaluated by conducting a retrospective analysis of emergency department visits recorded in the system during 2001 and by reviewing clinical charts of cases with respiratory diagnoses. Diagnosis codes, discharge disposition, and demographic data were relatively complete; additional clinical data were not. Diagnosis codes were rapidly and reliably recorded. Data available in the system allows a description of emergency department visits for respiratory syndrome in terms of age, gender, location, severity of illness, and distribution in time. Encrypted data were transmitted every four hours to the health department without added work for emergency department personnel. Although significant obstacles remain, electronic emergency department information systems such as this may provide rapid, reliable data for syndromic surveillance.

Tracking Oregon Medicaid patients' enrollment and health utilization patterns

The Oregon Medicaid program consists of various sub-programs with different eligibility requirements and multiple health care delivery systems. Administrative events, such as the loss of Medicaid eligibility or a change in health plan enrollment, can cause disruptions in the continuity of medical care and may contribute to missed opportunities to provide appropriate medical services, including preventive care. Thus, in order to improve public health surveillance and describe the health care utilization patterns of Oregon's Medicaid beneficiaries, a standardized approach was developed to track the enrollment status of Medicaid patients for extended periods of time.

Electronic Reporting of Pelvic Inflammatory Disease From an Emergency Department

BACKGROUND AND OBJECTIVES

Pelvic inflammatory disease (PID) is a clinically diagnosed condition that is preventable and underreported. We developed an electronic emergency department (ED) PID reporting system by using an automatic and secure system to send computerized clinician PID diagnoses to the state health department.

GOAL

The goal of this study was to assess if electronic transmission of ED PID data could enhance the completeness and timeliness of PID surveillance.

STUDY DESIGN

We conducted a retrospective chart review.

METHODS

To validate electronic ED diagnoses, we reviewed charts of 157 women with 7 clinicians' diagnoses compatible with PID. We determined which women met the Centers for Disease Control and Prevention (CDC) PID surveillance case definition and determined the positive predictive values of electronic ED diagnoses of PID. We compared completeness of electronic PID reporting with state sexually transmitted disease surveillance.

RESULTS

Three diagnoses were appropriate for electronic PID surveillance. Information on women with these diagnoses is sent daily to the health department with no extra effort needed from ED clinicians. Less than 10% of women who met the CDC PID case definition were reported within 6 months through conventional methods.

CONCLUSIONS

Electronic ED surveillance will improve completeness and timeliness of PID reporting.

Neurocysticercosis in Oregon, 1995-2000

The unexpected death of a teenager from neurocysticercosis prompted an investigation of this disease in Oregon. We found 89 hospitalizations, 43 newly diagnosed cases, and 6 deaths from 1995 to 2000. At least five cases occurred in persons who had not traveled or lived outside the United States. Enhanced surveillance for neurocysticercosis is warranted.

Security Aspects of Electronic Data Interchange Between a State Health Department and a Hospital Emergency Department

Electronic emergency department reporting provides the potential for enhancing local and state surveillance capabilities for a wide variety of syndromes and reportable conditions. The task of protecting data confidentiality and integrity while developing electronic data interchange between a hospital emergency department and a state public health department proved more complex than expected. This case study reports on the significant challenges that had to be resolved to accomplish this goal; these included application restrictions and incompatibilities, technical malfunctions, changing standards, and insufficient dedicated resources. One of the key administrative challenges was that of coordinating project security with enterprise security. The original project has evolved into an ongoing pilot, with the health department currently receiving secure data from the emergency department at four-hour intervals. Currently, planning is underway to add more emergency departments to the project.

Diabetes preventive care in Oregon's Medicaid population

The purpose of this study was to estimate the prevalence of diabetes in Oregon's adult Medicaid population and to compare the level of diabetes-related preventive care with the state's general population. Responses to telephone interviews conducted in 1999 among 2,770 randomly selected adult Medicaid beneficiaries and 7,229 Oregon residents were compared. Diabetes prevalence among adult Medicaid recipients (11.1% [95% Cl, 9.9% to 12.2%]) was more than twice that in the general population (4.7% [95% Cl, 4.2% to 5.3%]). During the year prior to the interview, adults with diabetes in the Medicaid and general populations reported performing the following preventive care, respectively: > or = 2 diabetes care visits (80%, 77%); foot examination (74%, 74%); dilated eye examination (73%, 68%); influenza vaccine (65%, 61%); self-monitored blood glucose daily (63%, 61%); pneumococcal vaccine (51%, 47%); regular aspirin use (48%, 53%); and awareness of Hemoglobin A1c (34%, 39%). Although the reported prevalence of diabetes in Oregon's Medicaid population is high, the prevalence of diabetes preventive care activities was similar to the state's general population. Nonetheless, specific services in both populations could be improved.

Public Health Surveillance Approaches in Oregonʼs Medicaid Population

The development of methods for public health surveillance in Medicaid populations is an important goal for public health practice. In Oregon, we developed approaches to case finding using claims and self-reported data obtained from the Medicaid beneficiary population. Disease rosters, derived from claims data, form the basis for analyses pertaining to particular health conditions. Self-reported information obtained through a telephone survey forms the basis for analyses pertaining to behavioral risk factors, disease history, and other information not available in claims data. We also describe some projects in which we plan to use combined claims and survey data. We describe our experiences with using these techniques and provide examples from projects in progress or planned. Our initial experiences suggest that these approaches enhance our ability to conduct public health surveillance in Oregon's Medicaid population.

Releasing pre-adoption birth records: the impact of Oregon's experience on its vital records department

OBJECTIVE

In November 1998, Oregon voters passed Ballot Measure 58, which allowed Oregon adoptees > or = 21 years of age access to their original birth records, which are sealed at adoption. The objective of this study was to evaluate the impact of the measure on the Oregon Health Division (since renamed Oregon Health Services) by assessing procedures used and resources needed after implementation of Measure 58.

METHODS

Vital records employees were interviewed about processing, storage, and archive retrieval procedures for pre-adoption birth records before, during, and after the implementation of Measure 58 and the effect on their usual workload. Personnel time, space, and fiscal resources used to process requests for pre-adoption records were also calculated.

RESULTS

The Oregon Health Division began to receive requests from adoptees immediately following the passage of Measure 58 in November 1998, but due to legal challenges, they could not be processed until May 31, 2000. From June 2, 2000, through October 20, 2000, 12 staff members and two supervisors issued more than 4,700 pre-adoption birth records while also processing their normal workload, which averages more than 135,400 vital record orders annually. Due to the need for retrieval from archives, requests for pre-adoption birth records were estimated to take 75 hours to process vs. 2-3 minutes for standard requests. Each batch of approximately 75 pre-adoption birth records required approximately 12.5 person-hours from vital records staff and 3-4 person-hours from archive personnel; in addition, supervisors spent time responding to incomplete orders, informing the public and the media, and responding to concerns of adoptees, birth parents, and adoptive parents. Fewer than 1% of requests went unfilled.

CONCLUSIONS

Implementation of Measure 58 utilized substantial resources of the Oregon Health Division. States contemplating similar legislation should consider increasing personnel and resources, preparing for intense public and media interest, and reorganizing the storage of adoptees' original birth records so they are easily retrieved.

Releasing pre-adoption birth records: a survey of Oregon adoptees

OBJECTIVE

In June 2000, Oregon implemented a citizen-initiated ballot measure that grants adult adoptees access to their birth records, which contain their birth parents' identifying information. Because other states are considering similar policy changes, the authors explored whether Oregon's new law is meeting the information needs of adoptees.

METHODS

Birth records were abstracted for a 9% (221/2,529) random sample of adoptees who obtained their records from June 20, 2000, to July 20, 2000, to describe the population and the information they obtained. Telephone interviews documented their motivations, expectations, and whether they considered the birth record useful.

RESULTS

The mean age of the adoptees was 41 years, 64% were female, and 97% were white. Virtually all received information about their birth mother; however, only one-third received information about their birth father. Of the 221 sampled, 123 (59%) participated in the telephone survey, 12 were ineligible, 84 could not be reached, and 2 refused. The most common motivations for requesting records were to find birth parents (29%) and to obtain medical information (29%). Twenty-nine percent received less information than they expected, with many expecting, but not receiving, birth father information. Thirty-three (47%) of the 70 adoptees who tried to find their birth mother were successful. The records were considered "very" useful by 52% of respondents, "somewhat" or "a little" useful by 42%, and "not at all" useful by 6%.

CONCLUSIONS

The results indicate that many adoptees received less information than they expected, and many did not meet their goals of finding birth parents or obtaining medical information. Nonetheless, the majority considered their birth records useful and important.

What white blood cell count should prompt antibiotic treatment in a febrile child? Tutorial on the importance of disease likelihood to the interpretation of diagnostic tests

Most diagnostic tests are not dichotomous (negative or positive) but, rather, have a range of possible results (very negative to very positive). If the pretest probability of disease is high, the test result that prompts treatment should be any value that is even mildly positive. If the pretest probability of disease is low, the test result needed to justify treatment should be very positive. Simple decision rules that fix the cutpoint separating positive from negative test results do not take into account the individual patient's pretest probability of disease. Allowing the cutpoint to change with the pretest probability of disease increases the value of the test. This is primarily an issue when the pretest probability of disease varies widely between patients and depends on characteristics that are not measured by the test. It remains an issue for decision rules based on multiple test results if these rules fail to account for important determinants of patient-specific risk. This tutorial demonstrates how the value of a diagnostic test depends on the ability to vary the cutpoint, using as an example the white blood cell count in febrile children at risk for bacteremia.

Emergency health surveillance after severe flooding in Louisiana, 1995

INTRODUCTION

In disaster situations, timely surveillance systems that provide illness, injury, and mortality information to public health officials and hospitals are essential for planning and evaluating interventions.

OBJECTIVES

To describe flood surveillance methodology, the impact of the event on hospitals, and the number of daily patient visits due to selected illnesses and injuries before, during, and after severe flooding in southeastern Louisiana in May 1995.

METHODS

Survey of disaster-area hospitals regarding flood impact. Emergency department surveillance of injuries and illnesses for the week before, the two days during, and the week after the flood.

RESULTS

There occurred an increase in the number of persons who drowned or were injured that presented to the moderately affected hospitals during the storm, but there was no increase in visits for gastroenteritis to any group of hospitals. Services were disrupted in more than half of hospitals. The severely affected hospitals had the least variation in the average number of daily visits. None of the drownings were reported by those hospitals that reported severe service disruption.

CONCLUSIONS

Data should be collected from all hospitals in or near disaster areas, even if they were not directly affected by the disaster. Public education about the danger of drowning during flash flooding must be improved. The Louisiana experience emphasizes the need for a disaster-preparedness plan for rapid surveillance of illnesses and injuries.

Optimal gestational age and birth-weight cutoffs to predict neonatal morbidity

BACKGROUND

Gestational age (GA) and birth weight (BW) criteria are used to identify newborns at risk for neonatal morbidity. Currently, preterm is GA less than 37 weeks; low birth weight is BW less than 2,500 grams; and small for gestational age (SGA) is BW less than the tenth percentile weight for the infant's GA. The optimal classification system balances the misclassification cost of false negatives against the cost of false positives.

OBJECTIVE

To calculate the relative misclassification costs implied by the current 37-week and 2,500-gram cutoffs, and to test the validity of the current definition of SGA as a predictor of term morbidities.

METHODS

GA, BW, and morbidity information were collected for 22,606 infants born between July 1981 and December 1992. Using this dataset, logistic regression coefficients were obtained modeling GA or BW as predictors of morbidities associated with prematurity. For a subset of 18,813 infants with GAs between 37 and 41 weeks, coefficients were obtained modeling both GA and BW as independent predictors of term morbidities. The logistic regression coefficients were used to calculate optimal birth weight, gestational age, and birth-weight-for-gestational-age cutoffs.

RESULTS

The current definitions of low birth weight and preterm imply that it is 18 to 28 times more costly to misclassify a sick infant as low-risk than to misclassify a well infant as high-risk.

CONCLUSIONS

Gestational age alone is better than birth weight alone at predicting preterm morbidities. No birth-weight cutoff can adequately predict term morbidities. A single weight-percentile cutoff for all gestational ages should not be used to identify newborns at high risk for neonatal morbidity.

Epidemiologic analysis of an urban, public emergency department's frequent users

OBJECTIVES

To determine how the demographic, clinical, and utilization characteristics of emergency department (ED) frequent users differ from those of other ED patients.

METHODS

A cross-sectional and retrospective cohort study was performed using a database of all 348,858 visits to the San Francisco General Hospital ED during a five-year period (July 1, 1993, to June 30, 1998). A "frequent user" visited the ED five or more times in a 12-month period.

RESULTS

Frequent users constituted 3.9% of ED patients but accounted for 20.5% of ED visits. The relative risk (RR) of frequent use was high among patients who were homeless (RR = 4.5), African American (RR = 1.8), and Medi-Cal sponsored (RR = 2.1). Frequent users were more likely to be seen for alcohol withdrawal (RR = 4.4), alcohol dependence (RR = 3.4), and alcohol intoxication (RR = 2.4). Frequent users were also more likely to visit for exacerbations of chronic conditions, including sickle cell anemia (RR = 8.0), renal failure (RR = 3.6), and chronic obstructive pulmonary disease (RR = 3.3). They were less likely to visit for all forms of trauma (RR = 0.43). Survival analysis showed that only 38% of frequent users for one year remained frequent users the next year. However, 56% of frequent users for two consecutive years remained frequent users in the third year.

CONCLUSIONS

Frequent use of the ED reflects the urban social problems of homelessness, poverty, alcohol abuse, and chronic illness. Frequent use of the ED shows a high rate of decline from one year to the next. This rate of decline slows after the first year and suggests the existence of a smaller group of chronic frequent users.

Multi-state outbreaks of acute gastroenteritis traced to fecal-contaminated oysters harvested in Louisiana

Norwalk-like viruses (NLVs), or small round structured viruses, are known to cause acute gastroenteritis associated with eating contaminated shellfish. Between 1993 and 1996, three oyster-related gastroenteritis outbreaks attributed to NLV occurred in Louisiana. Intensive trace-back and environmental investigations revealed that the overboard disposal of sewage by oyster harvesters into oyster-bed waters was the most likely source of contamination in at least two of the outbreaks. The small infectious dose of NLV, the large quantity of virus particles in stool, and the ability of oysters to concentrate virus particles suggest that oyster-related outbreaks will continue unless strong control measures are established. Efforts to halt improper sewage disposal in oyster-harvesting waters, including overboard sewage discharge, must be undertaken if future outbreaks are to be prevented.

Acute effects of nitrogen dioxide after accidental release

OBJECTIVES

Following an accidental release of nitrogen dioxide from a railroad tank car containing nitrous tetroxide, the authors undertook a study of the health effects of the release, measuring the association between acute low level exposure and pulmonary symptoms.

METHODS

The authors reviewed the records of three emergency departments, surveyed 80 emergency department patients, 552 community residents, 21 chemical plant workers, and 29 emergency workers, and conducted a case-control study. Pulmonary case status was defined as having an objective pulmonary finding noted on the emergency department record, reporting that the onset of symptoms was subsequent to the release, and being within the city limits at the time of the release. Self-reported case status was defined as reporting one or more symptoms consistent with exposure to nitrogen dioxide in the week after the release and having been within the city limits at the time of the release. Control subjects were survey respondents who reported no symptoms in the week after the release and had been within the city limits at the time of the release. Chemical exposure was characterized by proximity to, direction from, and being outdoors within one hour after the release. Duration of potential exposure was not measured. Logistic regression was used to estimate odds ratios and 95% confidence interval for symptoms by exposure level, adjusted for age, sex, smoking, and preexisting pulmonary conditions.

RESULTS

Local emergency department visits increased fivefold in the week after the release. The most common complaints recorded in a systematic sample of 528 visits in the first 30 hours after the release were headache (31%), burning eyes (30%), and sore throat (24%). Objective pulmonary findings were recorded for 41 (5%) patients in the week before and 165 (4%) in the week after the release. The odds of being a pulmonary case increased by 40% for each quarter-mile increment in proximity to the release (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.1, 1.7), while the odds of being a self-reported case increased by 20% for each quarter-mile increment in proximity (OR 1.2, 95% CI 1.1, 1.4). People who met the pulmonary case definition were 2.5 times (CI 1.3, 4.8) more likely than control subjects to have been outdoors and 6.4 times (CI 3.2, 12.6) more likely to report a preexisting pulmonary condition. Self-reported cases were 2.6 times (95% CI 1.8, 3.8) more likely than control subjects to have been outdoors and 1.9 times (95% CI 1.1, 3.1) more likely to report a preexisting pulmonary condition.

CONCLUSIONS

Emergency department visits increased five-fold, but serious acute health effects were uncommon. People who met the pulmonary case definition were six times more likely to report pulmonary symptoms than those without preexisting conditions. This study was not designed to determine any potential long-term effects of exposure.

The need for more aggressive follow-up of children born to hepatitis B surface antigen-positive mothers: lessons from the Louisiana Perinatal Hepatitis B Immunization Program

BACKGROUND

Preventing perinatal transmission of hepatitis B virus (HBV) is an important part of strategies to prevent HBV-related disease. To help prevent perinatal transmission the Louisiana Office of Public Health began in 1990 a statewide program to track children of hepatitis B surface antigen (HBsAg)-positive mothers. We examined data from this program to evaluate the effectiveness of the program and to assess the value of serologic testing in the program.

METHODS

We examined vaccination and testing records for all children listed in the program database who were old enough to have been tested, according to program recommendations, as of July, 1993.

RESULTS

Of 426 children 269 (63%) had been completely vaccinated. Also of these 426 children 194 (46%) were tested for hepatitis B surface antibody (anti-HBs) and 163 (38%) were tested for HBsAg. Among tested children 6 (4%) were HBsAg-positive and 22 (11%) were anti-HBs-negative. Incompletely vaccinated children were more likely than completely vaccinated children to be HBsAg-positive (risk ratio, 7.9; 95% confidence interval, 1.5 to 41.2) and less likely to be positive for anti-HBs (risk ratio, 0.5, confidence interval, 0.3 to 0.7). Children tested > or = 18 months after the last vaccine dose were more likely than children tested earlier to be anti-HBs-negative (risk ratio, 0.8; 95% confidence interval, 0.7 to 1.1).

CONCLUSIONS

Rates of vaccination completion and postvaccination serologic testing were low for children in this program. Even with these low vaccination rates, however, we estimate that the program prevented 74% of HBV infection and 87% of HBV carriage in this group of high risk children, suggesting that failure to vaccinate rather than vaccine failure was the major obstacle to prevention of perinatal HBV transmission. Serologic testing was useful in that it identified children with chronic HBV infection and children who may have needed additional doses of vaccine, but it should be performed < 18 months after the last dose of vaccine is given. More aggressive follow-up of these children for both vaccination and serologic testing is needed.

Spinal cord injuries in Louisiana due to falls from deer stands, 1985-1994

Serious injuries resulting in paralysis and death have occurred to hunters who have fallen from deer stands that were not equipped with safety restraints. Among the most serious of these are spinal cord injuries. We examined all deer stand-related spinal cord injuries reported to Louisiana's Spinal Cord Injuries Registry from 1985 through 1994. During the 1985 through 1991 hunting seasons, we received reports of 28 deer stand falls resulting in permanent paralysis (an average of four each year) and 13 reports of temporary neurologic deficit. These injuries led to first-year medical care charges estimated at more than $4.2 million. None of the patients in the reported cases were using a safety restraint at the time of injury. After a public information campaign to make hunters aware of the risk of using deer stands without safety belts was conducted in 1992, there were no reported spinal cord injuries associated with deer stand falls for the following three years.

Heat exposure in an enclosed automobile

During July 1995, an infant in southeast Louisiana died as a result of heat exposure in an enclosed automobile. To evaluate degree of heat exposure in a vehicle, we compared the temperature rise inside an enclosed, dark-colored vehicle with the temperature rise in light-colored vehicle with the windows partly open. Within 20 minutes, readings in both cars exceeded 125 degrees F and reached approximately 140 degrees F in 40 minutes--a temperature rise of over 45 degrees F. A person who is unable to remove himself from an enclosed vehicle is at risk for a life-threatening crisis if left alone in a sun-exposed car for even a relatively short period of time.

Epidemiologic applications of novel molecular methods to detect and differentiate small round structured viruses (Norwalk-like viruses)

The molecular epidemiology of a large, multistate outbreak of oyster-associated gastroenteritis [Kohn et al. (1995): Journal of the American Medical Association 273:466-471. Dowell et al. (1995): Journal of Infectious Diseases 171:1497-1503.] was examined using new methods to detect small round structured viruses (SRSVs) by reverse transcription-polymerase chain reaction (RT-PCR) and to characterize strains by Southern hybridization and nucleotide sequencing of 81-bp of a PCR product amplified from the RNA polymerase gene. Of 37 stool specimens examined from patients in eight clusters of the multistate outbreak, 32 (86%) gave RT-PCR products specific for SRSVs of P1-A phylogenetic group. Nineteen PCR products from the eight clusters were confirmed to have the identical sequence, indicating that this large outbreak was attributed to a single strain of SRSV. In one of the eight clusters, five (63%) of eight patients had a mixed infection with a second SRSV strain that belonged to P2-B phylogenetic group. Of 12 specimens from patients in five other outbreaks and one sporadic case which occurred at the same time as the multistate outbreak, 10 (83%) gave products specific for SRSVs representing four phylogenetic groups (P1-A, P1-B, P2-A, and P2-B). The sequences of the P1-A products from two outbreaks and that of the P2-B product from another outbreak were identical to the P1-A sequence from the eight clusters and the P2-B sequence from the one cluster of the multistate outbreak, respectively. These results demonstrate the first application of these methods to enhance our understanding of the molecular epidemiology of SRSVs and provide answers of public health interest that could not have been obtained using classical epidemiologic methods alone.

Fatal illness associated with a new hantavirus in Louisiana

A fatal case of hantaviral illness occurred in Louisiana, outside of the range of P. maniculatus, the rodent reservoir for Sin Nombre virus. Hantavirus RNA and antigens were detected in patient autopsy tissues, and nucleotide sequence analysis of amplified polymerase chain reaction (PCR) products identified a newly recognized unique hantavirus, provisionally named Bayou virus. Prominent features of the clinical illness are compatible with hantavirus pulmonary syndrome (HPS), but several features such as renal insufficiency and intraalveolar hemorrhage are more compatible with hemorrhagic fever with renal syndrome (HFRS), a disease associated with Eurasian hantaviruses.

Three summertime outbreaks of influenza type A

In the Northern Hemisphere, sporadic cases of influenza occur during the summer, yet summertime outbreaks are rare. From 12 August through 2 September 1993, three influenza outbreaks in Louisiana were investigated using medical-record review, interviews, viral cultures, serology, and active surveillance for influenza-like illness in Louisiana. Attack rates in the outbreaks were 61% (69/114), 42% (24/57), and 45% (23/51). Viruses isolated were most closely related to influenza A/Beijing/32/92 (H3N2). The identification of influenza A as the cause of the first two outbreaks led to the recommendation for amantadine use in the third outbreak. Active surveillance did not detect any other outbreaks of influenza-like illness during August or September 1993. Out-of-season influenza A outbreaks can therefore occur when little influenza-like illness is present in a community. Evaluation of outbreaks of acute, febrile respiratory illness outside the influenza season should include this possibility, since rapid detection can lead to the timely use of amantadine or rimantadine.

An outbreak of Norwalk virus gastroenteritis associated with eating raw oysters. Implications for maintaining safe oyster beds

OBJECTIVE

To determine the characteristics and the cause of an outbreak of gastroenteritis associated with eating raw oysters.

DESIGN

Survey of groups of persons reporting illness to the health department after eating oysters; survey of convenience sample of oyster harvesters; and tracing of implicated oysters.

SETTING

General community.

MAIN OUTCOME MEASURES

Relative risk for illness after oyster consumption, source bed of contaminated oysters, presence of antibodies to Norwalk virus in serum, presence of a Norwalk virus in stool by direct electron microscopy and reverse transcription-polymerase chain reaction (RT-PCR), and DNA sequences of RT-PCR products.

RESULTS

Seventy (83%) of 84 persons who ate raw oysters became ill vs three (7%) of 43 people who did not eat raw oysters (relative risk, 11.9; 95% confidence interval, 4.0 to 34.2). Eleven (79%) of 14 serum pairs had at least a fourfold increase in antibody to Norwalk virus. All 12 stool samples tested were positive by electron microscopy and/or RT-PCR for Norwalk virus. The RT-PCR products from all seven stool samples tested had identical DNA sequences. Implicated oysters were harvested November 9 through 13, 1993, from a remote oyster bed. Crews from 22 (85%) of 26 oyster harvesting boats working in this area reported routine overboard disposal of sewage. One harvester with a high level of antibodies to Norwalk virus reported having gastroenteritis November 7 through 10 and overboard disposal of feces into the oyster bed.

CONCLUSIONS

This outbreak was caused by contamination of oysters in the oyster bed, probably by stool from one or more ill harvesters. Education of oyster harvesters and enforcement of regulations governing waste disposal by oyster harvesting boats might prevent similar outbreaks.

Discrimination as a consequence of genetic testing

Genetic discrimination refers to discrimination directed against an individual or family based solely on an apparent or perceived genetic variation from the "normal" human genotype. We describe here the results of a case history study designed to assess whether or not genetic discrimination exists. Using the above definition of genetic discrimination and applying stringent criteria for case selection, we find that genetic discrimination exists and is manifested in many social institutions, especially in the health and life insurance industries. Stigmatization, and denial of services or entitlements to individuals who have a genetic diagnosis but who are asymptomatic or who will never become significantly impaired, is noted. Follow-up comprehensive studies on the significance and varieties of genetic discrimination are needed. In order to avoid creating a new social underclass based on genetic discrimination (the "asymptomatic ill"), existing and future genetic testing or screening programs need review by medical, scientific, legal, and social policy experts, as well as the public, and may require modification.