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

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

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

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

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

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

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

BACKGROUND AND OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Dental health care workers' response to the HIV epidemic

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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