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Internist, Infectious Disease Specialist (virus, bacteria, parasites), Pediatrician
27 years of experience

Credentials

Education ?

Medical School Score Rankings
University of North Carolina (1985)
  •  
Top 25%

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Haemophilus Infections
Secretarys recognition award us dept hum ser
Commendatra medal us public hlth serv
Outstanding unit citation us plubic hlth serv
Exceptional performance award indian health servic
Appointments
Emory Univ
CLINICAL ASSIT PROF MEDICINE
Associations
American Board of Pediatrics
American Board of Internal Medicine

Affiliations ?

Dr. Butler is affiliated with 2 hospitals.

Hospital Affiliations

Score

Rankings

  • Alaska Native Medical Center, Phs
    4315 Diplomacy Dr, Anchorage, AK 99508
    •  
  • Alaska Native Med Ctr
  • Publications & Research

    Dr. Butler has contributed to 145 publications.
    Title Endemic Foodborne Botulism Among Alaska Native Persons--alaska, 1947-2007.
    Date May 2011
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Foodborne botulism resulting from consumption of uncooked aquatic game foods has been an endemic hazard among Alaska Native populations for centuries. Our review was conducted to help target botulism prevention and response activities.

    Title Effects of Electronic Decision Support on High-tech Diagnostic Imaging Orders and Patients.
    Date April 2010
    Journal The American Journal of Managed Care
    Excerpt

    To evaluate the effects of providing appropriateness criteria through guideline-based electronic health record (EHR) decision support for high-tech diagnostic imaging (HTDI) procedures.

    Title Trends in Nephropathy Among Hiv-infected Patients.
    Date March 2010
    Journal Journal of the National Medical Association
    Excerpt

    Nephropathy complicates the course and adversely impacts on the prognosis of HIV-infected patients. We examined trends and correlates of all-cause nephropathy (ACN).

    Title Could Hiv-associated Nephropathy Be Associated with Mycoplasma Infection?
    Date November 2009
    Journal The Indian Journal of Medical Research
    Title Immunogenicity and Reactogenicity of Pneumococcal Polysaccharide and Conjugate Vaccines in Alaska Native Adults 55-70 Years of Age.
    Date August 2009
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Vaccination with conjugate vaccines stimulates T cell-dependent immunity, whereas vaccination with polysaccharide vaccines does not. Thus, vaccination with the 7-valent pneumococcal conjugate vaccine (PCV7) followed by the 23-valent pneumococcal polysaccharide vaccine (PPV23) may offer better protection against invasive pneumococcal disease for older adults than does vaccination with PPV23 alone, which is what is currently recommended.

    Title Effects of a Sexy Appearance on Perceived Competence of Women.
    Date March 2009
    Journal The Journal of Social Psychology
    Excerpt

    The present study replicates P. Glick, S. Larsen, C. Johnson, and H. Branstiter's (2005) previous research showing that a sexy appearance may be detrimental to women in high-status jobs. The authors used a larger sample and different stimulus materials and evaluation measures. As in the original experiment, participants rated sexually and professionally dressed women in both low- and high-status positions on perceived ability. The results were consistent with the original study and showed that high-status, sexually dressed women receive lower ratings in competence.

    Title Self-organized Gels in Dna/f-actin Mixtures Without Crosslinkers: Networks of Induced Nematic Domains with Tunable Density.
    Date January 2009
    Journal Physical Review Letters
    Excerpt

    We examine mixtures of DNA and filamentous actin (F-actin) as a model system of like-charged rigid rods and flexible chains. Confocal microscopy reveals the formation of elongated nematic F-actin domains reticulated via defect-free vertices into a network embedded in a mesh of random DNA. Synchrotron x-ray scattering results indicate that the DNA mesh squeezes the F-actin domains into a nematic state with an interactin spacing that decreases with increasing DNA concentration as d(actin) proportional, variantrho(DNA)(-1/2). Interestingly, the system changes from a counterion-controlled regime to a depletion-controlled regime with added salt, with drastic consequences for the osmotic pressure induced phase behavior.

    Title Invasive Pneumococcal Disease Epidemiology and Effectiveness of 23-valent Pneumococcal Polysaccharide Vaccine in Alaska Native Adults.
    Date August 2007
    Journal Vaccine
    Excerpt

    Alaska Native persons have age-adjusted invasive pneumococcal disease (IPD) rates two- to three-fold greater than non-Native Alaskans. To characterize IPD epidemiology and 23-valent polysaccharide pneumococcal vaccine (PPV-23) effectiveness in Alaska Native adults we reviewed IPD cases from Alaska-wide, laboratory-based surveillance. Sterile site isolates were serotyped. Vaccine effectiveness (VE) was estimated using the indirect cohort method. 394 cases (44.5 cases/100,000/year) occurred in 374 Alaska Native adults (36.0% aged > or =55 years). Underlying conditions included heavy alcohol use (65.7%), smoking (60.8%) and COPD (25.0%). Overall VE was 75% (95% confidence interval [CI]: 27%, 91%) but declined with increasing age; for persons > or =55 years (VE=<0; 95% CI: <0, 78%; p=0.713). Alaska Native adults experience high rates of IPD. The majority of IPD cases occurred in persons with underlying conditions and behaviors associated with increased risk of IPD in other populations. PPV-23 vaccine effectiveness was confirmed in younger Alaska Native adults but not among adults > or =55 years.

    Title Vaccines to Prevent Respiratory Infection: Opportunities on the Near and Far Horizon.
    Date June 2007
    Journal Current Opinion in Infectious Diseases
    Excerpt

    Illnesses caused by respiratory pathogens result in great loss of life, suffering and commitment of resources for treatment. That the suffering and loss of life can be prevented through immunization has already been clearly shown with existing vaccines, such as those for Haemophilus influenzae type b, Streptococcus pneumoniae, and influenza. The emergence of drug-resistant pathogens is making reliance on therapy more expensive and perhaps less successful, accentuating the need to focus on prevention. Although several effective vaccines to prevent respiratory infections currently exist, they are underutilized globally. Improvements in immunogenicity, efficacy, and ease of administration, and lowering the costs of some of the existing vaccines would augment the potential for prevention worldwide. The greatest opportunities for the prevention of respiratory infections will rest with vaccines that will become available in the future.

    Title Invasive Pneumococcal Disease Caused by Nonvaccine Serotypes Among Alaska Native Children with High Levels of 7-valent Pneumococcal Conjugate Vaccine Coverage.
    Date April 2007
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    CONTEXT: With routine childhood vaccination using heptavalent pneumococcal conjugate vaccine, one concern has been the potential for emergence and expansion of replacement disease caused by serotypes not contained in the heptavalent conjugate vaccine. OBJECTIVE: To determine whether replacement disease is associated with the overall decline in invasive pneumococcal disease among Alaska Native children. DESIGN, SETTING, AND PATIENTS: Alaska statewide longitudinal population-based laboratory surveillance of invasive Streptococcus pneumoniae infections from January 1, 1995, through December 31, 2006. MAIN OUTCOME MEASURES: Incidence and types of pneumococcal disease in children younger than 2 years. RESULTS: In the first 3 years after introduction of routine vaccination with heptavalent pneumococcal conjugate vaccine, overall invasive pneumococcal disease decreased 67% in Alaska Native children younger than 2 years (from 403.2 per 100,000 in 1995-2000 to 134.3 per 100,000 per year in 2001-2003, P<.001). However, between 2001-2003 and 2004-2006, there was an 82% increase in invasive disease in Alaska Native children younger than 2 years to 244.6/100,000 (P = .02). Since 2004, the invasive pneumococcal disease rate caused by nonvaccine serotypes has increased 140% compared with the prevaccine period (from 95.1 per 100,000 in 1995-2000 to 228.6 in 2004-2006, P = .001). During the same period, there was a 96% decrease in heptavalent vaccine serotype disease. Serotype 19A accounted for 28.3% of invasive pneumococcal disease among Alaska children younger than 2 years during 2004-2006. There was no significant increase in nonvaccine disease in non-Native Alaska children younger than 2 years. CONCLUSIONS: Alaska Native children are experiencing replacement invasive pneumococcal disease with serotypes not covered by heptavalent pneumococcal conjugate vaccine. The demonstration of replacement invasive pneumococcal disease emphasizes the importance of ongoing surveillance and development of expanded valency vaccines.

    Title Infectious Disease Hospitalizations Among Older American Indian and Alaska Native Adults.
    Date February 2007
    Journal Public Health Reports (washington, D.c. : 1974)
    Excerpt

    OBJECTIVES: American Indians and Alaska Natives (AI/AN) adults > or = 65 years of age (older adults) have the second highest age group-specific infectious disease (ID) hospitalization rate. To assess morbidity and disparities of IDs for older AI/AN adults, this study examined the epidemiology of overall and specific infectious disease hospitalizations among older AI/AN adults. METHODS: ID hospitalization data for older AI/AN adults were analyzed by using Indian Health Service hospital discharge data for 1990 through 2002 and comparing it with published findings for the general U.S. population of older adults. RESULTS: ID hospitalizations accounted for 23% of all hospitalizations among older AI/AN adults. The average annual ID hospitalization rate increased 5% for 1990-1992 to 2000-2002; however, the rate increased more than 20% in the Alaska and the Southwest regions. The rate for older AI/AN adults living in the Southwest region was greater than that for the older U.S. adult population. For 2000-2002, lower respiratory tract infections accounted for almost half of all ID hospitalizations followed by kidney, urinary tract, and bladder infections, and cellulitis. CONCLUSIONS: The ID hospitalization rate increased among older AI/AN adults living in the Southwest and Alaska regions, and the rate for the older AI/AN adults living in the Southwest region was higher than that for the U.S. general population. Prevention measures should focus on ways to reduce ID hospitalizations among older AI/AN adults, particularly those living in the Southwest and Alaska regions.

    Title Decline in Respiratory Syncytial Virus Hospitalizations in a Region with High Hospitalization Rates and Prolonged Season.
    Date February 2007
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    BACKGROUND: During 1993 to 1996, Alaska Native infants <1 year of age from the Yukon Kuskokwim (YK) Delta in Alaska experienced a respiratory syncytial virus (RSV) hospitalization rate 5 times the U.S. general infant population rate. We describe trends in lower respiratory tract infection (LRTI) and RSV hospitalizations in YK children from 1994 to 2004. METHODS: We abstracted hospital dates, RSV test results and clinical information from the hospital records for YK children <3 years of age hospitalized between July 1994 and June 2004. RESULTS:: The RSV hospitalization rate in YK Delta children <1 year of age decreased from 178 per 1000 infants per year (1994-1997) to 104 per 1000 infants per year (2001-2004) (P < 0.001), and the RSV hospitalization rate for premature infants decreased from 317 to 123 per 1000 infants per year (P < 0.001). The risk reduction for RSV hospitalization was greater in premature (relative risk, 0.39) than in term infants (relative risk, 0.60; P = 0.04). The rate of non-RSV LRTI hospitalizations increased from 153 to 215 per 1000 infants per year (P < 0.001). The median RSV season length was 30.5 weeks. Pneumonia was diagnosed in more than half of RSV admissions. CONCLUSIONS: In YK infants, the RSV hospitalization rate decreased by one-third between 1994 and 2004; however, the overall LRTI hospitalization rate did not change. The median RSV season was twice as long as for the U.S. population. Palivizumab prophylaxis may be responsible for the larger decrease in the RSV hospitalization rate among premature infants; however, the 2001-2004 RSV hospitalization rate among YK infants remained 3 times higher than the U.S. infant rate.

    Title Immunogenicity and Reactogenicity to Haemophilus Influenzae Type B (hib) Conjugate Vaccine Among Rural Alaska Adults.
    Date October 2006
    Journal Human Vaccines
    Excerpt

    BACKGROUND: Despite routine vaccination and declining disease rates, Haemophilus influenzae type b (Hib) invasive disease still occurs in rural Alaska. Colonization studies indicate persistent transmission of Hib among village residents, including adults. As part of a project to eliminate Hib carriage in three rural villages, we evaluated a cohort of Alaska adults for antibody response and reactogenicity to a single dose of Hib conjugate vaccine (HbOC). METHODS: 75 previously unvaccinated, randomly-selected adults in one village received a single dose of HbOC vaccine and completed a side-effects diary. Sera and oropharyngeal specimens were collected at baseline, two months and one year. RESULTS: No participants were colonized with Hib or reported serious side-effects. At baseline, 97% of adults had IgG anti-PRP concentrations > or = 0.15 microg/mL, 69% > or = 1 microg/mL, and 28% > or = 5 microg/mL. Two months post-vaccination, 100% of participants had concentrations > or = 0.15 microg/mL, 93% > or = 1 microg/mL, and 86% > or = 5 microg/mL. After 1 year, 98% had IgG anti-PRP concentrations > or = 0.15 microg/mL, 86% > or = 1 microg/mL, and 67% > or = 5 microg/mL. GMCs were 1.9, 33.3 and 8.4 microg/mL at baseline, 2 months and 1 year post-vaccine, respectively (p < 0.01). Serum bactericidal activity increased from a baseline geometric mean titer of 2,205 to 8,349 two months post vaccination and declined to 1102 after one year. CONCLUSIONS: HbOC vaccine was immunogenic and well-tolerated among Alaskan adults. Nearly 90% of the adults developed an antibody level associated with protection against Hib colonization which persisted for 1 year in 67% of participants.

    Title Relationship Between Ige and Specific Aeroallergen Sensitivity in Alaskan Native Children.
    Date September 2006
    Journal Annals of Allergy, Asthma & Immunology : Official Publication of the American College of Allergy, Asthma, & Immunology
    Excerpt

    BACKGROUND: The relationship between atopic disease and serum IgE levels varies among populations and geographic regions. The close association of atopy with IgE may not occur in subarctic populations as it does in developed countries in temperate climates. OBJECTIVE: To evaluate the relationship between total and specific IgE concentrations and clinical atopy in 5- to 8-year-old Alaskan native children. METHODS: Medical record reviews, interviews, physical examinations, serum IgE measurements, and radioallergosorbent testing (RAST) were performed. RESULTS: The IgE geometric mean was 122.1 IU/mL. Fifty-eight percent of patients had IgE levels greater than 70 IU/mL, and 17% had levels greater than 1,000 IU/mL; 14% had RAST values greater than 0.35 kU/L. Both IgE levels greater than 70 IU/mL and greater than 1,000 IU/mL were associated with RAST values greater than 0.35 IU/L (P = .004) and early wheezing (P = .005) but not with current wheezing, asthma, eczema, or a history of allergies. A RAST value greater than 3.51 kU/L was associated with eczema (P = .04) but not with allergies or wheezing. Children with current wheezing were more likely to have allergies (P = .03) but not eczema, an IgE level greater than 70 IU/mL, or a positive RAST value. Children hospitalized with respiratory syncytial virus (RSV) were not more likely than controls to have current wheezing. CONCLUSIONS: Elevated serum IgE concentrations, including levels greater than 1,000 IU/mL, are common among Alaskan native children; positive RAST reactions to aeroallergens are not. The IgE levels do not relate to wheezing, eczema, a history of allergies, or past hospitalization for RSV infection but likely reflect infections other than RSV and environmental factors in subarctic indigenous populations.

    Title Reactions After 3 or More Doses of Pneumococcal Polysaccharide Vaccine in Adults in Alaska.
    Date September 2006
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    BACKGROUND: Following vaccination with 23-valent pneumococcal polysaccharide vaccine (PPV), pneumococcal antibody levels decline to prevaccination levels within 6-10 years. The Advisory Committee on Immunization Practices does not recommend routine revaccination because data on the safety and effectiveness of additional doses are insufficient. METHODS: To determine whether medically attended adverse events occur more frequently after the third dose of PPV than after the first or second dose, we performed a retrospective review of medical records from a computer database for health care facilities that serve more than one-half of the Alaska Native population. All persons who had received > or = 3 PPV doses (n = 179) were included in the review, as were a randomly selected comparison group of 181 persons who had received 1 or 2 doses. RESULTS: Only 1 (0.55%) of 179 persons who had received > or = 3 PPV doses and 4 (2.76%) of 181 persons in the comparison group had a medically attended adverse event, and no severe adverse events were recorded. CONCLUSION: We found no difference in the risk of medically attended adverse events following > or = 3 doses of PPV, compared with 1 or 2 doses.

    Title The Alaska Haemophilus Influenzae Type B Experience: Lessons in Controlling a Vaccine-preventable Disease.
    Date September 2006
    Journal Pediatrics
    Excerpt

    OBJECTIVE: Before 1991, Alaska Native children experienced one of the highest rates of invasive Haemophilus influenzae type b disease. H influenzae type b vaccine has led to a near-elimination of invasive H influenzae type b disease in the United States. We describe challenges encountered in controlling H influenzae type b disease in Alaska and update the current status of H influenzae disease and carriage in Alaska as lessons to other populations. PATIENTS AND METHODS: We reviewed data from statewide H influenzae disease surveillance conducted during 1980-2004. Vaccine coverage data were based on audits from tribal facilities and the National Immunization Survey. H influenzae type b colonization data were based on 6 carriage studies. RESULTS: After universal infant vaccination in 1991, H influenzae type b disease among Alaska Native and non-Native children < 5 years of age decreased by 94% and 96%, respectively. After a 1996 change in H influenzae type b vaccine from polyribosylribitol phosphate-outer membrane protein conjugate vaccine to H influenzae type b oligosaccharide-CRM197 vaccine, the incidence of H influenzae type b disease increased in rural Alaska Natives from 19.8 to 91.1 cases per 100000 per year < 5 years of age. During 2001-2004, with use of polyribosylribitol phosphate-outer membrane protein conjugate vaccine, the rate of H influenzae type b disease in Alaska Native and non-Native children aged < 5 years decreased to 5.4 and 0 per 100000 per year, respectively. In postvaccine studies, H influenzae type b carriage has decreased in Alaska Native children < 5 years of age. CONCLUSIONS: H influenzae type b vaccination has resulted in a dramatic decrease in invasive H influenzae type b disease in Alaska; however, despite high rates of H influenzae type b vaccine coverage, H influenzae type b disease rates among rural Alaska Native children < 5 years of age remain higher than the rates among non-Native Alaska and other US children. Equity in disease rates may not be achieved in indigenous populations with the current vaccines unless other environmental and household factors contributing to disease transmission are addressed.

    Title Assessment of Carriage of Haemophilus Influenzae Type a After a Case of Invasive Disease.
    Date August 2006
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Title Nature Abhors Vacuum, but Public Health is Loving It: the Sustained Decrease in the Rate of Invasive Haemophilus Influenzae Disease.
    Date August 2006
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Title Immunologic Response to Haemophilus Influenzae Type B (hib) Conjugate Vaccine and Risk Factors for Carriage Among Hib Carriers and Noncarriers in Southwestern Alaska.
    Date August 2006
    Journal Clinical and Vaccine Immunology : Cvi
    Excerpt

    Continued Haemophilus influenzae type b (Hib) carriage in rural Alaska contributes to the ongoing risk of invasive disease. Community-wide Hib carriage surveys were conducted in three villages in southwestern Alaska. Sixteen carriers and 32 age- and village-matched controls were enrolled and were vaccinated with Hib oligosaccharide-CRM(197) conjugate vaccine. Serum immunoglobulin G (IgG) concentration, antibody avidity, and serum bactericidal activity (SBA) were measured prior to Hib vaccination and 2 and 12 months after vaccination. We identified no demographic or behavioral factors associated with Hib colonization. Prior to vaccination, Hib carriers had a higher IgG geometric mean concentration than controls did (8.2 versus 1.6 microg/ml; P < 0.001) and a higher SBA geometric mean titer (7,132 versus 1,235; P = 0.006). Both groups responded to vaccination with increased IgG and SBA. These data illustrate the role of Hib colonization as an immunizing event and show that Hib carriers in communities with ongoing transmission have no evidence of reduced immune responsiveness that may have put them at risk for colonization.

    Title Structure and Dynamics of Liquid Crystalline Pattern Formation in Drying Droplets of Dna.
    Date July 2006
    Journal Physical Review Letters
    Excerpt

    We investigate the formation of ringlike deposits in drying drops of DNA. In analogy with the colloidal "coffee rings," DNA is transported to the perimeter by the capillary flow. At the droplet edge, however, DNA forms a lyotropic liquid crystal (LC) with concentric chain orientations to minimize the LC elastic energy. During the final stages of drying, the contact line retracts, and the radial stress causes undulations at the rim that propagate inward through the LC and form a periodic zigzag structure. We examine the phenomenon in terms of a simple model based on LC elasticity.

    Title Counterions Between Charged Polymers Exhibit Liquid-like Organization and Dynamics.
    Date July 2006
    Journal Proceedings of the National Academy of Sciences of the United States of America
    Excerpt

    Current understanding of electrostatics in water is based on mean-field theories like the Poisson-Boltzmann formalism and its approximations, which are routinely used in colloid science and computational biology. This approach, however, breaks down for highly charged systems, which exhibit counterintuitive phenomena such as overcharging and like-charge attraction. Models of counterion correlations have been proposed as possible explanations, but no experimental comparisons are available. Here, collective dynamics of counterions that mediate like-charge attraction between F-actin filaments have been directly observed in aqueous solution using high-resolution inelastic x-ray scattering down to molecular length-scales. We find a previously undescribed acoustic-like phonon mode associated with correlated counterions. The excitation spectra at high wave-vector Q reveal unexpected dynamics due to ions interacting with their "cages" of nearest neighbors. We examine this behavior in the context of intrinsic charge density variations on F-actin. The measured speed of sound and collective relaxation rates in this liquid agree surprisingly well with simple model calculations.

    Title Indirect Effect of Conjugate Vaccine on Adult Carriage of Streptococcus Pneumoniae: an Explanation of Trends in Invasive Pneumococcal Disease.
    Date June 2006
    Journal The Journal of Infectious Diseases
    Excerpt

    BACKGROUND: Use of heptavalent protein-polysaccharide pneumococcal conjugate vaccine (PCV7) has been associated with decreases in PCV7-type invasive pneumococcal disease and nasopharyngeal (NP) carriage in children. Vaccine use has also indirectly decreased the rate of invasive disease in adults, presumably through decreased transmission of pneumococci from vaccinated children to adults. METHODS: We conducted NP carriage surveys in 8 villages in Alaska in 1998-2004. Streptococcus pneumoniae isolates were characterized by serotype and antimicrobial susceptibility. We analyzed trends in serotype distribution, antibiotic resistance, and factors associated with adult carriage of PCV7-serotype pneumococci before and after the introduction of PCV7 in 2001. RESULTS: We collected 15,598 NP swabs; overall, 52% of adults living in the villages surveyed participated in the colonization study. The proportion of adult carriers with PCV7-type pneumococcal carriage decreased from 28% of carriers in 1998-2000 to 4.5% of carriers in 2004 (P<.0001). Among adults, the proportion of colonizing isolates that were resistant to penicillin decreased from 13% in 1998-2000 to 6% in 2004 (P=.05), whereas the percentage of isolates with intermediate susceptibility to penicillin increased from 12% in 1998-2000 to 19% in 2004 (P<.01). Adults were more likely to carry PCV7-type pneumococci if they lived with a child <5 years old or if they lived with a child who had not been age-appropriately vaccinated with PCV7. CONCLUSIONS: Pediatric vaccination with PCV7 has resulted in decreased PCV7-type pneumococcal carriage among adults and helps to explain recent decreases in the rate of PCV7-type invasive pneumococcal disease among adults.

    Title Closer to Home: Local Care Improves Compliance with Rsv Prophylaxis in High-risk Infants.
    Date April 2006
    Journal International Journal of Circumpolar Health
    Title Potential Impacts of Climate Change on Infectious Diseases in the Arctic.
    Date February 2006
    Journal International Journal of Circumpolar Health
    Excerpt

    Climate change could cause changes in the incidence of infectious diseases in Arctic regions. Higher ambient temperatures in the Arctic may result in an increase in some temperature sensitive foodborne diseases such as gastroenteritis, paralytic shellfish poisoning and botulism. An increase in mean temperature may also influence the incidence of infectious diseases of animals that are spread to humans (zoonoses) by changing the population and range of animal hosts and insect vectors. An increase in flooding events may result in outbreaks of waterborne infection, such as Giardia lamblia or Cryptospordium parvum. A change in rodent and fox populations may result in an increase in rabies or echinococcosis. Temperature and humidity influence the distribution and density of many arthropod vectors which in turn may influence the incidence and northern range of vectorborne diseases such as West Nile virus. Recommendations include: the strenghtening of public health systems, disease surveillance coordinated with climate monitoring, and research into the detection, prevention, control and treatment of temperature-sensitive infectious diseases.

    Title Impact of Heptavalent Pneumococcal Conjugate Vaccine on Invasive Disease, Antimicrobial Resistance and Colonization in Alaska Natives: Progress Towards Elimination of a Health Disparity.
    Date February 2006
    Journal Vaccine
    Excerpt

    We evaluated invasive pneumococcal disease (IPD), antimicrobial resistance and nasopharyngeal colonization before and after introduction of pneumococcal conjugate vaccine (PCV7) in Alaska Natives (AN), a population with high IPD rates. We obtained IPD rates from population-based surveillance. Colonization was determined from annual surveys among rural AN of all ages and from urban children. After vaccine introduction, vaccine-type IPD rates declined by 91% among AN children <2 years, by 80% among non-Natives <2 years, and by 40% for adults of all races (P<0.001 each). IPD decreased for isolates resistant to penicillin, erythromycin and cotrimoxazole (P<0.001 each). Vaccine-type colonization decreased among rural and urban children <5 years and among rural adults (P<0.001 each). PCV7 vaccine has eliminated a longstanding disparity of vaccine-type IPD for AN children. Decreased vaccine-type colonization and IPD in adults demonstrate indirect vaccine effects.

    Title Persistence of Antibody to Hepatitis B and Protection from Disease Among Alaska Natives Immunized at Birth.
    Date January 2006
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    BACKGROUND: Alaska Native (AN) children were at high risk of acquiring hepatitis B virus (HBV) infection before vaccination began in 1983. We evaluated the long-term protection from hepatitis B (HB) vaccination among AN children immunized when infants. METHODS: During 1984-1995, we recruited a convenience sample of AN children who had received a three dose series of HB vaccine starting at birth and had serum antibody to hepatitis B (anti-HBs) concentrations of >/= 10 mIU/mL at 7-26 months of age. We evaluated anti-HBs concentrations and the presence of anti-HBc in participants' sera every other year up to age 16 years. Anti-HB core antigen (anti-HBc)-positive specimens were tested for hepatitis B surface antigen and for HBV DNA. RESULTS: We followed 334 children for 3151 person-years (median, 10 years per child) with 1610 specimens collected. Anti-HBs concentrations dropped rapidly among all participants. Among children 2, 5 and 10 years of age, 37 of 79 (47%), 33 of 176 (19%) and 8 of 95 (8%), respectively, had anti-HBs concentrations of >/= 10 mIU/mL. Receipt of recombinant vaccine was significantly associated with a more rapid antibody decline (P < 0.001). Six (1.8%) children acquired anti-HBc, 3 of whom had definite breakthrough infections (at least 2 consecutive anti-HBc-positive specimens or at least 1 anti-HBc-positive specimen and HBV DNA detection by PCR). None of these children had detectable hepatitis B surface antigen, and none had symptoms of hepatitis. CONCLUSIONS: Anti-HBs concentrations declined over time among AN infants successfully immunized with HB vaccine starting at birth. Transient anti-HBc appeared in a small percentage of children; however, none developed clinical signs of hepatitis or chronic HBV infection.

    Title The Changing Landscape of Epidemic Bacterial Meningitis in Africa: New Opportunities for Prevention.
    Date September 2005
    Journal The Journal of Infectious Diseases
    Title Outbreak of Invasive Haemophilus Influenzae Serotype a Disease.
    Date June 2005
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    Haemophilus influenzae serotype a is a rare cause of invasive disease. We report 5 cases of invasive H. influenzae type a that occurred in 3 infants living in a remote region of Alaska during the last 6 months of 2003. H. influenzae type a isolates from this outbreak were closely related as determined by pulsed field gel electrophoresis. Continued surveillance is necessary to monitor trends in H. influenzae invasive disease.

    Title Evaluation of a Volunteer Sample in Nasopharyngeal Colonization Surveys for Streptococcus Pneumoniae in Rural Alaska.
    Date April 2005
    Journal International Journal of Circumpolar Health
    Excerpt

    OBJECTIVE: To compare characteristics of persons in rural northern communities who participated in a study on antimicrobial use and drug-resistant Streptococcus pneumoniae (SP) to those who did not participate. STUDY DESIGN: The original study (1998--2000) was a community-based, controlled intervention trial designed to determine the penicillin susceptibility of nasopharyngeal SP isolates in relation to community-wide use of antibiotics. The study continued after 2000, in a subset of the original communities, to prospectively evaluate the impact of the heptavalent pneumococcal conjugate vaccine on the carriage of SP. The results presented here are an analysis of the first five years of data. METHODS: We conducted annual surveys (1998--2002) for nasopharyngeal colonization of SP using a volunteer sample of residents in rural communities. Medical chart reviews for health clinic visitation and antibiotic use were completed for all village residents. RESULTS: Participants were younger (22.8 vs. 28.4 years), had more health clinic utilization (3.3 vs. 2.4 visits) and received more antibiotics (1.0 vs. 0.6 courses) than non-participants. Differences between participants and non-participants were similar across all years of the study. CONCLUSIONS: Our study provides further empirical evidence that selection bias should be considered when designing studies. However, a volunteer sample provided internal consistency for comparison of our main study outcomes across time.

    Title Pspa Family Typing and Pcr-based Dna Fingerprinting with Box A1r Primer of Pneumococci from the Blood of Patients in the Usa with and Without Sickle Cell Disease.
    Date March 2005
    Journal Epidemiology and Infection
    Excerpt

    Disease and mortality rates for Streptococcus pneumoniae infections are much higher in patients with sickle cell disease (SCD) than in age-matched patients without SCD. Pneumococcal surface protein A (PspA) has been proposed as a component in human vaccines against S. pneumoniae to provide greater breadth of coverage than can be obtained with the 7-valent conjugate vaccine. The cross-reactivity of PspA is associated with the 'PspA family' structure. In this study we examined strains of S. pneumoniae from patients with and without SCD to determine whether the strains infecting the hypersusceptible population of SCD patients were limited to the same two PspA families already known to comprise over 95% of strains infecting non-SCD patients. Each strain was also evaluated according to the presence or absence of specific PCR fragments based on repetitive BOX elements to screen for possible SCD-associated clonal structure. Strains from SCD and non-SCD patients were similarly dispersed among the most common BOX PCR groups and strains from both groups expressed a similar distribution of PspA variants. Thus, a PspA vaccine designed for the population at large should also be appropriate for patients with SCD.

    Title Impact of a Conjugate Vaccine on Community-wide Carriage of Nonsusceptible Streptococcus Pneumoniae in Alaska.
    Date December 2004
    Journal The Journal of Infectious Diseases
    Excerpt

    BACKGROUND: Streptococcus pneumoniae is a leading cause of invasive bacterial disease and pneumonia among children. Antimicrobial resistance among pneumococci has increased in recent years and complicates treatment. The introduction of heptavalent pneumococcal conjugate vaccine (PCV7) could reduce acquisition of antimicrobial-resistant pneumococci. METHODS: We obtained 1350 nasopharyngeal swabs for culture from 1275 children aged 3-59 months presenting at 3 clinics in Anchorage, Alaska, during the winters of 2000, 2001, and 2002, as PCV7 was being introduced into the routine immunization schedule. We recorded the frequency of use of antibiotics as well as the dates of doses of PCV7 for enrolled children. We used multivariate logistic regression modeling to identify independent risk factors for overall carriage of pneumococci and carriage of PCV7-type pneumococci, cotrimoxazole-nonsusceptible (COT-NS) pneumococci, or penicillin-nonsusceptible (PCN-NS) pneumococci. RESULTS: The proportion of children who were up-to-date for age, with respect to PCV7 vaccination, increased from 0% in 2000 to 55% in 2002. Carriage of PCV7-type pneumococci decreased by 43% (P<.0001). Risk of carriage of PCV7-type pneumococci was lower in 2002 than in 2000, independent of vaccination status, suggesting an indirect effect of vaccination. Carriage of COT-NS, but not PCN-NS, pneumococci also decreased (38%; P=.02), not only among vaccinated children but also among unvaccinated children without recent use of antibiotics. CONCLUSIONS: Introduction of PCV7 into the routine infant immunization schedule in a community with a high prevalence of antimicrobial-resistant pneumococci appears to reduce transmission of PCV7 vaccine serotypes and COT-NS pneumococci but has no impact on overall carriage of pneumococci or carriage of PCN-NS pneumococci.

    Title Temporal and Geographic Stability of the Serogroup-specific Invasive Disease Potential of Streptococcus Pneumoniae in Children.
    Date October 2004
    Journal The Journal of Infectious Diseases
    Excerpt

    A meta-analysis study design was used to analyze 7 data sets of invasive and carriage pneumococcal isolates recovered from children, to determine whether invasive disease potential differs for each serotype and, if so, whether it has changed over time or differs geographically. Serotype- and serogroup-specific odds ratios (ORs) were calculated for each study and as a pooled estimate, with use of serotype 14 as the reference group. ORs varied widely: the serotypes with the highest ORs (1, 5, and 7) were 60-fold more invasive than those with the lowest ORs (3, 6A, and 15). There was a significant inverse correlation between invasive disease and carriage prevalence for the serotypes that we considered, which implies that the most invasive serotypes and serogroups were the least commonly carried and that the most frequently carried were the least likely to cause invasive disease. There was no evidence of any temporal change or major geographical differences in serotype- or serogroup-specific invasive disease potential.

    Title Community-onset Methicillin-resistant Staphylococcus Aureus Associated with Antibiotic Use and the Cytotoxin Panton-valentine Leukocidin During a Furunculosis Outbreak in Rural Alaska.
    Date June 2004
    Journal The Journal of Infectious Diseases
    Excerpt

    BACKGROUND: Community-onset methicillin-resistant Staphylococcus aureus (CO-MRSA) reports are increasing, and infections often involve soft tissue. During a CO-MRSA skin infection outbreak in Alaska, we assessed risk factors for disease and whether a virulence factor, Panton-Valentine leukocidin (PVL), could account for the high rates of MRSA skin infection in this region. METHODS: We conducted S. aureus surveillance in the outbreak region and a case-control study in 1 community, comparing 34 case patients with MRSA skin infection with 94 control subjects. An assessment of traditional saunas was performed. S. aureus isolates from regional surveillance were screened for PVL genes by use of polymerase chain reaction, and isolate relatedness was determined by use of pulsed-field gel electrophoresis (PFGE). RESULTS: Case patients received more antibiotic courses during the 12 months before the outbreak than did control subjects (median, 4 vs. 2 courses; P=.01) and were more likely to use MRSA-colonized saunas than were control subjects (44% vs. 13%; age-adjusted odds ratio, 4.6; 95% confidence interval, 1.7-12). The PVL genes were present in 110 (97%) of 113 MRSA isolates, compared with 0 of 81 methicillin-susceptible S. aureus isolates (P<.001). The majority of MRSA isolates were closely related by PFGE. CONCLUSION: Selective antibiotic pressure for drug-resistant strains carrying PVL may have led to the emergence and spread of CO-MRSA in rural Alaska.

    Title Specificity of the Antibody Response to the Pneumococcal Polysaccharide and Conjugate Vaccines in Human Immunodeficiency Virus-infected Adults.
    Date April 2004
    Journal Clinical and Diagnostic Laboratory Immunology
    Excerpt

    Nonspecific antibodies, which are thought to be nonprotective, have been shown to contribute a substantial proportion of the measured concentration in the standardized immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) for pneumococcal polysaccharide capsular antibodies. The presence of such antibodies in human immunodeficiency virus (HIV)-infected persons has not been evaluated. The amount of nonspecific antibodies is proportional to the reduction in IgG antibody concentration that occurs with serum absorption with the heterologous polysaccharide 22F. We measured the amount of nonspecific antibodies before and after vaccination with the pneumococcal conjugate vaccine (PCV; n = 33) or the pneumococcal polysaccharide vaccine (PPV; n = 34) in HIV-infected adults with CD4 counts of >/== 200 cells/mm3. Blood was drawn before and 2 months after vaccination. For prevaccination sera, we found a substantial amount of nonspecific antibodies for serotypes 4, 6B, 9V, and 23F (23 to 47% of measured IgG concentration), but not for serotype 14. There tended to be proportionately less nonspecific antibodies in postvaccine sera than prevaccine sera for PCV, but not for PPV. Subjects with a low HIV viral load (</= 400 copies/ml) had proportionately more nonspecific antibodies than those with higher viral load before and after both vaccines. After 22F absorption, the geometric mean concentrations of antibodies were significantly higher post-PCV than post-PPV for the high viral load group for all five serotypes, but for no serotypes in the low viral load group. These findings confirm that absorption with a heterologous pneumococcal polysaccharide (e.g., 22F) is necessary to remove nonspecific antibodies in a standardized IgG ELISA for pneumococcal capsular antibodies in HIV-infected adults.

    Title An Outbreak of Community-onset Methicillin-resistant Staphylococcus Aureus Skin Infections in Southwestern Alaska.
    Date March 2004
    Journal Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
    Excerpt

    OBJECTIVE: We investigated a large outbreak of community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections in southwestern Alaska to determine the extent of these infections and whether MRSA isolates were likely community acquired. DESIGN: Retrospective cohort study. SETTING: Rural southwestern Alaska. PATIENTS: All patients with a history of culture-confirmed S. aureus infection from March 1, 1999, through August 10, 2000. RESULTS: More than 80% of culture-confirmed S. aureus infections were methicillin resistant, and 84% of MRSA infections involved skin or soft tissue; invasive disease was rare. Most (77%) of the patients with MRSA skin infections had community-acquired MRSA (no hospitalization, surgery, dialysis, indwelling line or catheter, or admission to a long-term-care facility in the 12 months before infection). Patients with MRSA skin infections were more likely to have received a prescription for an antimicrobial agent in the 180 days before infection than were patients with methicillin-susceptible S. aureus skin infections. CONCLUSIONS: Our findings indicate that the epidemiology of MRSA in rural southwestern Alaska has changed and suggest that the emergence of community-onset MRSA in this region was not related to spread of a hospital organism. Treatment guidelines were developed recommending that beta-lactam antimicrobial agents not be used as a first-line therapy for suspected S. aureus infections.

    Title Sequelae of Severe Respiratory Syncytial Virus Infection in Infancy and Early Childhood Among Alaska Native Children.
    Date October 2003
    Journal Pediatrics
    Excerpt

    OBJECTIVE: In 1993-1996, we conducted a nested case-control study to determine risk factors for hospitalization with respiratory syncytial virus (RSV) infection among Alaska Native infants and young children. In the current study, we returned to former RSV case-patients and their control subjects during 1999-2001 to determine whether children who are hospitalized with RSV at <2 years of age are more likely to develop chronic respiratory conditions. METHODS: For each former RSV case-patient and control subject from remote villages in southwest Alaska, we reviewed medical records, interviewed parents, performed physical examinations and spirometry, collected sera, and analyzed chest radiographs. Case-patients were identified through surveillance for RSV hospitalization, and matched control subjects without lower respiratory infection (LRI)-related hospitalization were identified. RESULTS: Hospitalization for RSV infection was associated with a significant increase in wheezing, LRIs, and asthma diagnosis during the first 4 years of life. The association decreased with age and was no longer significant by 5 years of age. However, hospitalization for RSV infection was associated with increased respiratory symptoms and increased chronic productive cough at 5 to 8 years of age. Children who were hospitalized with RSV were not more likely at follow-up to have allergies, eczema, or a positive family history of asthma. CONCLUSIONS: Severe RSV infection in infancy may produce airway injury, which is manifested in chronic productive cough with or without wheezing and recurrent LRIs. Although the association of RSV infection with wheezing seems to be transient, children remain at higher risk for chronic productive cough at 5 to 8 years of age. RSV prevention modalities may prevent sequelae that occur early and later in childhood.

    Title The Relationship Among Previous Antimicrobial Use, Antimicrobial Resistance, and Treatment Outcomes for Helicobacter Pylori Infections.
    Date September 2003
    Journal Annals of Internal Medicine
    Excerpt

    BACKGROUND: The relationship between previous antimicrobial treatments and infection with drug-resistant Helicobacter pylori is unknown. OBJECTIVES: To determine whether previous use of antimicrobial agents predicts subsequent antibiotic resistance of H. pylori and whether resistance affects treatment outcome. DESIGN: Retrospective cohort analysis of adults recruited sequentially from a clinical practice. SETTING: A referral hospital in Anchorage, Alaska. PATIENTS: 125 adults infected with H. pylori. MEASUREMENTS: Medical records were reviewed for antimicrobial agents prescribed in the 10 years before diagnosis with H. pylori infection. Antimicrobial susceptibility of H. pylori isolates obtained from endoscopic gastric biopsy was determined by using agar dilution. Cure was determined by using the urea breath test 2 months after antimicrobial treatment. RESULTS: Among the 125 patients, 37 (30%) were found to have H. pylori isolates resistant to clarithromycin and 83 (66%) were found to have H. pylori isolates resistant to metronidazole. Resistance to clarithromycin was associated with previous use of any macrolide antibiotic (P < 0.001), and resistance to metronidazole was associated with previous use of metronidazole (P < 0.001). The odds of isolates being resistant to clarithromycin increased in relation to the number of courses of macrolides received (P < 0.001). Among 53 persons treated with clarithromycin-based regimens, treatment failed in 77% of those carrying clarithromycin-resistant H. pylori (10 of 13) and 13% of those with clarithromycin-susceptible strains (5 of 40) (relative risk, 6.2 [95% CI, 1.9 to 37.1]; P < 0.001). CONCLUSIONS: Previous use of macrolides and metronidazole is associated with H. pylori resistant to these antimicrobial agents. Clarithromycin resistance is associated with a greater risk for failure with clarithromycin-based treatments.

    Title Ion Multivalence and Like-charge Polyelectrolyte Attraction.
    Date September 2003
    Journal Physical Review Letters
    Excerpt

    It is known empirically that multivalent ions generate attractions between like-charged polyelectrolytes, with different valence requirements for different systems. How multivalent must an ion be before it can condense a given polyelectrolyte? Using charge-tunable M13 virus rods and a family of artificial homologous "dumbbell" divalent ions of different sizes, we have constructed a multivalent ion-polyelectrolyte phase diagram, and find an experimentally motivated general criterion for like-charged attraction based on the ion valence, ion size, and the Gouy-Chapman length.

    Title Comparing Potential Benefits of New Pneumococcal Vaccines with the Current Polysaccharide Vaccine in the Elderly.
    Date August 2003
    Journal Vaccine
    Excerpt

    We compared the hypothetical effects of the 23-valent polysaccharide pneumococcal vaccine with new vaccines on preventing invasive and noninvasive pneumococcal disease in persons >or=65 years. We estimated how much disease would occur if no polysaccharide vaccine were in use and used this baseline to compare the polysaccharide, a 7-valent conjugate vaccine, and hypothetical common antigen vaccine. The polysaccharide, conjugate, and common antigen vaccines prevented 10.6, 10.7, and 17.7% of invasive disease and 4.3, 5.6, and 10.0% of pneumonia, respectively. Superior effectiveness of new vaccines was dependent upon a presumed longer duration of protection than the 23V-PPV and effectiveness against noninvasive pneumonia. Our results suggest that new vaccines could improve disease prevention.

    Title Impact of Palivizumab Prophylaxis on Respiratory Syncytial Virus Hospitalizations in High Risk Alaska Native Infants.
    Date July 2003
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    BACKGROUND: Alaska Native children experience extremely high rates of hospitalization for respiratory syncytial virus (RSV) infection. We evaluated the effect of palivizumab prophylaxis on the incidence of RSV hospitalizations in high risk Alaska Native children. METHODS: We analyzed two retrospective cohorts. The first analysis, of southwest Alaska Native children hospitalized with acute respiratory infections during 1993 to 1996 and 1998 to 2001, compared RSV hospitalization rates among premature and nonpremature infants born before (1993 to 1996) and after (1998 to 2001) palivizumab use. The second analysis, of Alaska Native infants with a history of prematurity or lung disease during 1998 through 2001, compared RSV hospitalization among children receiving palivizumab during protected periods (within 32 days after a dose of palivizumab) and unprotected periods. RESULTS: First RSV hospitalizations in premature infants from southwest Alaska meeting criteria for palivizumab prophylaxis decreased from 439 per 1000 births before to 150 per 1000 births after palivizumab (relative rate, 0.34; 95% confidence interval, 0.17 to 0.68), whereas the rate in nonpremature infants remained stable (148 per 1000 births compared with 142 per 1000). Among high risk Alaska Native children during 1998 through 2001, the rate of first RSV hospitalization was 0.55 per 1000 protected days and 1.07 per 1000 unprotected days (relative rate, 0.52; 95% confidence interval, 0.28 to 0.93). CONCLUSIONS: Palivizumab reduced RSV hospitalizations in high risk infants in a region with high rates of RSV hospitalization.

    Title Cost-effectiveness of Vaccination Against Invasive Pneumococcal Disease Among People 50 Through 64 Years of Age: Role of Comorbid Conditions and Race.
    Date June 2003
    Journal Annals of Internal Medicine
    Excerpt

    BACKGROUND: Guidelines are increasingly recommending preventive services starting at 50 years of age, and policymakers are considering such a recommendation for pneumococcal polysaccharide vaccination. The finding that pneumococcal vaccination is cost-saving for people 65 years of age or older raises the question of the vaccination's implications for other older adults, especially black people, whose disease incidence exceeds that of nonblack people, and those with high-risk conditions. OBJECTIVE: To assess the implications of vaccinating black and nonblack people 50 through 64 years of age against invasive pneumococcal disease. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Published literature for vaccination effectiveness and cost estimates; data on disease incidence and case-fatality rates from the Centers for Disease Control and Prevention. TARGET POPULATION: Hypothetical cohort 50 through 64 years of age with the 1995 U.S. age distribution. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTION: Pneumococcal polysaccharide vaccination compared with no vaccination. OUTCOME MEASURES: Incremental medical costs and health effects, in quality-adjusted life-years per vaccinee. RESULTS OF BASE-CASE ANALYSIS: Vaccination saved medical costs and improved health among high-risk black people (27.55 dollars savings per vaccinee) and nonblack people (5.92 dollars savings per vaccinee), excluding survivors' future costs. For low-risk black and nonblack people and the overall general population, vaccination cost 2477 dollars, 8195 dollars, and 3434 dollars, respectively, to gain 1 year of healthy life. RESULTS OF SENSITIVITY ANALYSIS: Excluding survivors' future costs, in the general immunocompetent population, cost per quality-adjusted life-year in global worst-case results ranged from 21 513 dollars for black people to 68 871 dollars for nonblack people; in the high-risk population, cost ranged from 11 548 dollars for black people to 39 000 dollars for nonblack people. In the global best case, vaccination was cost-saving for black and nonblack people in the general immunocompetent and high-risk populations, excluding survivors' future costs. The cost-effectiveness range was narrower in probabilistic sensitivity analyses, with 95% probabilistic intervals ranging from cost-saving to 1594 dollars for black people and from cost-saving to 12 273 dollars for nonblack people in the general immunocompetent population. Costs per quality-adjusted life-year for low-risk people with case-fatality rates from 1998 were 2477 dollars for black people and 8195 dollars for nonblack people, excluding survivors' medical costs. CONCLUSIONS: These results support the current recommendation to vaccinate high-risk people and provide useful information for considering extending the recommendation to the general population 50 through 64 years of age. Lack of evidence about the effectiveness of revaccination for people 65 years of age or older, when disease risks are higher, argues for further research to guide vaccination policy.

    Title Classical and Latent Class Analysis Evaluation of Sputum Polymerase Chain Reaction and Urine Antigen Testing for Diagnosis of Pneumococcal Pneumonia in Adults.
    Date June 2003
    Journal The Journal of Infectious Diseases
    Excerpt

    Diagnosis of pneumococcal pneumonia is complicated by the lack of a diagnostic reference standard that is highly sensitive and specific. Latent class analysis (LCA) is a mathematical technique that relates an unobserved ("latent") infection to multiple diagnostic test results by use of a statistical model. We used classical analysis and LCA to evaluate the sensitivity and specificity of blood culture, sputum Gram stain, sputum polymerase chain reaction (PCR), and urine antigen testing for diagnosing pneumococcal pneumonia among 149 adults with community-acquired pneumonia. On the basis of LCA models, sensitivity of autolysin PCR and pneumolysin PCR was 82% and 89%, respectively, but specificity was low, 38% and 27%, respectively. For urine antigen testing, sensitivity was 77%-78%, and specificity was 67%-71%. Results of the LCA models were comparable with those obtained from classical analysis. LCA may be useful for diagnostic test evaluation and for determining the prevalence of pneumococcal infection in epidemiological studies of community-acquired pneumonia and in vaccine efficacy trials.

    Title Large Summertime Influenza A Outbreak Among Tourists in Alaska and the Yukon Territory.
    Date April 2003
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    We investigated a large summertime outbreak of acute respiratory illness during May-September 1998 in Alaska and the Yukon Territory, Canada. Surveillance for acute respiratory illness (ARI), influenza-like illness (ILI), and pneumonia conducted at 31 hospital, clinic, and cruise ship infirmary sites identified 5361 cases of ARI (including 2864 cases of ILI [53%] and 171 cases of pneumonia [3.2%]) occurring primarily in tourists and tourism workers (from 18 and 37 countries, respectively). Influenza A viruses were isolated from 41 of 210 patients with ILI at 8 of 14 land sites and 8 of 17 cruise ship infirmaries. Twenty-two influenza isolates were antigenically characterized, and all were influenza A/Sydney/05/97-like (H3N2) viruses. No other predominant pathogens were identified. We estimated that >33,000 cases of ARI might have occurred during this protracted outbreak, which was attributed primarily to influenza A/Sydney/05/97-like (H3N2) viruses. Modern travel patterns may facilitate similar outbreaks, indicating the need for increased awareness about influenza by health care providers and travelers and the desirability of year-round influenza surveillance in some regions.

    Title Viral Load Response to a Pneumococcal Conjugate Vaccine, Polysaccharide Vaccine or Placebo Among Hiv-infected Patients.
    Date February 2003
    Journal Aids (london, England)
    Excerpt

    We determined the HIV viral load in 66 adults randomly assigned to receive pneumococcal immunization with one or two doses of protein conjugate vaccine, one dose of polysaccharide vaccine, one dose of each, or placebo. Second doses were given 8 weeks after the first. Mean baseline viral load and CD4 cell count were 3.41 copies/ml (log10) and 457 cells/microl, respectively. We found no change in viral load during 24 weeks of follow-up for any vaccine or combination of vaccines or placebo.

    Title Macrolide-resistant Pneumococcal Endocarditis and Epidural Abscess That Develop During Erythromycin Therapy.
    Date February 2003
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Suppurative complications of Streptococcus pneumoniae infections have become uncommon in the antibiotic era. We report a case of pneumococcal bacteremia and pneumonia complicated with epidural abscess and endocarditis in which macrolide resistance (the MLS(B) phenotype) emerged during erythromycin therapy. Genetic determinants known to mediate the most common mechanisms of macrolide resistance (methylation of the 23S rRNA and antibiotic efflux) were not detected by polymerase chain reaction or DNA hybridization. Sequence analysis of the DNA encoding the 23S rRNA of the macrolide-resistant isolate from the patient demonstrated the replacement of adenine by thymine at position 2058 (A2058T) in 2 of 4 alleles. Clinicians should be alert to the possibility of the emergence of resistance during macrolide therapy for community-acquired pneumonia, particularly if suppurative complications of pneumococcal infection are suspected.

    Title Investigation of Bioterrorism-related Anthrax, United States, 2001: Epidemiologic Findings.
    Date December 2002
    Journal Emerging Infectious Diseases
    Excerpt

    In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.

    Title Call-tracking Data and the Public Health Response to Bioterrorism-related Anthrax.
    Date December 2002
    Journal Emerging Infectious Diseases
    Excerpt

    After public notification of confirmed cases of bioterrorism-related anthrax, the Centers for Disease Control and Prevention's Emergency Operations Center responded to 11,063 bioterrorism-related telephone calls from October 8 to November 11, 2001. Most calls were inquiries from the public about anthrax vaccines (58.4%), requests for general information on bioterrorism prevention (14.8%), and use of personal protective equipment (12.0%); 882 telephone calls (8.0%) were referred to the state liaison team for follow-up investigation. Of these, 226 (25.6%) included reports of either illness clinically confirmed to be compatible with anthrax or direct exposure to an environment known to be contaminated with Bacillus anthracis. The remaining 656 (74.4%) included no confirmed illness but reported exposures to "suspicious" packages or substances or the receipt of mail through a contaminated facility. Emergency response staff must handle high call volumes following suspected or actual bioterrorist attacks. Standardized health communication protocols that address contact with unknown substances, handling of suspicious mail, and clinical evaluation of suspected cases would allow more efficient follow-up investigations of clinically compatible cases in high-risk groups.

    Title Collaboration Between Public Health and Law Enforcement: New Paradigms and Partnerships for Bioterrorism Planning and Response.
    Date December 2002
    Journal Emerging Infectious Diseases
    Excerpt

    The biological attacks with powders containing Bacillus anthracis sent through the mail during September and October 2001 led to unprecedented public health and law enforcement investigations, which involved thousands of investigators from federal, state, and local agencies. Following recognition of the first cases of anthrax in Florida in early October 2001, investigators from the Centers for Disease Control and Prevention (CDC) and the Federal Bureau of Investigation (FBI) were mobilized to assist investigators from state and local public health and law enforcement agencies. Although public health and criminal investigations have been conducted in concert in the past, the response to the anthrax attacks required close collaboration because of the immediate and ongoing threat to public safety. We describe the collaborations between CDC and FBI during the investigation of the 2001 anthrax attacks and highlight the challenges and successes of public health and law enforcement collaborations in general.

    Title Observed Costs and Health Care Use of Children in a Randomized Controlled Trial of Pneumococcal Conjugate Vaccine.
    Date November 2002
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    BACKGROUND: Pneumococcal conjugate vaccine for infants has recently been found to be effective for prevention of meningitis, bacteremia, pneumonia and otitis media, but it is more costly than previously introduced vaccines. AIM: We sought to determine the savings in medical costs through 36 months of life attributable to the use of the vaccine in healthy infants in a large randomized trial. METHODS: We analyzed the actual medical costs of 36 471 children involved in a randomized trial of heptavalent pneumococcal conjugate vaccine conducted in the Northern California Kaiser Permanente Medical Care Program. The costs of the vaccine and vaccine administration were excluded. RESULTS: Compared with the control group, the vaccinated group experienced a 2% reduction in clinic related costs [$48; 95% confidence interval (CI), $10 to $83] and a nearly significant 14% reduction in outpatient hospitalization costs ($32; CI -$1 to $66). The savings in total medical costs were 1.2%, but this difference was not significant ($41; CI -$204 to $270). Inpatient hospital costs were highly variable and were responsible for the lack of precision in the difference in total cost. In a post hoc analysis that excluded hospital costs not believed to be potentially pneumococcal related, savings in medical costs were $78 and significant (CI $5 to $158). CONCLUSIONS: The pneumococcal conjugate vaccine reduced ambulatory care costs in children in the first 36 months of life, but without a larger trial, the magnitude of the savings in total medical costs is uncertain. These results indicate, however, that any medical cost savings that are associated with the vaccine are unlikely to be high enough to offset the cost of the vaccine at its current price.

    Title Changes in Antibiotic-prescribing Practices and Carriage of Penicillin-resistant Streptococcus Pneumoniae: A Controlled Intervention Trial in Rural Alaska.
    Date June 2002
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    From 1998 to 2000, 13 rural Alaskan villages (population, 3326) were surveyed annually by nasopharyngeal cultures for Streptococcus pneumoniae carriage. Data regarding antibiotic use for the entire population was abstracted from clinic records. In 1999, education of medical providers and the community about appropriate antibiotic use began in 4 villages; this program was expanded to include all villages in 2000. Antibiotic courses per person decreased by 31% in the initial intervention villages and by 35% in the remaining villages after education (P<.01 for each). Samples were obtained for culture from a mean of 31% of the population each year; 31% carried pneumococcus. No sustained decrease in carriage of penicillin-nonsusceptible strains was observed. When linear regression was used, serotype accounted for 81% of the variance in pneumococcal minimum inhibitory concentrations after the intervention, compared with 7% for antibiotic use. This suggests that reducing the carriage of serotypes associated with antibiotic resistance by use of pneumococcal conjugate vaccines may have a greater short-term impact than does decreasing antibiotic use.

    Title Botulism Among Alaska Natives in the Bristol Bay Area of Southwest Alaska: a Survey of Knowledge, Attitudes, and Practices Related to Fermented Foods Known to Cause Botulism.
    Date June 2002
    Journal International Journal of Circumpolar Health
    Excerpt

    OBJECTIVES: Botulism cases due to traditional Alaska Native fermented foods occur periodically in Southwest Alaska. In this population, we conducted a survey on knowledge, attitudes, and practices related to botulism and fermented foods. METHODS: We interviewed 140 adults randomly chosen from nine villages. Data collected included fermented food consumption frequency; knowledge about the cause and symptoms of botulism; and fermented food preparation methods. RESULTS: Most respondents (81%) had eaten Alaska Native fermented foods at least once. Over 70% identified botulism as a foodborne illness, and over 87% believed eating certain Native fermented foods could cause botulism. One-third of fermented food preparers used plastic containers for fermentation. To prevent botulism, 45% vwould consider boiling fermented foods, and 65% would not eat foods fermented in plastic or glass containers. CONCLUSIONS: Despite high awareness of botulism in this population, one-third of fermented food preparers use plastic containers, a practice which may increase the risk of botulism. Misconceptions and acceptable prevention messages about botulism, such as using traditional nonplastic fermentation methods, were identified and included in an educational video.

    Title Effect of High-dose Amoxicillin on the Prevalence of Penicillin-resistant Streptococcus Pneumoniae in Rural Alaska.
    Date May 2002
    Journal Jama : the Journal of the American Medical Association
    Title Randomized Trial of the Quantitative and Functional Antibody Responses to a 7-valent Pneumococcal Conjugate Vaccine And/or 23-valent Polysaccharide Vaccine Among Hiv-infected Adults.
    Date January 2002
    Journal Vaccine
    Excerpt

    In a double-blinded, randomized trial, human immunodeficiency virus (HIV)-infected adults with > or = 200 CD4 cells/microl received placebo (PL), 7-valent conjugate, or 23-valent pneumococcal polysaccharide (PS) vaccine in one of the following two-dose combinations given 8 weeks apart: conjugate-conjugate, conjugate-polysaccharide, placebo-polysaccharide, placebo-placebo. A total of 67 persons completed the study. Neither significant increases in HIV viral load nor severe adverse reactions occurred in any group. After controlling for confounders, when compared with persons receiving placebo-polysaccharide, persons receiving conjugate-conjugate and conjugate-polysaccharide had higher antibody concentrations (serotypes 4, 6B, 9V and serotype 23F, respectively) and opsonophagocytic titers (functional antibody assay, serotypes 9V, 23F and serotypes 4, 6B, 9V, respectively) after the second dose (P<0.05). The second dose with either conjugate or polysaccharide following the first conjugate dose, however, produced no further increase in immune responses.

    Title Pontiac Fever Due to Legionella Micdadei from a Whirlpool Spa: Possible Role of Bacterial Endotoxin.
    Date December 2001
    Journal The Journal of Infectious Diseases
    Excerpt

    During January 1998, a cluster of illnesses occurred among hotel guests in Wisconsin. Ill persons had been exposed to the hotel's whirlpool spa and swimming pool. Symptoms included headache, fever, chills, myalgia, shortness of breath, and fatigue. A diagnosis of Pontiac fever was made, based on serologic evidence of acute infection with Legionella micdadei. High concentrations of heterotrophic bacteria were recovered from the spa, despite apparently high disinfectant levels. L. micdadei was isolated from the swimming pool filter and water from the spa after heat enrichment but not from pools and spas at nearby hotels. Water from hotel pools and spas was tested to determine endotoxin levels; water from the spa of the implicated hotel contained the highest concentration of endotoxin (14,400 endotoxin units/mL). Additional studies are needed to determine the role of endotoxin from legionellae or other bacteria in the pathogenesis of Pontiac fever.

    Title Emerging Infectious Diseases Among Indigenous Peoples.
    Date October 2001
    Journal Emerging Infectious Diseases
    Title Rethinking Recommendations for Use of Pneumococcal Vaccines in Adults.
    Date October 2001
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Streptococcus pneumoniae remains a major cause of disease worldwide; the emergence of antibiotic-resistant strains emphasizes the importance of disease prevention by use of vaccines. Recent studies have provided information that is useful for the evaluation of current vaccine recommendations. Recommendations target most people who are at high risk for invasive pneumococcal disease. However, higher risk has also been identified for African Americans and smokers, but these groups are not specifically targeted by current recommendations. The vaccine is effective against invasive disease in immunocompetent people, although studies in immunocompromised subjects have found few subgroups in which the vaccine appears to be effective. Questions with regard to optimal timing and indications for revaccination remain a challenge, because the duration of protection and effectiveness of revaccination remain unknown. New pneumococcal vaccines appear promising but will need to be tested against the performance of the polysaccharide vaccine. Improving delivery of the currently available pneumococcal polysaccharide vaccine to adults who will benefit should be a high priority.

    Title Treating Cardiovascular Disease with Antimicrobial Agents: a Survey of Knowledge, Attitudes, and Practices Among Physicians in the United States.
    Date September 2001
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    To assess physicians' knowledge, attitudes, and prescribing behaviors with regard to the association between Chlamydia pneumoniae and cardiovascular disease, we surveyed 750 physicians in Alaska, 1172 in West Virginia, and 569 infectious disease (ID) specialists in a nationwide network during February-May 1999. Eighty-five percent knew of the association between C. pneumoniae and atherosclerosis, but this awareness was more common among ID specialists and cardiologists than among generalists (96% vs. 77%; P<.001). Knowledge scores were significantly higher among ID specialists and cardiologists (P<.001) and among physicians who saw relatively more patients who had myocardial infarction and/or were at risk of atherosclerotic disease. Four percent of physicians had treated or recommended treating cardiovascular diseases with antimicrobial agents; this percentage was significantly higher among cardiologists, physicians who empirically treat patients with peptic ulcers with antimicrobial agents, and physicians with a relatively high knowledge score.

    Title Streptococcus Pneumoniae Serotype 4 Outbreak in a Home for the Aged: Report and Review of Recent Outbreaks.
    Date February 2001
    Journal Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
    Excerpt

    OBJECTIVE: To describe a pneumonia outbreak caused by Streptococcus pneumoniae among residents of a home for the aged and to review contemporary pneumococcal outbreaks. DESIGN: Epidemiological investigation. METHODS: S pneumoniae isolates were serotyped and analyzed by pulsed-field gel electrophoresis. Paired sera were tested for antibodies to pneumococcal surface adhesin A protein (PsaA, a 37-kDa cell-wall protein). Pneumococcal outbreaks reported in the last decade in English were reviewed. RESULTS: Pneumonia developed in 18 of 200 residents. In 11 (61%), a pneumococcal etiology was demonstrated. S pneumoniae, serotype 4, was isolated from the blood cultures of 3 patients; all isolates were indistinguishable by pulsed-field gel electrophoresis. Pneumococcal involvement was established in 2 by sputum culture and latex agglutination of parapneumonic fluid and in 6 others by a twofold rise in optical density of serum antibody reactive to PsaA. Pneumococcal immunization had not previously been received by any patient; mortality was 22%. No additional cases were noted following administration of pneumococcal vaccine and antibiotic prophylaxis with penicillin or erythromycin. Twenty-six outbreaks of invasive pneumococcal disease since 1990 were reviewed. Twelve occurred in the United States, and serotypes 23F, 14, and 4 accounted for 8 (67%) of 12 outbreaks. All confirmed serotypes in US outbreaks are included in the 23-valent vaccine. More than one half of pneumococcal outbreaks worldwide involved elderly persons in hospitals or long-term-care facilities. CONCLUSIONS: A pneumococcal pneumonia outbreak occurred among unvaccinated residents of a residential facility for the aged. Institutionalized elderly persons are at risk of outbreaks of pneumococcal disease and should be vaccinated.

    Title Strengths and Limitations of Molecular Subtyping in a Community Outbreak of Legionnaires' Disease.
    Date February 2001
    Journal Epidemiology and Infection
    Excerpt

    An epidemiological and microbiological investigation of a cluster of eight cases of Legionnaires' disease in Los Angeles County in November 1997 yielded conflicting results. The epidemiological part of the investigation implicated one of several mobile cooling towers used by a film studio in the centre of the outbreak area. However, water sampled from these cooling towers contained L. pneumophila serogroup 1 of another subtype than the strain that was recovered from case-patients in the outbreak. Samples from two cooling towers located downwind from all of the case-patients contained a Legionella strain that was indistinguishable from the outbreak strain by four subtyping techniques (AP-PCR, PFGE, MAb, and MLEE). It is unlikely that these cooling towers were the source of infection for all the case-patients, and they were not associated with risk of disease in the case-control study. The outbreak strain also was not distinguishable, by three subtyping techniques (AP-PCR, PFGE, and MAb), from a L. pneumophila strain that had caused an outbreak in Providence, RI, in 1993. Laboratory cross-contamination was unlikely because the initial subtyping was done in different laboratories. In this investigation, microbiology was helpful for distinguishing the outbreak cluster from unrelated cases of Legionnaires' disease occurring elsewhere. However, multiple subtyping techniques failed to distinguish environmental sources that were probably not associated with the outbreak. Persons investigating Legionnaires' disease outbreaks should be aware that microbiological subtyping does not always identify a source with absolute certainty.

    Title Experience with the Prevention of Invasive Haemophilus Influenzae Type B Disease by Vaccination in Alaska: the Impact of Persistent Oropharyngeal Carriage.
    Date October 2000
    Journal The Journal of Pediatrics
    Excerpt

    OBJECTIVES: To report the epidemiology of invasive Haemophilus influenzae type b (Hib) disease in high-risk Alaska Native infants before and after universal infant Hib vaccination and evaluate an increase in invasive Hib disease in 1996 after changing Hib vaccine type. STUDY DESIGN: Statewide laboratory surveillance for invasive Hib disease has been conducted since 1980. Three cross-sectional Hib carriage studies were conducted in 1997 and 1998. RESULTS: The invasive Hib disease rate in Alaska Natives decreased from 332 cases per 100,000 children <5 years old in 1980-1991 to 17:100,000 in 1992-1995 but increased primarily in rural areas to 57.9:100,000 after a switch in Hib vaccine types. Carriage studies in 5 rural Alaska Native villages showed oropharyngeal Hib carriage as high as 9.3% in children aged 1 to 5 years; in contrast, carriage in urban Alaska Native children was <1%. CONCLUSIONS: Although Hib disease has decreased in Alaska, the rate of Hib disease and carriage in rural Alaska Natives did not decrease to the same extent as in non-Natives and urban Alaska Natives. Use of polyribosylribitol phosphate-outer-membrane protein conjugate vaccine for the first vaccine dose is critical to disease control in this population with continued transmission in infants <6 months of age. The ability to eliminate Hib carriage and disease may be affected by population characteristics, vaccination coverage, and Hib vaccine type used. This may pose a challenge to global elimination of Hib.

    Title Serotype Distribution and Antimicrobial Resistance Patterns of Invasive Isolates of Streptococcus Pneumoniae: Alaska, 1991-1998.
    Date September 2000
    Journal The Journal of Infectious Diseases
    Excerpt

    From January 1991 through December 1998, a total of 1046 pneumococcal isolates were received from 23 laboratories participating in the statewide surveillance system. Of these, 1037 were recovered from normally sterile sites (blood and cerebrospinal and pleural fluid) and were available for serotyping and susceptibility testing. Ninety-two percent of these isolates were serotypes represented in the 23-valent pneumococcal polysaccharide vaccine. Serotypes in the 7-valent pneumococcal conjugate vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F) were recovered from 72% of Alaska Natives and 84% of non-Native children <5 years old with invasive disease. Statewide, 7.3% and 3.2% of isolates had intermediate and high levels of resistance to penicillin, respectively; 9.2% were resistant to erythromycin (minimal inhibitory concentration, >/=1 microg/mL) and 19% to trimethoprim/sulfamethoxazole (minimal inhibitory concentration, >/=4/76 microg/mL). Twelve percent of invasive isolates were resistant to >/=2 classes of antibiotics; of these, serotype 6B accounted for 33%, and 63% were recovered from children <5 years old.

    Title Pneumococcal Drug Resistance: the New "special Enemy of Old Age".
    Date June 2000
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Streptococcus pneumoniae is a leading cause of illness and death among the elderly. The recent emergence of drug-resistant strains has complicated selection of antimicrobial therapy for suspected pneumococcal infections. In some areas of North America, nearly 40% of pneumococcal isolates from the blood or cerebrospinal fluid of persons > or = 65 years old had reduced susceptibility to penicillin. Of all penicillin-resistant infections, >30% occur in persons > or = 65 years old. The increasing prevalence of drug-resistant pneumococci and recent outbreaks of pneumococcal disease in chronic-care facilities emphasize the importance of efforts to prevent these infections in the elderly. Limiting selection for drug-resistant strains through judicious use of antimicrobial drugs and preventing invasive pneumococcal infections through increased use of pneumococcal vaccine form the foundation of these efforts.

    Title Screening for Hepatitis C Virus in a Health Maintenance Organization.
    Date June 2000
    Journal Archives of Internal Medicine
    Excerpt

    BACKGROUND: Chronic infection with hepatitis C virus (HCV) is a major public health problem and is associated with over 10,000 deaths a year in the United States. In its early stages, HCV tends to be asymptomatic and can be detected only through screening. OBJECTIVES: To develop and validate a database risk algorithm for HCV infection using electronic data at HealthPartners, a health maintenance organization (HMO) in Minnesota. A secondary objective was to evaluate the benefit of screening health care workers for HCV. METHODS: A database risk algorithm was developed using diagnostic and procedure codes in the administrative database to identify at-risk enrollees. One thousand three hundred eighty enrollees (an at-risk sample and a control sample) and 502 health care workers participated in anonymous screening. Both descriptive statistics and logistic regression were used to examine the frequency of HCV infection, associations with risk factors, self-selection factors in participation, and concordance between the database risk algorithm and the risk profile questionnaire. RESULTS: Eleven enrollees tested positive for HCV, 9 from the at-risk sample and 2 from the control sample. All health care workers tested negative for HCV. Both lifestyle and medical risk factors were associated with positive test results for HCV. Enrollees with alcohol-drug diagnoses were less likely to participate in screening. A substantial proportion of enrollees with risk factors was identified either by the database risk algorithm or the risk profile questionnaire, but not by both. CONCLUSION: While the frequency of HCV infection was lower than previous estimates for the US population, the strong correlation with risk factors suggests that using the database risk algorithm for screening is a useful approach. Managed care plans with suitable data on their enrollee populations are in a key position to serve an important public health role in detecting asymptomatic patients who are infected with HCV.

    Title Respiratory Syncytial Virus: Current Status and Hope for the Future.
    Date April 2000
    Journal Alaska Medicine
    Title Projected Cost-effectiveness of Pneumococcal Conjugate Vaccination of Healthy Infants and Young Children.
    Date March 2000
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    CONTEXT: Pneumococcal conjugate vaccine for infants has recently been found effective against meningitis, bacteremia, pneumonia, and otitis media. OBJECTIVE: To evaluate the projected health and economic impact of pneumococcal conjugate vaccination of healthy US infants and young children. DESIGN: Cost-effectiveness analysis based on data from the Northern California Kaiser Permanente randomized trial and other published and unpublished sources. SETTING AND PATIENTS: A hypothetical US birth cohort of 3.8 million infants. INTERVENTIONS: Hypothetical comparisons of routine vaccination of healthy infants, requiring 4 doses of pneumococcal conjugate vaccine (at 2, 4, 6, and 12-15 months), and catch-up vaccination of children aged 2 to 4.9 years requiring 1 dose, with children receiving no intervention. MAIN OUTCOME MEASURES: Cost per life-year saved and cost per episode of meningitis, bacteremia, pneumonia, and otitis media prevented. RESULTS: Vaccination of healthy infants would prevent more than 12000 cases of meningitis and bacteremia, 53000 cases of pneumonia, 1 million episodes of otitis media, and 116 deaths due to pneumococcal infection. Before accounting for vaccine costs, the vaccination program would save $342 million in medical and $415 million in work-loss and other costs from averted pneumococcal disease. Vaccination of healthy infants would result in net savings for society if the vaccine cost less than $46 per dose, and net savings for the health care payer if the vaccine cost less than $18 per dose. At the manufacturer's list price of $58 per dose, infant vaccination would cost society $80000 per life-year saved or $160 per otitis media episode prevented (other estimated costs would be $3200 per pneumonia case prevented, $15000 for bacteremia, and $280000 for meningitis). The cost-effectiveness of an additional program to administer 1 dose of vaccine to children aged 2 to 4.9 years would vary depending on the children's ages, relative risks of pneumococcal disease, and vaccine cost. CONCLUSIONS: Pneumococcal conjugate vaccination of healthy US infants has the potential to be cost-effective. To achieve cost savings, its cost would need to be lower than the manufacturer's list price. In addition to tangible costs, the vaccine should be appraised based on the less tangible value of preventing mortality and morbidity from pneumococcal disease.

    Title Epidemiology of Pneumococcal Infections in the Elderly.
    Date March 2000
    Journal Drugs & Aging
    Excerpt

    The risk of invasive Streptococcus pneumoniae infection (primarily bacteraemia and meningitis) is greatest among the very young and the very old. Persons in certain racial groups, including African-Americans, American Indians, Native Alaskans and Australian Aborigines, are also at increased risk of disease. Other factors that appear to increase the risk of pneumococcal infection are lower socioeconomic status, recent infection with influenza and possibly other viral respiratory tract infections, chronic medical conditions, and immunosuppressive medications. Reported annual incidences of invasive pneumococcal disease among persons aged > or = 65 years in North America and Europe range from 25 to 90 cases/100,000 persons. In the US and Canada, these rates represent between 15,000 and 30,000 cases annually among the elderly. Mortality caused by pneumococcal infections is highest among the elderly, with nearly 1 in 5 cases resulting in death. Worldwide, S. pneumoniae is the leading cause of community-acquired pneumonia requiring hospitalisation. The high fatality rates, as well as recent outbreaks of pneumococcal infection among unvaccinated nursing home residents and the emergence of drug-resistant pneumococcal strains, highlight the importance of preventing invasive infection by vaccination.

    Title Cigarette Smoking and Invasive Pneumococcal Disease. Active Bacterial Core Surveillance Team.
    Date March 2000
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND: Approximately half of otherwise healthy adults with invasive pneumococcal disease are cigarette smokers. We conducted a population-based case-control study to assess the importance of cigarette smoking and other factors as risk factors for pneumococcal infections. METHODS: We identified immunocompetent patients who were 18 to 64 years old and who had invasive pneumococcal disease (as defined by the isolation of Streptococcus pneumoniae from a normally sterile site) by active surveillance of laboratories in metropolitan Atlanta, Baltimore, and Toronto. Telephone interviews were conducted with 228 patients and 301 control subjects who were reached by random-digit dialing. RESULTS: Fifty-eight percent of the patients and 24 percent of the control subjects were current smokers. Invasive pneumococcal disease was associated with cigarette smoking (odds ratio, 4.1; 95 percent confidence interval, 2.4 to 7.3) and with passive smoking among nonsmokers (odds ratio, 2.5; 95 percent confidence interval, 1.2 to 5.1) after adjustment by logistic-regression analysis for age, study site, and independent risk factors such as male sex, black race, chronic illness, low level of education, and living with young children who were in day care. There were dose-response relations for the current number of cigarettes smoked per day, pack-years of smoking, and time since quitting. The adjusted population attributable risk was 51 percent for cigarette smoking, 17 percent for passive smoking, and 14 percent for chronic illness. CONCLUSIONS: Cigarette smoking is the strongest independent risk factor for invasive pneumococcal disease among immunocompetent, nonelderly adults. Because of the high prevalence of smoking and the large population attributable risk, programs to reduce both smoking and exposure to environmental tobacco smoke have the potential to reduce the incidence of pneumococcal disease.

    Title An Outbreak of Acute Respiratory Disease Caused by Mycoplasma Pneumoniae and Adenovirus at a Federal Service Training Academy: New Implications from an Old Scenario.
    Date February 2000
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Outbreaks of Mycoplasma pneumoniae and adenovirus have been reported in military institutions for several decades. During a recent outbreak in a federal service training academy, we performed an epidemiological and laboratory investigation to better characterize and control the outbreak. Of 586 students responding to a questionnaire, 317 (54%) reported having a respiratory illness during the outbreak period. Among 42 students who underwent complete laboratory testing, 24 (57%) had evidence of M. pneumoniae infection, 8 (19%) had evidence of adenovirus infection, and 4 (10%) had evidence of both. Polymerase chain reaction testing of oropharyngeal swabs revealed more acute M. pneumoniae infections (57% positive) than did serology or culture. Multivariate analysis revealed that visiting the campus health clinic >3 times for a nonrespiratory condition, such as injury, was a significant risk factor for illness among freshmen early in the course of the outbreak, whereas having an ill roommate was a risk factor throughout the duration of the outbreak.

    Title Effectiveness of Pneumococcal Polysaccharide Vaccine for Preschool-age Children with Chronic Disease.
    Date January 2000
    Journal Emerging Infectious Diseases
    Excerpt

    To estimate the effectiveness of pneumococcal polysaccharide vaccine, we serotyped isolates submitted to the Pneumococcal Sentinel Surveillance System from 1984 to 1996 from 48 vaccinated and 125 unvaccinated children 2 to 5 years of age. Effectiveness against invasive disease caused by serotypes included in the vaccine was 63%. Effectiveness against serotypes in the polysaccharide vaccine but not in a proposed seven-valent protein conjugate vaccine was 94%.

    Title Hospital Characteristics Associated with Colonization of Water Systems by Legionella and Risk of Nosocomial Legionnaires' Disease: a Cohort Study of 15 Hospitals.
    Date January 2000
    Journal Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
    Excerpt

    OBJECTIVE: To investigate an increase in reports of legionnaires' disease by multiple hospitals in San Antonio, Texas, and to study risk factors for nosocomial transmission of legionnaires' disease and determinants for Legionella colonization of hospital hot-water systems. SETTING: The 16 largest hospitals in the cities of San Antonio, Temple, and Austin, Texas. DESIGN: Review of laboratory databases to identify patients with legionnaires' disease in the 3 years prior to the investigation and to determine the number of diagnostic tests for Legionella performed; measurement of hot-water temperature and chlorine concentration and culture of potable water for Legionella. Exact univariate calculations, Poisson regression, and linear regression were used to determine factors associated with water-system colonization and transmission of Legionella. RESULTS: Twelve cases of nosocomial legionnaires' disease were identified; eight of these occurred in 1996. The rise in cases occurred shortly after physicians started requesting Legionella urinary antigen tests. Hospitals that frequently used Legionella urinary antigen tests tended to detect more cases of legionnaires' disease. Legionella was isolated from the water systems of 11 of 12 hospitals in San Antonio; the 12th had just experienced an outbreak of legionnaires' disease and had implemented control measures. Nosocomial legionellosis cases probably occurred in 5 hospitals. The number of nosocomial legionnaires' disease cases in each hospital correlated better with the proportion of water-system sites that tested positive for Legionella (P=.07) than with the concentration of Legionella bacteria in water samples (P=.23). Hospitals in municipalities where the water treatment plant used monochloramine as a residual disinfectant (n=4) and the hospital that had implemented control measures were Legionella-free. The hot-water systems of all other hospitals (n=11) were colonized with Legionella. These were all supplied with municipal drinking water that contained free chlorine as a residual disinfectant. In these contaminated hospitals, the proportion of sites testing positive was inversely correlated with free residual chlorine concentration (P=.01). In all hospitals, hot-water temperatures were too low to inhibit Legionella growth. CONCLUSIONS: The increase in reporting of nosocomial legionnaires' disease was attributable to increased use of urinary antigen tests; prior cases may have gone unrecognized. Risk of legionnaires' disease in hospital patients was better predicted by the proportion of water-system sites testing positive for Legionella than by the measured concentration of Legionella bacteria. Use of monochloramine by municipalities for residual drinking water disinfection may help prevent legionnaires' disease.

    Title Epidemiologic Relation Between Hiv and Invasive Pneumococcal Disease in San Francisco County, California.
    Date January 2000
    Journal Annals of Internal Medicine
    Excerpt

    BACKGROUND: Patients with AIDS have a high incidence of invasive pneumococcal disease, but no population-based data are available on secular trends or rates of this disease in specific demographic groups. OBJECTIVE: To compare clinical characteristics, rates, and trends of pneumococcal disease in HIV-infected and non-HIV-infected persons. DESIGN: Population-based laboratory surveillance and chart review. SETTING: All of the 13 microbiology laboratories in San Francisco County, California. PATIENTS: Persons who had a sterile site culture that was positive for Streptococcus pneumoniae between October 1994 and June 1997. MEASUREMENTS: Stratified incidence rates and adjusted rate ratios, serotyping of isolates, and comparison of secular trends and rates according to census tract by Poisson regression. RESULTS: Persons infected with HIV accounted for 54.2% of 399 patients 18 to 64 years of age who had pneumococcal disease. The incidence of pneumococcal disease per 100 000 person-years was 35.0 cases overall and 802.9 cases in patients with AIDS. Compared with persons who were not known to be HIV-infected, the rate ratio for patients with AIDS was 46:0 (95% CI, 36.0 to 58.9); 55.2% of cases were attributable to HIV. In HIV-infected patients, 82.5% of isolates were serotypes that are included in the pneumococcal polysaccharide vaccine. The incidence of pneumococcal disease in black patients with AIDS (2384.6 cases per 100 000 person-years) was 5.4 times that in nonblack patients with AIDS. Rates by census tract were inversely associated with income (P < 0.001), During the study period, the incidence of pneumococcal disease decreased from 10.6 cases per 1000 person-years to 4.2 cases per 1000 person-years in patients with AIDS (P = 0.004, Poisson regression). CONCLUSIONS: In a community with a high prevalence of HIV infection, much of the burden of pneumococcal disease was attributable to AIDS. High incidence rates were seen in young adults and especially in black persons. Efforts to increase pneumococcal vaccination rates should target HIV-infected adults, particularly those living in poor urban areas.

    Title International Circumpolar Surveillance of Infectious Diseases: Monitoring Community Health in the Arctic.
    Date January 2000
    Journal International Journal of Circumpolar Health
    Title Carriage of Multidrug-resistant Streptococcus Pneumoniae and Impact of Chemoprophylaxis During an Outbreak of Meningitis at a Day Care Center.
    Date December 1999
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Three cases of meningitis due to multidrug-resistant serotype 14 Streptococcus pneumoniae occurred at a day care center (DCC) over 5 days. Cultures of nasopharyngeal samples were done at the index DCC, 2 comparison DCCs, and a pediatrics practice. Isolates were serotyped and subtyped by pulsed-field gel electrophoresis (PFGE) with SmaI. Pneumococcal carriage rates ranged from 44%-65% at the 3 DCCs and 29% in the pediatrics practice. Carriage of multidrug-resistant serotype 14 S. pneumoniae was noted in 13%-19% of children at the 3 DCCs. An outbreak strain was identified by PFGE at the index DCC and 1 other DCC; a closely related strain was found in the third DCC. Carriage of the outbreak strain was associated with being age 0-24 months, antibiotic use, upper respiratory tract infections, and otitis media. DCC contacts of the ill children were offered chemoprophylaxis with rifampin and clindamycin, which produced a profound but transient decrease in carriage. No additional cases occurred.

    Title Acute Otitis Media: Management and Surveillance in an Era of Pneumococcal Resistance. Drug-resistant Streptococcus Pneumoniae Therapeutic Working Group.
    Date November 1999
    Journal The Nurse Practitioner
    Excerpt

    Experts in the management of otitis media and the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group were convened by the Centers for Disease Control and Prevention to respond to changes in antimicrobial susceptibility among pneumococci. The objective was to provide consensus recommendations for the management of acute otitis media (AOM) and for the surveillance of drug-resistant Streptococcus pneumoniae. After summarizing published and unpublished data from the scientific literature and the experience of the panel members, the group concluded that oral amoxicillin should remain the first-line antimicrobial agent for treating AOM. For patients with clinically defined treatment failure after 3 days of therapy, useful alternative agents include amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone. The group also made recommendations to improve surveillance and to obtain antimicrobial susceptibility patterns for local geographic areas.

    Title The Challenge of Ongoing Haemophilus Influenzae Type B Carriage and Transmission in Alaska.
    Date November 1999
    Journal Alaska Medicine
    Excerpt

    Cases of invasive Haemophilus influenzae type b disease in Alaskan children quickly dropped 10-fold after widespread vaccination with a conjugate vaccine (PRP-OMP) began in 1991. However, reemergence of invasive disease in 1996-97 soon followed a change to a combination diphtheria-tetanus toxoid-pertussis/H. influenzae type b vaccine which incorporates a different conjugate vaccine (HbOC). Previously unrecognized persistence of H. influenzae type b carriage in rural Alaska, coupled with characteristics of the immune response to HbOC, are the likely explanations for disease reemergence. The current vaccine recommendation--PRP-OMP for the first dose, followed by HbOC to complete the vaccination series--appears to protect Alaskan infants even in the face of continuing carriage and transmission. Successful control of invasive H. influenzae type b disease in Alaskan children will require not only appropriate immunization, but also continuing surveillance for both disease and carriage, identification of factors associated with carriage, and investigation into the feasibility of using vaccination plus antimicrobial drugs to eliminate this pathogen.

    Title Pneumococcal Vaccines: History, Current Status, and Future Directions.
    Date August 1999
    Journal The American Journal of Medicine
    Excerpt

    Streptococcus pneumoniae is the leading cause of community-acquired pneumonia and bacterial meningitis. Although effective antimicrobial drugs have reduced case fatality, the pneumococcus remains a leading global cause of morbidity and mortality. Therefore, prevention of infection by vaccination with the pneumococcal polysaccharide vaccine is recommended for persons at high risk for serious pneumococcal disease, such as the elderly and individuals with certain underlying medical conditions. Pneumococcal polysaccharide vaccines are safe and effective for the prevention of invasive infection among immunocompetent children and adults but are not immunogenic in infants. Conjugation of pneumococcal polysaccharides to a carrier protein improves immune responses among infants, and conjugate vaccines are currently being evaluated in large efficacy trials. The role of pneumococcal conjugate vaccines in adults has not been determined. Pneumococcal vaccines directed against pneumococcal proteins and DNA vaccines that induce anti-pneumococcal antibodies have been evaluated in animal models and may someday provide complementary or alternative methods for preventing pneumococcal infection. Improved utilization of the pneumococcal polysaccharide vaccine and continued development of improved vaccines are essential, and the emergence of drug-resistant strains of S. pneumoniae highlights the importance of preventing pneumococcal infections by vaccination.

    Title Emerging Infectious Diseases in Alaska and the Arctic: a Review and a Strategy for the 21st Century.
    Date August 1999
    Journal Alaska Medicine
    Excerpt

    Emergence of new, previously unknown, and drug-resistant infectious diseases pose a major threat to global health. The emergence of infectious diseases in Alaska and the Arctic parallels the resurgence of infectious diseases worldwide. The Centers for Disease Control and Prevention has developed a strategy to revitalize the capacity to protect the public from emerging infectious diseases by improving four major public health activities: surveillance and response, applied research, infrastructure and training, and prevention and control. The plan targets high-priority emerging infectious disease problems and particular groups of people at increased risk. These target areas encompass a number of diseases of special concern in Alaska, such as drug-resistant Streptococcus pneumoniae infections, foodborne botulism, alveolar hydatid disease, viral hepatitis, Helicobacter pylori infections, Haemophilus influenzae type b bacteremia and meningitis, and infections of immunocompromised persons, pregnant women and newborns, and tourists. To address these and other emerging infectious disease issues, including the threat of bioterrorism in Alaska and the Arctic, future issues of Alaska Medicine will include updates on specific emerging infectious diseases for health care providers, clinical laboratory workers, and community public health professionals who form the front lines for recognizing, treating, and preventing emerging infectious diseases.

    Title A Survey of Methods Used to Detect Nosocomial Legionellosis Among Participants in the National Nosocomial Infections Surveillance System.
    Date August 1999
    Journal Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
    Excerpt

    OBJECTIVE: To help define the scope of nosocomial legionnaire's disease (LD) and to assess use of recommended diagnostic methods and transmission control practices. METHODS: We surveyed 253 hospitals participating in the National Nosocomial Infections Surveillance (NNIS) System. The anonymous survey included questions about episodes of nosocomial LD, environmental sampling practices, maintenance of hospital water systems, and diagnostic techniques. RESULTS: Of 192 hospitals that responded, 29% reported at least one episode of nosocomial LD from 1990 through 1996, and 61% of these reported at least two episodes. Of 79 hospitals with transplant programs, 42% reported nosocomial LD, compared with 20% of hospitals without transplant programs. Environmental sampling had been conducted by 55% of hospitals, including 79% of those reporting nosocomial LD. Legionella were isolated in 34% that sampled potable water and 19% that sampled cooling system reservoirs. Supplemental potable-water decontamination systems were installed in 20% of hospitals. Only 19% routinely performed testing for legionellosis among patients at high risk for nosocomial LD. CONCLUSIONS: Nosocomial LD is relatively common among NNIS hospitals, especially those performing organ transplants. Environmental sampling for Legionella is a common practice among NNIS hospitals, and Legionella often are isolated from sampled hospital cooling towers and hospital potable-water systems. Hospitals have responded to suspected nosocomial LD infection with a variety of water sampling and control strategies; some have not attempted to sample or decontaminate water systems despite identified transmission.

    Title Acute Otitis Media: Management and Surveillance in an Era of Pneumococcal Resistance--a Report from the Drug-resistant Streptococcus Pneumoniae Therapeutic Working Group.
    Date May 1999
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    OBJECTIVE: To provide recommendations [corrected] for the management of acute otitis media (AOM) and the surveillance of drug-resistant Streptococcus pneumoniae (DRSP). Five questions were addressed: (1) Can amoxicillin remain the best initial antimicrobial agent for treating AOM in the current period of increasing prevalence of DRSP? (2) What are suitable alternative agents for use if amoxicillin fails? (3) Should empiric treatment of AOM vary by geographic region? (4) Where can clinicians learn about resistance patterns in their patient populations? (5) What modifications to laboratory surveillance would improve the utility of the information for clinicians treating AOM? PARTICIPANTS: Experts in the management of otitis media and the DRSP Therapeutic Working Group. This group was convened by the CDC to respond to changes in antimicrobial susceptibility among pneumococci and includes clinicians, academicians and public health practitioners. EVIDENCE: Published and unpublished data summarized from the scientific literature and experience from the experts present. PROCESS: [corrected] After group presentations and review of background materials, subgroup chairs prepared draft responses to the five questions, discussed the responses as a group and edited those responses [corrected]. CONCLUSIONS: Oral amoxicillin should remain the first line antimicrobial agent for treating AOM. In view of the increasing prevalence of DRSP, the safety of amoxicillin at higher than standard dosages and evidence that higher dosages of amoxicillin can achieve effective middle ear fluid concentrations, an increase in the dosage used for empiric treatment from 40 to 45 mg/kg/day to 80 to 90 mg/kg/day is recommended. For patients with clinically defined treatment failure after 3 days of therapy, useful alternative agents include oral amoxicillin-clavulanate, cefuroxime axetil and intramuscular ceftriaxone. Many of the 13 other Food and Drug Administration-approved otitis media drugs lack good evidence for efficacy against DRSP. Currently local surveillance data for pneumococcal resistance that are relevant for the clinical management of AOM are not available from most areas in the United States. Recommendations to improve surveillance include establishing criteria for setting susceptibility breakpoints for clinically appropriate antimicrobials to ensure relevance for treating AOM, testing middle ear fluid or nasal swab isolates in addition to sterile site isolates and testing of drugs that are useful in treating AOM. The management of otitis media has entered a new era with the development of DRSP. These recommendations are intended to provide a framework for appropriate clinical and public health responses to this problem.

    Title More Than 10 Years of Unrecognized Nosocomial Transmission of Legionnaires' Disease Among Transplant Patients.
    Date March 1999
    Journal Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
    Excerpt

    OBJECTIVE: To investigate a cluster of cases of legionnaires' disease among patients at a hospital. SETTING: A university hospital that is a regional transplant center. DESIGN: Retrospective review of microbiology and serology data from the hospital laboratories and prospective surveillance via the radiology department; a case-control study and environmental sampling within the hospital and from nearby cooling towers. RESULTS: Diagnosis of seven cases of legionnaires' disease in the first 9 months of 1996 led to recognition of a nosocomial outbreak that may have begun as early as 1979. Review of charts from 1987 through September 1996 identified 25 culture-confirmed cases of nosocomial or possibly nosocomial legionnaires' disease, including 18 in bone marrow and heart transplant patients. Twelve patients (48%) died. During the first 9 months of 1996, the attack rate was 6% among cardiac and bone marrow transplant patients. For cases that occurred before 1996, intubation was associated with increased risk for disease. High-dose corticosteroid medication was strongly associated with the risk for disease, but other immunosuppressive therapy or cancer chemotherapy was not. Several species and serogroups of Legionella were isolated from numerous sites in the hospital's potable water system. Six of seven available clinical isolates were identical and were indistinguishable from environmental isolates by pulsed-field gel electrophoresis. Initial infection control measures failed to interrupt nosocomial acquisition of infection. After extensive modifications to the water system, closely monitored repeated hyperchlorinations, and reduction of patient exposures to aerosols, transmission was interrupted. No cases have been identified since September 1996. CONCLUSIONS: Legionella can colonize hospital potable water systems for long periods of time, resulting in an ongoing risk for patients, especially those who are immunocompromised. In this hospital, nosocomial transmission possibly occurred for more than 17 years and was interrupted in 1996, after a sudden increase in incidence led to its recognition. Hospitals specializing in the care of immunocompromised patients (eg, transplant centers) should prioritize surveillance for cases of legionnaires' disease. Aggressive control measures can interrupt transmission of this disease successfully.

    Title A Recurrent Outbreak of Nosocomial Legionnaires' Disease Detected by Urinary Antigen Testing: Evidence for Long-term Colonization of a Hospital Plumbing System.
    Date March 1999
    Journal Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
    Excerpt

    BACKGROUND: In 1994, a hospital reported an increase in nosocomial legionnaires' disease after implementing use of a rapid urinary antigen test for Legionella pneumophila serogroup 1 (Lp-1). This hospital was the site of a previous nosocomial legionnaires' disease outbreak during 1980 to 1982. METHODS: Infection control records were reviewed to compare rates of nosocomial pneumonia and the proportion of cases attributable to legionnaires' disease during the 1994 outbreak period with those during the same period in 1993. Water samples were collected for Legionella culture from the hospital's potable water system and cooling towers, and isolates were subtyped by monoclonal antibody (MAb) testing and arbitrarily primed polymerase chain reaction (AP-PCR). RESULTS: Nosocomial pneumonia rates were similar from April through October 1993 and April through October 1994: 5.9 and 6.6 per 1,000 admissions, respectively (rate ratio [RR], 1.1; P=.56); however, 3.2% of nosocomial pneumonias were diagnosed as legionnaires' disease in 1993, compared with 23.9% in 1994 (RR, 9.4; P<.001). In 1994, most legionnaires' disease cases were detected by the urinary antigen testing alone. MAb testing and AP-PCR demonstrated identical patterns among Lp-1 isolates recovered from a patient's respiratory secretions, the hospital potable water system, and stored potable water isolates from the 1980 to 1982 outbreak. CONCLUSIONS: There may have been persistent transmission of nosocomial legionnaires' disease at this hospital that went undiscovered for many years because there was no active surveillance for legionnaires' disease. Introduction of a rapid urinary antigen test improved case ascertainment. Legionella species can be established in colonized plumbing systems and may pose a risk for infection over prolonged periods.

    Title Accuracy of Icd-9-cm Codes in Detecting Community-acquired Pneumococcal Pneumonia for Incidence and Vaccine Efficacy Studies.
    Date February 1999
    Journal American Journal of Epidemiology
    Excerpt

    Studies have used medical record discharge data as coded by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to estimate pneumococcal pneumonia incidence and vaccine efficacy. However, the accuracy of coding data to identify laboratory-confirmed pneumococcal pneumonia is not known. With the use of information collected in Ohio for a community-based pneumonia incidence study, the authors calculated the sensitivities, specificities, positive predictive values (PPV), and negative predictive values (NPV) of specific codes for pneumococcal pneumonia among hospitalized patients with community-acquired pneumonia. Sensitivities of the most common ICD-9-CM codes listed in the first five positions for patients with laboratory-confirmed pneumococcal pneumonia were 58.3% (code 481.0, pneumococcal pneumonia), 20.4% (38.0, streptococcal septicemia), 19.2% (38.2, pneumococcal septicemia), 15.0% (518.81, respiratory failure), 14.2% (486.0, pneumonia, organism unspecified), and 11.3% (482.3, streptococcal pneumonia). Using the first five listed ICD-9-CM codes rather than just the first listed code increased sensitivity without causing substantial change in specificity, PPV, and NPV. Sensitivity, PPV, and NPV of individual and groups of codes varied with different case definitions of pneumococcal pneumonia. Incidence and vaccine efficacy studies with the ability to validate diagnoses by medical chart review can use a combination of many ICD-9-CM codes to maximize sensitivity. However, without the ability to review medical charts, researchers must carefully decide which codes would best suit their studies.

    Title Safety of Revaccination with Pneumococcal Polysaccharide Vaccine.
    Date January 1999
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    CONTEXT: Revaccination of healthy adults with pneumococcal polysaccharide vaccine (PPV) within several years of first vaccination has been associated with a higher than expected frequency and severity of local injection site reactions. The risk of adverse events associated with revaccination of elderly and chronically ill persons 5 or more years after first vaccination, as is currently recommended, has not been well defined. OBJECTIVE: To determine whether revaccination with PPV at least 5 years after first vaccination is associated with more frequent or more serious adverse events than those following first vaccination. DESIGN: Comparative intervention study conducted between April 1996 and August 1997. PARTICIPANTS: Persons aged 50 to 74 years either who had never been vaccinated with PPV (n = 901) or who had been vaccinated once at least 5 years prior to enrollment (n = 513). INTERVENTION: PPV vaccination. MAIN OUTCOME MEASURES: Postvaccination local injection site reactions and prevaccination concentrations of type-specific antibodies. RESULTS: Those who were revaccinated were more likely than those who received their first vaccinations to report a local injection site reaction of at least 10.2 cm (4 in) in diameter within 2 days of vaccination: 11% (55/513) vs 3% (29/901) (relative risk [RR], 3.3; 95% confidence interval [CI], 2.1-5.1). These reactions resolved by a median of 3 days following vaccination. The highest rate was among revaccinated patients who were immunocompetent and did not have chronic illness: 15% (33/228) compared with 3% (10/337) among comparable patients receiving their first vaccinations (RR, 4.9; 95% CI, 2.4-9.7). The risk of these local reactions was significantly correlated with prevaccination geometric mean antibody concentrations. CONCLUSIONS: Physicians and patients should be aware that self-limited local injection site reactions occur more frequently following revaccination compared with first vaccination; however, this risk does not represent a contraindication to revaccination with PPV for recommended groups.

    Title Epidemiology of Emerging Pneumococcal Drug Resistance: Implications for Treatment and Prevention.
    Date December 1998
    Journal Vaccine
    Excerpt

    Drug-resistant Streptococcus pneumoniae infection are becoming increasingly common throughout the world. These strains pose new challenges in the treatment of suspected pneumococcal infections, and they highlight the importance of limiting selection for resistant strains through judicious antibiotic use and preventing infection by immunization of persons at high risk. The clinical impact of drug-resistant S. pneumoniae infection has not been fully defined, but anecdotal reports suggest that outcome is poor for persons with drug-resistant pneumococcal meningitis. The American Academy of Pediatrics has recommended adding vancomycin to the treatment of suspected pneumococcal meningitis cases until the results of culture and susceptibility testing are available. Additional data are needed to determine the optimal empiric antibiotic regimen for nonmeningeal invasive pneumococcal infections. A 23-valent pneumococcal capsular polysaccharide vaccine can prevent many drug-resistant and susceptible invasive pneumococcal infections. The vaccine is recommended in the United States for persons at increased risk of pneumococcal infection due to certain medical conditions and for all persons > or = 65 years old. Vaccine efficacy for immunocompetent persons > or = 65 years is 75%. However, the vaccine is underutilized, and a substantial reduction in the morbidity and mortality associated with invasive pneumococcal infections is unlikely until the vaccine is used more widely among persons at risk for disease.

    Title Legionnaires' Disease: Clinical, Epidemiological, and Public Health Perspectives.
    Date September 1998
    Journal Seminars in Respiratory Infections
    Excerpt

    Legionnaires' disease is a modern environmental infectious disease. It stems from the capacity of the causative agent, Legionella, to multiply within amoebae in warm water and the use, during the 20th century, of devices that maintain water at warm temperatures and produce aerosols. When contaminated with Legionella, aerosols consisting of respirable droplets place the bacteria in juxtaposition with alveolar macrophages, which, as with amoebae, they may parasitize, resulting in illness in susceptible persons. The disease is much more common than previously appreciated with at least 13,000 cases estimated to occur per year in the United States, based on prospective studies. Two highly specific tests, urinary antigen detection and sputum culture, are available for diagnosis during illness. With 60% to 80% sensitivity, urinary antigen tests rapidly detect antigens of Legionella pneumophila serogroup 1, which are responsible for 70% of the cases of legionnaires' disease; results can be available within a few hours. Culture of sputum is 50% to 60% sensitive, but several days are required for growth, and many patients do not produce sputum. Serologic testing, although useful for epidemiologic studies when convalescent-phase antibody titers can be compared with acute-phase titers, is not helpful for clinical decision making because of the low positive predictive value of commercially available acute-phase serologic tests. Erythromycins, intravenous azithromycin, and levofloxacin are currently approved by the US Food and Drug Administration for treatment of legionnaires' disease. However, clarithromycin and several other fluoroquinolones are active against Legionella and may also provide effective therapy. Recent recommendations from the Centers for Disease Control and Prevention's Hospital Infection Control Practices Advisory Committee should be helpful in reducing nosocomial legionnaires' disease. Recommendations are in place or are being developed to minimize the risk of disease in a variety of other settings.

    Title Detection of Chlamydiosis in a Shipment of Pet Birds, Leading to Recognition of an Outbreak of Clinically Mild Psittacosis in Humans.
    Date August 1998
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Avian chlamydiosis was detected in a shipment of > 700 pet birds from a Florida bird distributor that were sold to nine Atlanta-area pet stores in August 1995. Respiratory illness among persons who had recently acquired birds from this shipment was reported to local public health officials. The attack rate of acute respiratory illness was 10.7% among persons in households exposed to birds from the implicated flock vs. 1.8% among control households (odds ratio, 6.60; 95% confidence interval, 1.39-31.2). Illness and serological evidence of infection in the absence of symptoms were more common among persons in households with recently purchased birds that were sick or that had died and among persons who had had direct contact with the birds. Clinical psittacosis or serological evidence of Chlamydia psittaci infection was found in 30.7% of households with birds from the infected flock. Mild illnesses and asymptomatic infections in exposed persons were unusual features of this outbreak.

    Title Effectiveness of Pneumococcal Vaccine.
    Date July 1998
    Journal Lancet
    Title The Use of Streptococcus Pneumoniae Nasopharyngeal Isolates from Healthy Children to Predict Features of Invasive Disease.
    Date June 1998
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    BACKGROUND: The role of sampling nasopharyngeal carriage isolates of Streptococcus pneumoniae to determine characteristics of isolates causing invasive disease has not been established. METHODS: Data were compared from two 1995 studies of S. pneumoniae in Metropolitan Toronto and Peel Region (population, 3.1 million). The first was a prospective survey of nasopharyngeal (NP) carriage in child care centers. The second was a prospective surveillance for all cases of invasive disease. RESULTS: There were 545 NP S. pneumoniae isolates obtained from 532 children and 96 cases of invasive S. pneumoniae disease in children. The prevalences of reduced antibiotic susceptibility in the NP carriage and invasive studies, respectively, were: penicillin (16% vs. 11%, P=0.29); erythromycin (12% vs. 7%, P=0.25); and multiresistant (16% vs. 12%, P=0.34). The power to rule out a difference between the groups was <30% for each comparison. Trimethoprim/sulfamethoxazole resistance was more common in NP carriage isolates than invasive isolates (38% vs. 23%, P=0.02). Serotype 14 was more common in invasive isolates, whereas serogroup 6 was more common in NP carriage isolates. Antibiotic-resistant isolates were predominantly serogroups 6, 19 and 23 in both studies. CONCLUSIONS: Nasopharyngeal carriage isolates of S. pneumoniae reflect the antibiotic susceptibility rates of invasive isolates found in the same period for most antibiotics. However, even a large study like this may have limited power to detect a difference. The most common NP carriage serotypes are the same as the invasive isolates, although the rank order of specific serotypes is different. Routine surveys of S. pneumoniae NP carriage are not feasible because of the cost of serotyping and limited power of the observations, unless sample sizes are extremely large.

    Title An Outbreak of Multidrug-resistant Pneumococcal Pneumonia and Bacteremia Among Unvaccinated Nursing Home Residents.
    Date June 1998
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND: Outbreaks of pneumococcal disease are uncommon and have occurred mainly in institutional settings. Epidemic, invasive, drug-resistant pneumococcal disease has not been seen among adults in the United States. In February 1996, there was an outbreak of multidrug-resistant pneumococcal pneumonia among the residents of a nursing home in rural Oklahoma. METHODS: We obtained nasopharyngeal swabs for culture from residents and employees. Streptococcus pneumoniae isolates were serotyped and compared by pulsed-field gel electrophoresis. A retrospective cohort study was conducted to identify factors associated with colonization and disease. RESULTS: Pneumonia developed in 11 of 84 residents (13 percent), 3 of whom died. Multidrug-resistant S. pneumoniae, serotype 23F, was isolated from blood and sputum from 7 of the 11 residents with pneumonia (64 percent) and from nasopharygeal specimens from 17 of the 74 residents tested (23 percent) and 2 of the 69 employees tested (3 percent). All the serotype 23F isolates were identical according to pulsed-field gel electrophoresis. Recent use of antibiotics was associated with both colonization (relative risk, 2.3; 95 percent confidence interval, 1.3 to 4.2) and disease (relative risk, 3.6; 95 percent confidence interval, 1.2 to 10.8). Only three residents (4 percent) had undergone pneumococcal vaccination. After residents received pneumococcal vaccine and prophylactic antibiotics, there were no additional cases of pneumonia, and the rates of carriage decreased substantially. CONCLUSIONS: In this outbreak a single pneumococcal strain was disseminated among the residents and employees of a nursing home. The high prevalence of colonization with a virulent organism in an unvaccinated population contributed to the high attack rate. Clusters of pneumococcal disease may be underrecognized in nursing homes, and wider use of pneumococcal vaccine is important to prevent institutional outbreaks of drug-resistant S. pneumoniae infection.

    Title Outbreak of Legionnaires' Disease at a Bar After Basement Flooding.
    Date April 1998
    Journal Lancet
    Title Hemolytic Uremic Syndrome Associated with Invasive Streptococcus Pneumoniae Infection.
    Date April 1998
    Journal Pediatrics
    Title Epidemic Legionnaires' Disease Two Decades Later: Old Sources, New Diagnostic Methods.
    Date April 1998
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    In July 1995 we investigated a pneumonia outbreak in a Pennsylvania town. We conducted epidemiological and molecular microbiological studies to determine the outbreak source and interrupt transmission of disease. Legionnaires' disease (LD) was quickly identified by urine antigen testing, and a newly developed immunohistochemical stain confirmed nosocomial transmission to a hospital inpatient. LD was confirmed in 22 patients. Case-patients were more likely than controls to have been within 1,000 feet of the hospital (matched odds ratio, 21.0; 95% confidence interval, 2.9-368) during the 2 weeks prior to illness. Legionella pneumophila serogroup 1 (Lp-1) was isolated from hospital cooling towers (CTs) and rooftop air samples but not from hospital potable water or community CTs. Hospital CT and air Lp-1 isolates matched all five patient isolates by monoclonal antibody, arbitrarily primed polymerase chain reaction, and pulsed-field gel electrophoresis subtyping. Strategies to prevent LD must include minimizing transmission from CTs.

    Title Cost-effectiveness of Vaccination Against Pneumococcal Bacteremia Among Elderly People.
    Date November 1997
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    CONTEXT: Clinical, epidemiologic, and policy considerations support updating the cost-effectiveness of pneumococcal vaccination for elderly people and targeting the evaluation only to prevention of pneumococcal bacteremia. OBJECTIVE: To assess the implications for medical costs and health effects of vaccination against pneumococcal bacteremia in elderly people. DESIGN: Cost-effectiveness analysis of pneumococcal vaccination compared with no vaccination, from a societal perspective. SETTING AND PARTICIPANTS: The elderly population aged 65 years and older in the United States in 3 geographic areas: metropolitan Atlanta, Ga; Franklin County, Ohio; and Monroe County, New York. MAIN OUTCOME MEASURES: Incremental medical costs and health effects, expressed in quality-adjusted life-years per person vaccinated. RESULTS: Vaccination was cost saving, ie, it both reduced medical expenses and improved health, for all age groups and geographic areas analyzed in the base case. For people aged 65 years and older, vaccination saved $8.27 and gained 1.21 quality-adjusted days of life per person vaccinated. Vaccination of the 23 million elderly people unvaccinated in 1993 would have gained about 78000 years of healthy life and saved $194 million. In univariate sensitivity analysis, the results remained cost saving except for doubling vaccination costs, including future medical costs of survivors, and lowering vaccination effectiveness. With assumptions most unfavorable to vaccination, cost per quality-adjusted life-year ranged from $35 822 for ages 65 to 74 years to $598 487 for ages 85 years and older. In probabilistic sensitivity analysis, probability intervals were more narrow, with less than 5% probability that the ratio for ages 85 years and older would exceed $100000. CONCLUSIONS: Pneumococcal vaccination saves costs in the prevention of bacteremia alone and is greatly underused among the elderly population, on both health and economic grounds. These results support recent recommendations of the Advisory Committee on Immunization Practices and public and private efforts under way to improve vaccination rates.

    Title Epidemiology of Pneumococcal Serotypes and Conjugate Vaccine Formulations.
    Date July 1997
    Journal Microbial Drug Resistance (larchmont, N.y.)
    Excerpt

    The incidence of bacteremia and meningitis due to Streptococcus pneumoniae is highest among preschool-age children, particularly those < 2 years of age. Clinical trials of capsular polysaccharide vaccines among young children have been disappointing. Conjugation of bacterial polysaccharides to proteins can increase antibody responses following vaccination of young children. Most conjugate vaccines proposed to date have been seven-valent. To identify serotypes most commonly associated with infection in young children, we serotyped pneumococcal isolates submitted to the CDC through national surveillance from 3884 children < 6 years old with pneumococcal bacteremia (n = 3169), meningitis (n = 401), or otitis media (n = 314) from 1978 to 1994. Seven serotypes (14, 6B, 19F, 18C, 23F, 4, and 9V) accounted for 3045 (78%) isolates. A conjugate pneumococcal vaccine protecting against these seven serotypes and serologically cross-reactive serotypes could potentially prevent 86% of bacteremia, 83% of meningitis, and 65% of otitis media cases. The proportion of isolates covered by such a vaccine increased from 78% to 87% from 1978 to 1994. Of 70 isolates submitted during 1992-1994 which were nonsusceptible to penicillin (minimal inhibitory concentration [MIC] > 0.1 microgram/mL, 56 (80%) were among the seven most prevalent serotypes. All 21 isolates resistant to penicillin (MIC > or = 2.0 micrograms/mL) were among these seven serotypes.

    Title Perspectives in Fatal Epidemics.
    Date March 1997
    Journal Infectious Disease Clinics of North America
    Excerpt

    This article discusses four epidemics of fatal infectious diseases: a 1993 cluster of deaths among previously healthy persons in the southwestern United States that led to the identification of a new clinical syndrome, hantavirus pulmonary syndrome; the first epidemic of Ebola hemorrhagic fever identified in nearly two decades occurring in 1995 in Zaire, which resulted in 317 cases with a mortality rate of 77%; an outbreak of Legionnaires' disease among cruise ship passengers in 1994; and a 1989 cluster of illnesses among nonhuman primates in Reston, Virginia leading to the identification of a new strain of Ebola virus. In each outbreak, the public health emergency was recognized and reported by alert clinicians, and the control of disease was facilitated through rapid, coordinated responses involving multiple agencies. Such collaboration between clinical and public health entities and among various agencies will be increasingly needed as surveillance and diagnostic capabilities for emerging and reemerging infectious diseases are enhanced around the world.

    Title The Continued Emergence of Drug-resistant Streptococcus Pneumoniae in the United States: an Update from the Centers for Disease Control and Prevention's Pneumococcal Sentinel Surveillance System.
    Date November 1996
    Journal The Journal of Infectious Diseases
    Excerpt

    As part of ongoing national surveillance, serotyping and antimicrobial susceptibility testing were done on all pneumococcal isolates recovered from normally sterile body sites of patients at 12 hospitals in 11 states during 1993-1994. Of 740 isolates, 14.1% were penicillin-nonsusceptible Streptococcus pneumoniae (PNSP; MIC > or = 0.1 microgram/mL), 3.2% were penicillin-resistant (MIC > or = 2.0 micrograms/mL), and 25.5% were nonsusceptible to more than one antimicrobial agent. PNSP were more prevalent among children < 6 years old (18.4%) than patients > or = 18 years old (11.7%) and among white persons (16.2%) than black persons (12.1%). PNSP represented 15 serotypes, but 89% of PNSP were serotypes in the 23-valent pneumococcal vaccine. The proportion of isolates with reduced susceptibility and the number of serotypes of nonsusceptible strains are increasing in the United States. Improved local surveillance for PNSP infections, judicious use of antibiotics, and development and use of effective pneumococcal vaccines will be required to treat and prevent disease caused by these strains.

    Title Lessons Learned from the Hantaviruses and Other Hemorrhagic Fever Viruses.
    Date March 1996
    Journal The American Journal of the Medical Sciences
    Excerpt

    In recent years, numerous previously known infections pathogens and their associated diseases have been recognized. Among these newly identified agents are the viruses that cause the hemorrhagic fevers, including Sin Nombre virus, the etiologic agent of the 1993 outbreak of hantavirus pulmonary syndrome in the American Southwest. Epidemiologic and laboratory investigations of the hemorrhagic fevers and their etiologic agents provide lessons that may be used collectively as a paradigm of the nature of emerging and re-emerging infectious diseases.

    Title Assessment of the Full Content of Physique Stereotypes with a Free-response Format.
    Date October 1995
    Journal The Journal of Social Psychology
    Excerpt

    A major limitation of physique stereotyping research is that American subjects have used a restricted set of traits provided by the experimenter to evaluate endomorphs, mesomorphs, and ectomorphs. A free-response procedure was used in Study 1 to identify the full domain of traits associated with each physique. Although many of the traits identified were similar to those used in previous research, a number of new trait dimensions were uncovered. In Study 2, the large number of traits generated with the free-response format was reduced by combining synonyms. This new set of traits was placed in semantic differential format and given to a new sample of subjects to evaluate. The results paralleled those of the first study with the exception that ectomorphs were seen more favorably. This discrepancy, as well as the fact that raters listed trait antonyms within each of the three major physiques in Study 1, suggests the possibility of unique subtypes within the global stereotypes. Examples of these subtypes are proposed.

    Title Potential Interventions for the Prevention of Childhood Pneumonia: Geographic and Temporal Differences in Serotype and Serogroup Distribution of Sterile Site Pneumococcal Isolates from Children--implications for Vaccine Strategies.
    Date October 1995
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    Streptococcus pneumoniae is a leading cause of fatal bacterial pneumonia in young children. Pneumococcal polysaccharide vaccines have not been promoted for use in young children because many constituent serotypes are not immunogenic in children < 2 years old. Conjugating pneumococcal polysaccharide epitopes to a protein carrier would likely increase vaccine immunogenicity in children. We reviewed published and unpublished pneumococcal serotype and serogroup data from 16 countries on 6 continents to determine geographic and temporal differences in serotype and serogroup distribution of sterile site pneumococcal isolates among children and to estimate coverage of proposed and potential pneumococcal conjugate vaccine formulas. The most common pneumococcal serotypes or groups from developed countries were, in descending order, 14, 6, 19, 18, 9, 23, 7, 4, 1 and 15. In developing countries the order was 6, 14, 8, 5, 1, 19, 9, 23, 18, 15 and 7. Development of customized heptavalent vaccine formulas, one for use in all developed countries and one for use in all developing countries, would not provide substantially better coverage against invasive pneumococcal disease than two currently proposed heptavalent formulas. An optimal nanovalent vaccine for global use would include serotypes 1, 5, 6B, 7F, 9V, 14, 18C, 19F and 23F. Geographic and temporal variation in pneumococcal serotypes demonstrates the need for a species-wide pneumococcal vaccine.

    Title A Household-based, Case-control Study of Environmental Factors Associated with Hantavirus Pulmonary Syndrome in the Southwestern United States.
    Date July 1995
    Journal The American Journal of Tropical Medicine and Hygiene
    Excerpt

    During an outbreak of hantavirus pulmonary syndrome (HPS) in the southwestern United States, trained environmental assessment teams conducted surveys at 17 case-patient homes and matched controls from June through August 1993. Variables related to rodent abundance were quantified and standardized rodent trapping was conducted around and within households. The majority of households were located in pinon-juniper vegetation zones, and there were no significant differences in the type of house in which cases and controls lived. The only environmental factor that distinguished case households from controls was significantly higher small rodent densities (median trap success for case sites = 17.3%, 12.7% for near controls, and 8.3% for far controls). Frequency of hantaviral infection in deer mice (Peromyscus maniculatus) did not vary significantly among households of cases and controls, with a range of 27.5-32.5% antibody-positive. Indices of rodent fecal contamination were slightly higher in case houses. The data indicate that higher rodent densities were associated with households in which HPS cases occurred. Strategies that control rodent numbers and decrease rodent access to dwellings may reduce risk of human infection.

    Title A Case-control Study of Hantavirus Pulmonary Syndrome During an Outbreak in the Southwestern United States.
    Date May 1995
    Journal The Journal of Infectious Diseases
    Excerpt

    In May 1993, an outbreak of hantavirus pulmonary syndrome (HPS) occurred in the southwestern United States. A case-control study determined risk factors for HPS. Seventeen case-patients were compared with 3 groups of controls: members of case-patient households (household controls), members of neighboring households (near controls), and members of randomly selected households > or = 24 km away (far controls). Investigators trapped more small rodents at case households than at near (P = .03) or far control households (P = .02). After the number of small rodents was controlled for, case-patients were more likely than household controls to hand plow (odds ratio [OR], 12.3; 95% confidence interval [CI], 1.1-143.0) or to clean feed storage areas (OR, 33.4; 95% CI, 1.7-666.0). Case-patients were more likely than near controls to plant (OR, 6.2; 95% CI, 1.1-34.0) and more likely than far controls to clean animal sheds (OR, 11.9; 95% CI, 1.4-103.0). Peridomestic cleaning, agricultural activities, and an increased number of small rodents at the household were associated with HPS.

    Title Serotype Distribution of Streptococcus Pneumoniae Infections Among Preschool Children in the United States, 1978-1994: Implications for Development of a Conjugate Vaccine.
    Date May 1995
    Journal The Journal of Infectious Diseases
    Excerpt

    Conjugation of pneumococcal polysaccharide antigens to a protein carrier may improve protective immunity after vaccination of young children, an age group with high incidence of Streptococcus pneumoniae infection and poor immune responses to polysaccharide vaccines. To identify serotypes most commonly associated with infection in young children, pneumococcal isolates were serotyped from 3884 children < 6 years old (including 3007 < 2 years old) with pneumococcal bacteremia (n = 3169), meningitis (n = 401), or otitis media (n = 314). The isolates were submitted as part of a national surveillance during 1978-1994. Seven serotypes (14, 6B, 19F, 18C, 23F, 4, and 9V) accounted for 3045 isolates (78%). A conjugate pneumococcal vaccine protecting against these seven serotypes and serologically cross-reactive serotypes could potentially prevent 86% of bacteremia and 83% of meningitis but only 65% of otitis media cases. The proportion of isolates covered by such a vaccine increased from 78% to 87% during 1978-1994. Surveillance for pneumococcal serotypes causing infection is needed to detect shifts in serotype distribution over time.

    Title Hantaviruses and Hantavirus Pulmonary Syndrome.
    Date February 1995
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Title Optimal Graft Fixation--the Effect of Gap Size and Screw Size on Bone Plug Fixation in Acl Reconstruction.
    Date January 1995
    Journal Arthroscopy : the Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association
    Excerpt

    In reconstruction of the anterior cruciate ligament (ACL), using central one-third patellar tendon graft, an early weak link is the bone plug junction. To study this, we carried out experiments to determine the relationship between gap size, screw size, and pullout force of patellar bone plugs inserted in the femur of the porcine model. Forty-nine porcine knees were obtained. Holes 11 mm in diameter were drilled in the intercondylar notch of the femur. Bone plugs fashioned from the patella were made to fit the holes with gap sizes of 1, 2, 3, or 4 mm. The bone plugs were inserted into the holes in the femur and secured by means of 20-mm-long screws (either 7- or 9-mm diameter). The bone plugs were then pulled out using a tensile testing machine and the pullout force was measured. The results suggest that a 7-mm (or a 9-mm) diameter screw can be used for gaps of 1 and 2 mm, and a 9-mm diameter screw should be used for gaps of 3 and 4 mm.

    Title Guideline for Prevention of Nosocomial Pneumonia. The Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention.
    Date January 1995
    Journal Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
    Title Guideline for Prevention of Nosocomial Pneumonia. The Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention.
    Date January 1995
    Journal American Journal of Infection Control
    Title A Cluster of Anaphylactic Reactions in Children with Spina Bifida During General Anesthesia: Epidemiologic Features, Risk Factors, and Latex Hypersensitivity.
    Date August 1994
    Journal The Journal of Allergy and Clinical Immunology
    Excerpt

    BACKGROUND: Anaphylactic reactions (ARs) in high-risk pediatric patients undergoing general anesthesia, especially those with spina bifida, have been attributed to anesthetics, muscle relaxants, antimicrobials, ethylene oxide, and latex. METHODS: To identify risk factors for AR during general anesthesia and to investigate the role of latex allergy, we studied epidemiologic and immunologic characteristics of patients with ARs during general anesthesia during a 13-month cluster of such reactions at Children's Hospital of Wisconsin (case patients). Patients with AR were compared with patients with spina bifida undergoing uneventful general anesthesia during the same period (control patients). For each case patient and control patient, we conducted a chart review; a parental interview; skin prick testing with latex, anesthetics, aeroallergens, and banana extract; ELISA and RAST for latex-specific IgE; a total serum IgE; and an ELISA for IgE antibody to ethylene oxide. RESULTS: Anaphylactic reactions occurred exclusively in patients with spina bifida (n = 10) or patients with a congenital urinary tract anomaly (n = 1). Case-patients were more likely than control patients to have a history of asthma (p = 0.002), rubber contact allergy (p = 0.001), food allergy (p = 0.001), rash caused by adhesive tape (p = 0.05), daily rectal disimpaction (p < 0.001), nine or more prior surgical procedures (p < 0.002), latex-specific IgE (p = 0.027), or elevated total serum IgE levels (p = 0.002). Multivariate analysis identified non-white race, rubber contact allergy, history of food allergy, and nine or more surgical procedures as significant independent risk factors. Logistic model equation identified the predicted probability of AR with a sensitivity, specificity, and positive predictive value of 82%, 97%, and 82%, respectively. CONCLUSIONS: These findings demonstrate that atopy, especially symptomatic latex allergy, is associated with AR during anesthesia in patients with spina bifida. Until a standardized latex test is available, a medical history of immediate rubber contact allergy, non-white race, food allergy, or nine or more prior surgical procedures can identify patients with spina bifida at highest risk for ARs. A complete history, including rubber contact and food allergy, should be compiled on all patients with spina bifida before surgery.

    Title Household-acquisition of Measles and Illness Severity in an Urban Community in the United States.
    Date July 1994
    Journal Epidemiology and Infection
    Excerpt

    Studies from developing countries suggest that persons with household-acquired (HA) measles are at greater risk of severe illness than persons with community-acquired (CA) infection. Reported measles cases occurring among Milwaukee residents from May 1989 to June 1990 were used to assess whether household-acquisition was a risk factor for severe measles in the United States. A case was classified as HA if onset of rash occurred 7-18 days after onset of rash in another case in the same household. Hospitalization rates were similar for 128 patients with HA measles (27%) and for 1004 patients with CA measles (26%). Multiple logistic regression was used to evaluate the association between hospitalization and household-acquisition after controlling for socioeconomic status, measles vaccination history, age, race, and date of onset of rash. Patients with HA measles were no more likely to be hospitalized than patients with CA measles (odds ratio 0.9, 95% confidence interval 0.6, 1.5). HA measles cases were not more severe than CA measles cases during this urban outbreak in the United States.

    Title Emergence of Drug-resistant Pneumococcal Infections in the United States.
    Date June 1994
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    OBJECTIVE--To estimate drug susceptibility patterns of Streptococcus pneumoniae in selected hospitals in the United States and to characterize the epidemiology of invasive drug-resistant pneumococcal infections. DESIGN--Minimum inhibitory concentrations (MICs) for a variety of commonly used antimicrobial drugs were determined for pneumococcal isolates submitted to the Centers for Disease Control and Prevention (CDC). Risk factors for drug-resistant pneumococcal infection were evaluated. SETTING--Hospital laboratories in the United States submitting pneumococcal isolates to the CDC between October 1, 1991, and September 30, 1992. PARTICIPANTS--A total of 544 persons with pneumococci isolated from normally sterile sites. RESULTS--A total of 13 hospitals in 12 states actively participated in an ongoing pneumococcal surveillance study. Resistance to penicillin was detected in 6.6% of isolates, including 1.3% of isolates with MICs of 2.0 micrograms/mL or more (compared with < 0.02% of isolates with MIC > or = 2.0 micrograms/mL identified by CDC surveillance from 1979 to 1987). A total of 16.4% were resistant to at least one of the following drugs or drug classes: penicillin, cephalosporins, macrolides, combination trimethoprim and sulfamethoxazole, and chloramphenicol. Six serotypes (6B, 23F, 14, 9V, 19A, and 19F) accounted for nearly 85% of strains resistant to at least one drug class. Children were more likely than adults to be infected with strains resistant to trimethoprim-sulfamethoxazole, erythromycin, or chloramphenicol. CONCLUSIONS--Emergence of drug-resistant pneumococcal infections will present critical challenges to clinicians for treating patients with pneumococcal disease. Widened and intensified surveillance is needed. These data suggest that current recommendations for use of 23-valent pneumococcal capsular polysaccharide vaccines should be aggressively promoted and that development and evaluation of new conjugate pneumococcal vaccines may be a crucial part of strategies for prevention.

    Title Histoplasmosis During Childhood.
    Date May 1994
    Journal Southern Medical Journal
    Excerpt

    To define the clinical presentation of histoplasmosis among hospitalized children, we reviewed the charts of patients treated for histoplasmosis at Vanderbilt University Children's Hospital during the years 1968 through 1988. Thirty-five patients with histoplasmosis diagnosed by culture, pathologic examination, or serologic testing were identified, including 29 patients (83%) with pulmonary/mediastinal infection, 5 (14%) with disseminated disease, and 1 (3%) with primary cutaneous histoplasmosis. The most common symptoms included fever, present in 26 patients (74%), and cough, present in 20 (57%). Of 26 patients with fever, 18 (69%) had fever of > 2 weeks' duration and 7 (27%) had temperatures > or = 40.5 degrees C (> or = 105 degrees F). Abnormal physical findings were few, but 19 patients (54%) had wheezing. Chest radiographs were obtained in all cases except one; 31 (91%) showed abnormalities, including adenopathy in 25 cases (74%) and infiltrates in 19 (56%). Histoplasmin skin tests were positive for 22 (96%) of the 23 patients tested. No cases of classic disseminated histoplasmosis of infancy were identified. Histoplasmosis should be considered in the differential diagnosis when children living in endemic areas are evaluated for persistent fever, cough, and/or wheezing, particularly if adenopathy is seen on the chest radiograph.

    Title Personality Correlates of the Hypercompetitive Attitude Scale: Validity Tests of Horney's Theory of Neurosis.
    Date April 1994
    Journal Journal of Personality Assessment
    Excerpt

    This study focused on assessing the concurrent validity of Horney's ideas about the personalities of hypercompetitive individuals based on her theory of neurosis. One hundred and sixty university men and women provided data by responding to a test battery of personality inventories containing measures of hypercompetitive attitudes and several theoretically relevant constructs. The results strongly support Horney's contentions. Stepwise multiple regression analysis indicated that hypercompetitive individuals were high in narcissism, Type E orientation, and several aspects of sensation seeking. The discussion centered on hypercompetitiveness as a mental health problem in American society and on the scale's utility in the diagnosis of the problem and in the assessment of therapeutic change in clients.

    Title Perceived and Ideal Physiques in Male and Female University Students.
    Date February 1994
    Journal The Journal of Social Psychology
    Title Pneumococcal Polysaccharide Vaccine Efficacy. An Evaluation of Current Recommendations.
    Date October 1993
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    OBJECTIVE--To determine pneumococcal polysaccharide vaccine efficacy in selected populations at risk for serious pneumococcal infection for whom vaccination is currently recommended and to assess duration of protection after vaccination. DESIGN--Vaccine efficacy was estimated using indirect cohort analysis to compare the proportion of pneumococcal infections caused by serotypes included in the vaccines of vaccinated and unvaccinated persons who were identified during 14 years of national surveillance. SETTING--Hospital laboratories in the United States that submitted pneumococcal isolates to the Centers for Disease Control and Prevention between May 1978 and April 1992. PARTICIPANTS--A total of 2837 persons older than 5 years who had pneumococcus isolated from blood or cerebrospinal fluid. RESULTS--Overall efficacy for preventing infection caused by serotypes included in the vaccine was 57% (95% confidence interval [CI], 45% to 66%). Efficacy among persons with diabetes mellitus was 84% (95% CI, 50% to 95%); with coronary vascular disease, 73% (95% CI, 23% to 90%); with congestive heart failure, 69% (95% CI, 17% to 88%); with chronic pulmonary diseases, 65% (95% CI, 26% to 83%); and with anatomic asplenia, 77% (95% CI, 14% to 95%). Efficacy was not documented for patients with alcoholism or cirrhosis, sickle cell disease, chronic renal failure, lymphoma, leukemia, or multiple myeloma, although sample sizes were small for these groups. Efficacy for immunocompetent persons older than 65 years was 75% (95% CI, 57% to 85%). Efficacy did not decline with increasing interval after vaccination: 5 to 8 years after vaccination it was 71% (95% CI, 24% to 89%), and 9 years or more after vaccination it was 80% (95% CI, 16% to 95%). CONCLUSIONS--Intensified efforts to improve pneumococcal vaccine coverage among certain populations for whom vaccination is currently recommended is indicated, but universal revaccination is not warranted at this time.

    Title Use of Polymerase Chain Reaction in an Epidemiologic Investigation of Pontiac Fever.
    Date September 1993
    Journal The Journal of Infectious Diseases
    Excerpt

    In June 1992, 13 (38%) of 34 resort guests experienced illness that met a symptom-based case definition of Pontiac fever. Each ill guest reported using an indoor hot tub compared with 6 (29%) of 21 nonill guests (P < .001). Water samples from the indoor hot tub were culture-negative for legionellae using standard techniques, coculture with amebae, and intraperitoneal inoculation of guinea pigs. However, polymerase chain reaction (PCR) testing of the water samples indicated the presence of Legionella pneumophila. Direct fluorescent antibody testing identified the organism as serogroup 6. Seroconversion to L. pneumophila serogroup 6 occurred in 7 (64%) of 11 ill guests and none of 5 nonill guests (P = .03). These results suggest that in certain circumstances, culture of environmental samples should be supplemented with additional tests such as PCR. These results are also consistent with the concept that Pontiac fever can be caused by nonviable legionellae.

    Title Measles Severity and Serum Retinol (vitamin A) Concentration Among Children in the United States.
    Date June 1993
    Journal Pediatrics
    Excerpt

    BACKGROUND. Studies in developing countries have shown that children with measles have low serum retinol concentrations and that lower retinol levels are associated with measles-related mortality. Vitamin A therapy has been shown to reduce mortality among African children with acute measles. OBJECTIVES. To determine whether serum retinol concentration is low among children with measles in the United States and to determine whether retinol concentration is associated with illness severity. SETTING. Pediatric referral hospital and clinic in Milwaukee, WI, during the measles outbreak of 1989-1990. PATIENTS. One hundred fourteen patients < or = 5 years of age evaluated for serologically confirmed measles with serum obtained within 5 days following rash onset. METHODS. Serum retinol concentration was determined by high-performance liquid chromatography. Clinical data were collected by hospital record review. A modified Pediatric Risk of Mortality (PRISM) score was used to assess physiologic instability as a measure of illness severity. RESULTS. Retinol concentrations ranged from 0.25 to 1.18 mumol/L (median 0.58 mumol/L); 82 (72%) patients had low retinol concentration (< or = 0.70 mumol/L). Median retinol concentrations were lower among hospitalized patients (0.56 vs 0.70, P = .006) and patients with pneumonia (0.52 vs 0.64, P = .02) but higher among children with otitis media (0.63 vs 0.54, P = .01). Higher modified PRISM scores, reflecting greater physiologic instability, were associated with lower retinol concentration (beta coefficient -.0147, P = .025). In multivariate analysis, higher modified PRISM scores were associated with lower retinol concentration (beta coefficient -.0144, P = .025) even after controlling for hospitalization, presence of complications, race, age, receipt of Aid to Families With Dependent Children, gender, and interval from rash onset until serum was collected. CONCLUSIONS. Among these children with measles in an urban United States community, retinol concentrations were depressed, and the degree of depression was associated with illness severity. Vitamin A therapy should be considered for children with measles in the United States who require hospitalization.

    Title Treating Measles: the Appropriateness of Admission to a Wisconsin Children's Hospital.
    Date March 1993
    Journal American Journal of Public Health
    Excerpt

    OBJECTIVE. A large number of children with measles were hospitalized at a children's hospital during a metropolitan measles outbreak. In this study we addressed the appropriateness of those admissions. METHODS. Charts of all 634 patients with a diagnosis of measles who were treated between August 1989 and April 1990 were reviewed. Determination of the appropriateness of hospital admission was based on severity of illness and presence of severe complications of measles. RESULTS. Of 564 patients with clinical measles or serologic evidence of recent infection, 252 were inpatients (median age 1.5 years) and 312 were outpatients (median age 2.1 years). Fifty-nine (23.4%) of the inpatients had been inappropriately admitted. Inpatients were significantly more likely than outpatients to have physiologic instability or a clinical complication. Children 15 months of age or younger were more likely to be hospitalized, as were children evaluated in the first 3 months of the outbreak period, even if admission was not appropriate on the basis of physiologic instability or complications. CONCLUSIONS. Younger patients with measles and patients evaluated earlier in the epidemic were more likely to be admitted to the hospital even when admission was inappropriate as assessed by degree of physiologic instability or presence of complications.

    Title Performance of Retrieved Kuntscher Intramedullary Rods: Improved Corrosion Resistance with Contemporary Material Design.
    Date October 1992
    Journal Clinical Materials
    Excerpt

    Eighteen Kuntscher-type intramedullary rods were obtained after human implantation periods ranging from 1 to 23 years. A clinical evaluation, metallurgical and chemical analyses of each implant were performed. Idiopathic, implant-related pain was the most common reason for removal, but was not related to extent of implant corrosion. When classified as early versus contemporary material compositions, a significant increase in surface corrosion, inclusion content and carbon content were demonstrated in rods made of the earlier composition of stainless steel. Intergranular corrosion was associated with structural design, rather than material microcleanliness or composition. While contemporary intramedullary fracture fixation provides excellent clinical results, the present investigation suggests that the performance of stainless steel implants may be improved through continued refinement of steel composition, careful consideration of structural design and fabrication techniques, and by routine removal of implants at the earliest opportunity.

    Title Clusters of Invasive Group A Streptococcal Infections in Family, Hospital, and Nursing Home Settings.
    Date October 1992
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    The spread of group A streptococcal infection to close contacts of infected persons is well recognized. With the resurgence of invasive group A streptococcal infections, there is an increased potential for clusters of patients with invasive disease. We reviewed data collected since December 1988 at the Centers for Disease Control (Atlanta) to identify clusters of infection in which one or more patients had invasive disease. Twelve family clusters were identified. Infection in index cases included the toxic shock-like syndrome and septicemia. Infection in family contacts included invasive infections, pharyngitis, or asymptomatic carriage. Most invasive disease occurred in adults, while the majority of noninvasive infections were in children. Five nosocomial clusters with spread of infection from patients to hospital personnel were documented. All index patients had the toxic shock-like syndrome; secondary infections included the toxic shock-like syndrome, pneumonia, bullous cellulitis, lymphangitis, and pharyngitis. Clusters of invasive infections also were identified in five nursing homes. Pneumonia, cutaneous infections, and the toxic shock-like syndrome occurred most commonly. Clustering by nursing home unit occurred in three outbreaks. In hospitals and nursing homes, improved infection control will likely decrease secondary spread; in families, spread of disease may be prevented by identifying and treating those harboring the organism or by chemoprophylaxis. Studies that characterize the rate of secondary infection are needed before definitive recommendations can be made.

    Title Postlaminectomy Kyphosis. Causes and Surgical Management.
    Date August 1992
    Journal The Orthopedic Clinics of North America
    Excerpt

    Postlaminectomy instability of the cervical spine can be managed either anteriorly or posteriorly. The posterior procedures that have been described are best performed at the time of the original decompressive procedure. Thus, the development of a kyphotic deformity is prevented. Generally, it is technically easier to achieve anterior stabilization and arthrodesis if a postlaminectomy kyphosis develops.

    Title Severe Illness Associated with Group A-hemolytic Streptococcal Infections.
    Date November 1991
    Journal Wisconsin Medical Journal
    Excerpt

    The Wisconsin Division of Health (DOH) began surveillance for severe illnesses associated with group A beta-hemolytic streptococcus (GABS) infections in late 1989 to describe the current epidemiologic features and clinical spectrum of these infections in the state. Severe illness was defined by the isolation of GABS from the blood or by the development of one or more of the following in a patient infected with GABS: shock, extensive tissue injury, desquamating rash, disseminated intravascular coagulation, renal failure, adult respiratory distress syndrome, or death. Case reports involving 28 patients with severe GABS-related illnesses with onset from November 1989 through October 1990 were received by the DOH. The majority of the case-patients had sepsis (57%), cellulitis (50%) or both. Nine (32%) cases were fatal. Those who died were older than those who survived (median age 74 years v 43 years, p = 0.002) and were more likely to have clinical diagnoses that included pneumonia (relative risk [RR] 3.0, 95% confidence interval [CI] 1.2, 7.3) or necrotizing fasciitis/myositis (RR 3.7, 95% CI 1.5, 9.0). The median interval from illness onset to hospitalization was similar for fatal cases (1 day) and non-fatal cases (2 days), suggesting that early intervention after the appearance of clinical illness may not improve the outcome.

    Title Pleuropneumonia Caused by Multiply Resistant Haemophilus Influenzae Type B Infection Acquired in the United States.
    Date August 1991
    Journal The Pediatric Infectious Disease Journal
    Title Eosinophilia-myalgia Syndrome in Wisconsin.
    Date April 1991
    Journal Wisconsin Medical Journal
    Excerpt

    Eosinophilia-myalgia syndrome (EMS) is a newly recognized illness characterized by intense eosinophilia, debilitating myalgia, and absence of any condition that could account for the eosinophilia or myalgia. The disorder has previously been associated with ingestion of capsules containing the amino acid L-tryptophan. In 1989, the Wisconsin Division of Health began surveillance for EMS. Each of 25 persons reported with the illness and meeting a standardized case definition were using L-tryptophan when their symptoms began, between June 1989 and January 1990. The median age of the patients was 43 years (range 26-82 years); 92% were female, and 96% were white. The majority of patients reported were using L-tryptophan for insomnia (36%), premenstrual syndrome (28%), or depression (20%). Common signs and symptoms in these cases included cough or dyspnea (60%), arthralgia (44%), edema of the extremities (44%), fever (36%), and rash (32%). Other epidemiologic investigations to date suggest that EMS may be associated with a product contaminant.

    Title Superficial Cultures in Neonatal Sepsis Evaluations. Impact on Antibiotic Decision Making.
    Date November 1990
    Journal Clinical Pediatrics
    Excerpt

    The authors performed a retrospective analysis of neonatal superficial cultures and their effect on antimicrobial decision making during a nine-month period at Nashville General Hospital. They obtained and reviewed charts of infants (n = 66) having paired superficial (skin and/or gastric aspirate) and deep (blood and cerebrospinal fluid) cultures for the evaluation of early-onset sepsis. Superficial cultures were positive for pathogens (any streptococcus or enteric gram-negative) in 15% (10/66) of cases. Antimicrobial decision making was affected in only one of these cases, and in a seemingly inappropriate manner. In summary, there was no evidence or review that superficial cultures used in sepsis evaluation influenced physician antimicrobial decision making; in one case they may have led to unnecessary antibiotic exposure.

    Title Clinical and Roentgenographic Evaluation of Bipolar Prostheses with Noncemented Anatomic Medullary Locking Femoral Stems.
    Date May 1990
    Journal Clinical Orthopaedics and Related Research
    Excerpt

    Fifty-six DePuy anatomic medullary locking femoral bipolar prostheses were reviewed clinically and roentgenographically in 50 patients at an average follow-up period of 30 months (range, 24-71 months). Forty-four of the implantations were in 40 male and 12 were in ten female patients. Forty-five devices were placed in primary operations, while 11 were used in revisions. The overall average age was 53.5 years. The average Harris hip scores for the primary bipolars were 29.8 preoperative and 77.3 postoperative, while the revision bipolars had Harris hip scores of 35.9 preoperative and 75.1 postoperative. Nearly one-half (47%) of all primary and 54% of the revision patients experienced pain to some degree on ambulation. Roentgenographically, all femoral components appeared to be well fixed biologically. Roentgenographic changes occurred with time in both primary and revision prostheses. On roentgenographic zonal analysis of primary prostheses, radiolucencies greater than 1 mm were present most frequently in the most proximal lateral zone and at the distal tip of the prosthesis. Although the use of noncemented bipolar prostheses generally shows acceptable clinical results, noncemented fixed acetabular components with noncemented femoral components produce a more satisfactory clinical result.

    Title Complications with the Variable Spinal Plating System.
    Date June 1989
    Journal Spine
    Excerpt

    From January 1986 to June of 1987, 40 patients underwent transpedicle fixation and fusion using the variable spinal plate system. Nineteen patients had undergone surgery at the same level or levels, and 21 patients had undergone no previous surgery. Diagnostic categories include spondylolisthesis, thoracolumbar and lumbar fractures, internal disc derangement, spinal stenosis, pseudarthrosis, mechanical instability, and fracture mal-union. Minimum follow-up has been 14 months, with the average being 20 months. Overall results showed 13 excellent, 12 good, seven fair, and eight poor. The overall complication rate was 45%. In those patients undergoing no previous surgery, it was 29%, but with those patients having previous surgery, it was 63%. Most of these complications were minor in nature and resolved before discharge. Implant failure occurred in seven patients, and consisted of screw breakage. Design modifications currently available should help minimize this complication. Although this method of internal fixation and fusion is technically demanding and has a high complication rate, it is considered to be indicated in lumbar fractures, revision of pseudarthrosis, spondylolisthesis with or without reduction, and failed surgery with marked instability.

    Title The Os in Os Appearance in the Spine and Pelvis of Adults.
    Date June 1989
    Journal Orthopaedic Review
    Excerpt

    Three cases of radiodense lines contained within bone and coursing parallel to the bony surfaces in skeletally mature patients are discussed. These lines were found to be distinct with normal appearing bone on either side and formed a miniature model of the present bony structure. This "bone within a bone" appearance was discovered on roentgenograms of patients with no history of musculoskeletal disorders. This radiologic finding probably represents a time-limited insult to the immature skeleton and appears to have no clinical significance.

    Title Perinatal Medical Negligence Closed Claims from the St. Paul Company, 1980-1982.
    Date November 1988
    Journal The Journal of Reproductive Medicine
    Excerpt

    One hundred fifty-three closed claims involving perinatal injury or death filed from 1980 through 1982 with the St. Paul Fire and Marine Insurance Company were studied. The claims included were those in which an indemnity was paid or $1,000 or more was expended on the legal defense. Five obstetricians reviewed these cases to identify obstetric and neonatal risk factors. In addition, cases were classified as to the presence or absence of medical negligence. Most of the complications leading to claims arose during labor and delivery. Many claims resulted from the failure to evaluate or treat in a manner consistent with accepted standards of care. Many lacked documentation of the physician's recognition of the risk factors involved. Low Apgar scores at both one and five minutes were the newborn risk factors seen most commonly. In the opinion of the reviewers, medical negligence occurred in 47% of the cases. Indemnity payment occurred with most of the claims judged to be associated with medical negligence. Payment to the claimant was made in a number of cases in which the reviewer thought no malpractice occurred. These results suggest that improvements may be needed in prenatal and perinatal health care as well as in the legal system used to address the problem of perinatal medical negligence.

    Title Anterior Lumbar Fusion Utilizing Transvertebral Fibular Graft.
    Date August 1988
    Journal Spine
    Excerpt

    In those instances of failed posterior arthrodesis for spondylolisthesis, iatrogenic spondylolisthesis due to posterior neural decompression or severe (grade III or IV) spondylolisthesis, anterior stabilization using a fibular strut graft appears to be feasible and successful. Eleven patients were treated with this technique and ten achieved solid anterior arthrodesi; the eleventh fused posterolaterally. All improved symptomatically with no postoperative complications, including sexual dysfunction in the male.

    Title Fasciocutaneous Flap Closure of a Grade Iii Lower Third Tibial Fracture: an Alternative to Free Flap Coverage.
    Date May 1988
    Journal Annals of Plastic Surgery
    Excerpt

    We present a patient who sustained a close-range shotgun wound resulting in a grade III fracture of the lower tibia. The wound was debrided on several occasions and, on day 4, was closed with a flexor digitorum muscle and pedicled fasciocutaneous flap. Grades III and IV lower one-third tibial fractures generally require a free flap to accomplish stable soft-tissue coverage. Free-tissue transfer, however, remains a tedious and lengthy procedure. Occasionally a fasciocutaneous flap may be available to facilitate wound closure and spare the patient a lengthy procedure and distant donor site. The established principles of compound tibial coverage must be adhered to when choosing a local fasciocutaneous flap.

    Title The Role of Arthroscopic Surgery in the Evaluation of Acute Traumatic Hemarthrosis of the Knee.
    Date April 1988
    Journal Clinical Orthopaedics and Related Research
    Excerpt

    Eighty patients presented for evaluation with an acute traumatic hemarthrosis of the knee and negligible instability on clinical examination. All had an examination under general anesthesia followed by arthroscopy. Anatomical lesions were demonstrated in 71 of 80 knees (89%) including anterior cruciate ligament (ACL) disruption in 50 (62%). Twenty-nine of 50 patients (58%) with arthroscopically-demonstrated ACL injuries had associated meniscal tears. Fifteen (19%) demonstrated isolated meniscal tears and nine (11%) osteochondral fractures not detected by conventional roentgenograms. The frequent occurrence of injuries to other joint structures in conjunction with ACL injuries was remarkable. An acute traumatic hemarthrosis of the knee often masks significant lesions. Arthroscopy aids the orthopedic surgeon in determining the full extent of the intraarticular damage.

    Title Healthy Children: an Assessment of Community-based Primary Care Health Programs for Children and Their Impact on Access, Cost, and Quality.
    Date January 1988
    Journal Advances in Pediatrics
    Title Investigation of Obstetric Malpractice Closed Claims: Profile of Event.
    Date November 1985
    Journal American Journal of Perinatology
    Excerpt

    The files of 220 obstetric closed-claim cases were reviewed by five obstetricians to determine whether information could be collected an analyzed to identify common predisposing factors to claims and to suggest preventative measures. The data suggests these cases contain common easily identified obstetric risk factors, most of which occurred in labor and delivery (66%). Fifty-four percent of the risks were recognized, 32% correctly managed, and a high percentage of risks were considered by the reviewers to be directly related to the obstetric outcome leading to the claim (66%). The authors feel obstetric closed claims can be studied and suggestions made to aid obstetricians in providing care. Identification of common obstetric risks and correct management of these risks is poor in these cases. Recognition and management guidelines are imperative in ensuring good obstetric outcome. These two physician-controlled factors played important parts in the majority of cases reviewed. It would appear from this study that obstetric malpractice closed claims are amenable to study; physicians and their patients would benefit from better data collection systems to identify risks in individual pregnancies; physicians need readily available resources to aid their management of patients; only through modification of physician behavior can suits be avoided.

    Title Magnesium Sulfate and Beta-mimetic Dual-agent Tocolysis in Preterm Labor After Single-agent Failure.
    Date November 1985
    Journal The Journal of Reproductive Medicine
    Excerpt

    Twenty-three patients in preterm labor failed to respond to single-agent tocolytic therapy or could not tolerate the dosage necessary to inhibit contractions. A combination of magnesium sulfate and ritodrine or terbutaline was used to inhibit labor in these patients. Fourteen patients (60.9%) responded to dual-agent tocolysis by delaying delivery for 48 hours or more. Six patients had delivery delayed for more than one week. Five patients had multiple gestations; three of them had delivery delayed more than 48 hours. Five patients developed pulmonary edema under treatment with dual-agent tocolysis; all responded to diuretic and/or oxygen therapy after the termination of tocolysis. Dual-agent tocolysis may significantly prolong some pregnancies complicated by preterm labor, but only at some risk to maternal well-being.

    Title Prematurity and Orgasmic Coitus During Pregnancy: Data on a Small Sample.
    Date October 1976
    Journal Fertility and Sterility
    Excerpt

    Nineteen mothers of premature infants were interviewed in an attempt to determine a possible relationship between prematurity and orgasmic coitus during pregnancy. Although the limited number of subjects precludes tests of statistical significance and definite conclusions, the findings do suggest possible associations. While there appeared to be no relationship between prematurity and coitus per se during pregnancy, the association of frequent or intense orgasm with prematurity does raise some questions that further investigation might answer. Because of the hazard of prematurity to the subsequent development of the child, further exploration of the possible relationship of prematurity to orgasmic coitus during pregnancy appears warranted.

    Title Endometrial Aspiration in Fertility Control. A Report of 500 Cases.
    Date August 1976
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Outpatient endometrial aspiration was offered to patients who suspected that they were pregnant, but were within 5 to 21 days after failure of expected menstruation and had a uterus of normal size on pelvic examination. This is a report of 500 consecutive cases treated between September, 1973, and April, 1975. Histologic examination of the aspirated tissue was obtained on all 500 cases (100 per cent). Follow-up examination and urine pregnancy was obtained on 407 patients (81.4 per cent). Histologic evidence of pregnancy was obtained in 323 patients (64.6 per cent). Complications were limited to five infections (1 per cent), only one of which led to hospitalization of the patient, and failure to completely evacuate the pregnant uterus in 39 patients (12.1 per cetn of the 323 pregnant). Thirty-four of these had the uterus emptied by a second outpatient procedure and five patients were hospitalized to complete their abortion.

    Title Reducing Complications in Laparoscopy.
    Date February 1976
    Journal Advances in Planned Parenthood
    Title The Pelvic Examination and the Black Gynecologist.
    Date October 1973
    Journal American Journal of Obstetrics and Gynecology
    Title A Critical Evaluation of Complications in Laparoscopy.
    Date July 1973
    Journal The Journal of Reproductive Medicine
    Title Counseling the Coronary Patient on Sexual Activity.
    Date July 1972
    Journal Postgraduate Medicine
    Title Abortion Screening and Counseling: a Brief Guideline for Physicians.
    Date February 1972
    Journal Postgraduate Medicine
    Title Abortion Request and Post-operative Response. A Washington Community Survey.
    Date November 1970
    Journal Northwest Medicine
    Title Mineralogy and Petrology of Coarse Particulate Material from Lunar Surface at Tranquillity Base.
    Date
    Journal Science (new York, N.y.)
    Excerpt

    Five grams of coarse fines (10085,11) contains 1227 grains, mostly mafic holocrystalline rock fragments, microbreccia, and glass spatter and agglomerates with less abundant anorthosite fragments and regularly shaped glass. The crystalline lithic fragments in the coarse fines and microbreccias represent a closely related suite of gabbroid igneous rocks that have a wider range of modal analyses and textures than seen in the larger crystalline rock samples returned by Apollo 11. Petrographic evidence of shock metamorphism is common, and the abundant glass is almost all shock-produced. None of the glass observed is similar to tektite glass.

    Title Chondrules in Apollo 14 Samples: Implications for the Origin of Chondritic Meteorites.
    Date
    Journal Science (new York, N.y.)
    Excerpt

    Chondrules have been observed in several breccia samples returned by the Apollo 14 mission. These lunar chondrules are believed to have formed during a large impact event, perhaps the one that formed the Imbrian Basin. This suggests that some meteoritic chondrules are also formed by impact processes such as crystallization after shock melting and abrasion and diffusion in base-surge and fall-back deposits generated by impacts on planetary surfaces.

    Title Technique for Enabling Prism Coupling.
    Date
    Journal Applied Optics
    Excerpt

    An alignment technique has been developed for coupling to optical modes in a waveguide using right angle prisms.

    Title Variable Standing-wave Ratio Magnetostatic Wave-optical Interaction in Yig Films.
    Date
    Journal Applied Optics
    Excerpt

    The collinear and anticollinear interaction of guided light with magnetostatic forward volume waves in yttrium iron garnet epitaxial thin films was investigated experimentally. We set out to demonstrate double-beam modulation with the above interaction. This was not achieved, but the simultaneous occurrence of the above effects was used to expand the magnetostatic wave-optical interaction bandwidth.

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