Burney A. Kieke

Concentration of enteroviruses, adenoviruses, and noroviruses from drinking water by use of glass wool filters

ABSTRACT Available filtration methods to concentrate waterborne viruses are either too costly for studies requiring large numbers of samples, limited to small sample volumes, or not very portable for routine field applications. Sodocalcic glass wool filtration is a cost-effective and easy-to-use method to retain viruses, but its efficiency and reliability are not adequately understood. This study evaluated glass wool filter performance to concentrate the four viruses on the U.S. Environmental Protection Agency contaminant candidate list, i.e., coxsackievirus, echovirus, norovirus, and adenovirus, as well as poliovirus. Total virus numbers recovered were measured by quantitative reverse transcription-PCR (qRT-PCR); infectious polioviruses were quantified by integrated cell culture (ICC)-qRT-PCR. Recovery efficiencies averaged 70% for poliovirus, 14% for coxsackievirus B5, 19% for echovirus 18, 21% for adenovirus 41, and 29% for norovirus. Virus strain and water matrix affected recovery, with significant interaction between the two variables. Optimal recovery was obtained at pH 6.5. No evidence was found that water volume, filtration rate, and number of viruses seeded influenced recovery. The method was successful in detecting indigenous viruses in municipal wells in Wisconsin. Long-term continuous filtration retained viruses sufficiently for their detection for up to 16 days after seeding for qRT-PCR and up to 30 days for ICC-qRT-PCR. Glass wool filtration is suitable for large-volume samples (1,000 liters) collected at high filtration rates (4 liters min−1), and its low cost makes it advantageous for studies requiring large numbers of samples.

Influenza Vaccine Effectiveness in the United States During 2012–2013: Variable Protection by Age and Virus Type

Background. During the 2012–2013 influenza season, there was cocirculation of influenza A(H3N2) and 2 influenza B lineage viruses in the United States. Methods. Patients with acute cough illness for ≤7 days were prospectively enrolled and had swab samples obtained at outpatient clinics in 5 states. Influenza vaccination dates were confirmed by medical records. The vaccine effectiveness (VE) was estimated as [100% × (1 − adjusted odds ratio)] for vaccination in cases versus test-negative controls. Results. Influenza was detected in 2307 of 6452 patients (36%); 1292 (56%) had influenza A(H3N2), 582 (25%) had influenza B/Yamagata, and 303 (13%) had influenza B/Victoria. VE was 49% (95% confidence interval [CI], 43%–55%) overall, 39% (95% CI, 29%–47%) against influenza A(H3N2), 66% (95% CI, 58%–73%) against influenza B/Yamagata (vaccine lineage), and 51% (95% CI, 36%–63%) against influenza B/Victoria. VE against influenza A(H3N2) was highest among persons aged 50–64 years (52%; 95% CI, 33%–65%) and persons aged 6 months–8 years (51%; 95% CI, 32%–64%) and lowest among persons aged ≥65 years (11%; 95% CI, −41% to 43%). In younger age groups, there was evidence of residual protection from receipt of the 2011–2012 vaccine 1 year earlier. Conclusions. The 2012–2013 vaccines were moderately effective in most age groups. Cross-lineage protection and residual effects from prior vaccination were observed and warrant further investigation.

Viruses in Nondisinfected Drinking Water from Municipal Wells and Community Incidence of Acute Gastrointestinal Illness

Background: Groundwater supplies for drinking water are frequently contaminated with low levels of human enteric virus genomes, yet evidence for waterborne disease transmission is lacking. Objectives: We related quantitative polymerase chain reaction (qPCR)–measured enteric viruses in the tap water of 14 Wisconsin communities supplied by nondisinfected groundwater to acute gastrointestinal illness (AGI) incidence. Methods: AGI incidence was estimated from health diaries completed weekly by households within each study community during four 12-week periods. Water samples were collected monthly from five to eight households per community. Viruses were measured by qPCR, and infectivity assessed by cell culture. AGI incidence was related to virus measures using Poisson regression with random effects. Results: Communities and time periods with the highest virus measures had correspondingly high AGI incidence. This association was particularly strong for norovirus genogroup I (NoV-GI) and between adult AGI and enteroviruses when echovirus serotypes predominated. At mean concentrations of 1 and 0.8 genomic copies/L of NoV-GI and enteroviruses, respectively, the AGI incidence rate ratios (i.e., relative risk) increased by 30%. Adenoviruses were common, but tap-water concentrations were low and not positively associated with AGI. The estimated fraction of AGI attributable to tap-water–borne viruses was between 6% and 22%, depending on the virus exposure–AGI incidence model selected, and could have been as high as 63% among children < 5 years of age during the period when NoV-GI was abundant in drinking water. Conclusions: The majority of groundwater-source public water systems in the United States produce water without disinfection, and our findings suggest that populations served by such systems may be exposed to waterborne viruses and consequent health risks.

Influenza vaccine effectiveness in Wisconsin during the 2007–08 season: Comparison of interim and final results

BACKGROUND During the 2007-08 influenza season, we reported an interim vaccine effectiveness (VE) estimate of 44% for preventing medically attended influenza. In this analysis we report results for the entire season and compare them with the interim estimate. METHODS Patients with feverishness, chills, or cough <8 days duration were prospectively recruited over 10 weeks and tested for influenza by real-time reverse transcriptase PCR (rRT-PCR). Case-control analyses were performed using data from patients with rRT-PCR confirmed influenza (cases) and ill patients without influenza (test-negative controls). VE was estimated as 100×(1-adjusted odds ratio) in a logistic regression model adjusting for age, week, and high risk medical condition. A sample of influenza isolates was antigenically characterized. RESULTS Influenza was detected by rRT-PCR in 865 (44%) of 1972 patients; 73% were type A and 27% were type B. VE was 37% (95% CI, 22-49%) overall and 44% (95% CI, 27-58%) among participants tested 0-3 days after illness onset. VE was 39% (95% CI, 2-62%) in children 6-59 months old and 37% (95% CI, -2% to 61%) in adults ≥50 years old. VE was 41% (95% CI, 24-53%) for influenza A and 31% (95% CI, 3-51%) for influenza B. All 24 characterized influenza A viruses were antigenically matched to the H3N2 vaccine strain, although 14 viruses exhibited mild antigenic drift. There was a lineage mismatch with the vaccine strain for all 39 characterized influenza B viruses. CONCLUSIONS The 2007-08 influenza vaccine provided modest protection against medically attended influenza in this population. The interim estimate of VE after 17 days closely approximated the final season VE, supporting the potential use of interim VE estimates while influenza seasons are still in progress.

Impact of Statewide Program To Promote Appropriate Antimicrobial Drug Use

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.

Visits to emergency departments for gynecologic disorders in the United States, 1992-1994.

Objective To assess rates of visits to emergency departments for gynecologic disorders among women of reproductive age in the United States. Methods Data from the National Hospital Ambulatory Medical Care Survey for 1992-1994 were analyzed to determine rates of visits to emergency departments among women, ages 15-44 years. Average annual rates per 1000 women were calculated using age, race, and region-specific population estimates. Rate ratios were used to compare rates among subgroups. Results Approximately 1.4 million gynecologic visits were made to emergency departments annually, for an average annual rate of 24.3 visits per 1000 women, ages 15–44 years (95% confidence interval [CI] 22.0, 26.6). The most frequent diagnoses were pelvic inflammatory disease (average annual rate 5.8, 95% CI 5.0, 6.6), lower genital tract infections including sexually transmitted diseases (average annual rate 5.7, 95% CI 4.8, 6.6), and menstrual disorders (average annual rate 2.9, 95% CI 2.3, 3.5). Nearly half of all gynecologic visits resulted in diagnoses of genital tract infections. Younger women (ages 15–24 years) were 2.3 (95% CI 2.0, 2.6) times as likely as older women (ages 25–44 years), and black women were 3.6 (95% CI 2.9, 4.3) times as likely as white women, to visit emergency departments for gynecologic disorders. Rate ratios for genital tract infections were 10–20 times higher for younger black women than for older, white women. Conclusion Almost half of gynecologic visits to emergency departments were related to genital tract infections, which largely are preventable.

Comparison of clinical features and outcomes of medically attended influenza A and influenza B in a defined population over four seasons: 2004–2005 through 2007–2008

Please cite this paper as: Irving et al. (2012) Comparison of clinical features and outcomes of medically attended influenza A and influenza B in a defined population over four seasons: 2004–2005 through 2007–2008. Influenza and Other Respiratory Viruses 6(1), 37–43.

Eczematous skin disease and recall of past diagnoses: implications for smallpox vaccination.

Context People with a history of atopic dermatitis or eczema in themselves or their close contacts should not receive preexposure smallpox vaccination because of the risk for eczema vaccinatum. Contribution This population-based study suggests that about 40% of people would not correctly report that they or a close contact has these skin conditions even though medical records confirm that they do. Implications Relying on patient self-report about dermatologic contraindications to smallpox vaccination would miss a substantial proportion of people with true contraindications. The Editors A national discussion of the pros and cons of resuming a smallpox vaccination policy began shortly after the terrorist attacks on 11 September 2001 and continues today (1-3). Routine vaccination for smallpox in the United States was discontinued in 1972, and approximately 119 million Americans younger than 30 years of age have never been immunized against smallpox (1). Older individuals who received the vaccine in childhood probably have waning immunity, and their response to smallpox remains unknown (1, 4). Thus, if smallpox were purposely reintroduced in the United States, many Americans would be expected to be at risk for death or disability if infected. A national stockpile of smallpox vaccine sufficient to vaccinate the entire U.S. population is now available, and preexposure vaccination of U.S. health care workers is under way (5, 6). Although successful primary vaccination with vaccinia confers a high level of protection from smallpox for 5 to 10 years (7), the risk for serious adverse events after vaccination is significant, especially in certain high-risk populations. Populations at risk include immunosuppressed individuals (such as transplant recipients, persons with generalized malignant conditions, and patients receiving high-dose corticosteroids), HIV-positive individuals, and individuals with certain types of preexisting skin disease (5, 8-10). Eczema vaccinatum is a localized or generalized cutaneous dissemination of vaccinia virus that occurs in persons with a history of atopic dermatitis or eczema. In 1968, it occurred at a rate of 39 cases per 1 million primary vaccinations (8). This illness is typically mild and self-limited; however, it can be severe or fatal, especially in young children (4, 9, 11-14). Persons with a history of atopic dermatitis or eczema who are household contacts of recent smallpox vaccinees are also at increased risk (11-13, 15, 16). Eczema vaccinatum may be more severe in contacts of persons vaccinated than in the vaccine recipients themselves (12-16). The Advisory Committee on Immunization Practices recommends that smallpox vaccine not be offered before smallpox exposure to people with a history of eczema or atopic dermatitis, regardless of disease severity or activity, or to household contacts of such individuals (5). Eczema is a general term used to describe chronic skin inflammation with erythematous, pruritic, scaling, oozing, vesiculating, or crusting lesions (17-19). Atopic dermatitis is a more specific term describing chronic eczematous lesions that appear in response to various stimuli, including allergens, irritants, stress, and infection (17, 18). Individuals with atopic dermatitis often have other atopic diseases, such as asthma and hay fever (17-19). Although dermatologists frequently distinguish between eczema and atopic dermatitis, other physicians and medical researchers often use the two terms interchangeably (17, 20, 21). The prevalence of eczema and atopic dermatitis appears to have increased in recent years, especially among children (22, 23). However, estimates of general population prevalence are limited. Few studies have included adults (24, 25), and most estimates have been based on self-reported data (18, 20, 22, 23, 26, 27). We sought to determine the prevalence of clinically diagnosed eczema and atopic dermatitis in a defined population and to estimate the proportion of this population with contraindications to smallpox vaccination. Self-reported medical conditions may be used to screen potential recipients of smallpox vaccine; thus, we attempted to determine how well adults could accurately recall past diagnoses of atopic dermatitis for themselves, their children, or other members of their household. This study was reviewed and approved by the Marshfield Clinic Institutional Review Board. All survey respondents provided verbal informed consent before the telephone interview. Methods Marshfield Clinic is a multispecialty group practice providing comprehensive care at 40 regional locations in north-central Wisconsin. Physicians at Marshfield Clinic use the Marshfield Enhanced Charting and Coding Acquisition (MECCA) system to record diagnoses and procedures in a computerized medical record. MECCA stores diagnoses and other patient information using standardized, clinically relevant terms, often with more precision than International Classification of Diseases, 9th Revision (ICD-9), codes. MECCA terms are selected by physicians for each patient encounter and are then automatically mapped to traditional ICD-9 diagnosis codes. Population The central region of the Marshfield Epidemiologic Study Area (MESA) includes 14 ZIP codes within the primary service area of the Marshfield Clinic. MESA was established in 1991 as a resource to facilitate population-based health research by linking residency in a defined population with the extensive electronic medical data resources of Marshfield Clinic (28). Marshfield Clinic provides medical care for nearly the entire residential population in this ZIP code region. Previous validation surveys of the MESA population indicate that Marshfield Clinic data systems capture more than 95% of the people, 100% of deaths, 94% of hospital discharges, and 92% of outpatient visits (28). According to the U.S. Census, 53 753 people were living in the central region of MESA in 2000. Residents of MESA are mostly non-Hispanic white persons (97.4%). With the exception of residents of the city of Marshfield (population, 19 000), most MESA residents live in areas that meet the federal definition of rural (population < 2500). Case Ascertainment Case ascertainment for prevalence estimation focused on current MESA residents in whom atopic dermatitis or eczema had been diagnosed in 2000 or 2001. We selected patients given a diagnosis with one of five MECCA lexicon termsatopic dermatitis; atopic eczema; dermatitis, atopic; eczema; or eczematous dermatitis-on two or more occasions separated by at least 60 days. We excluded patients with a diagnosis of nummular eczema, dyshidrotic eczema, or focal (hand/ear) eczema because these conditions have not been identified as risk factors for eczema vaccinatum. Ascertainment of diagnoses was restricted to a 2-year period because MECCA was not universally used at Marshfield Clinic before 2000. However, ICD-9 diagnosis codes are available in Marshfield Clinic automated records dating back to 1979. The ICD-9 code for atopic dermatitis (691.8) is specific for that diagnosis, but the ICD-9 code for eczema (692.9, unspecified dermatitis) is nonspecific. The latter includes many other types of dermatitis (for example, contact dermatitis, photodermatitis, seborrheic dermatitis) and therefore could not be used to estimate the prevalence of eczema before the implementation of MECCA in 2000. Medical Record Review To assess the validity of the MECCA terms for atopic dermatitis and eczema, we manually abstracted medical records for a randomly selected sample of 100 patients given a diagnosis with the selected MECCA terms. Records were also reviewed for a random sample of 100 MESA residents in whom unspecified dermatitis (ICD-9 code, 692.9) was diagnosed from 2000 through 2001 during two or more medical encounters separated by at least 60 days, but who did not have a MECCA diagnosis code for eczema or atopic dermatitis. Although no specific diagnostic test is available for atopic dermatitis or eczema, several groups of researchers and clinicians have developed various criteria lists for the diagnosis of atopic dermatitis (17, 22, 29). Recurrent pruritic skin lesions, a personal or family history of atopy, and early onset of symptoms are criteria common to all of these classification schemes. Data on lesion structure, symptoms, and history of asthma and allergy were abstracted from patient charts. Prevalence of Atopic Dermatitis and Eczema For this study, we defined prevalence as the proportion of MESA residents on 31 December 2001 who had a history of physician-diagnosed atopic dermatitis or eczema (on two or more visits 60 days apart) in 2000 and 2001. Population counts from the 2000 U.S. Census for the MESA ZIP codes were used as the denominators for all rate calculations. Age- and sex-specific prevalence estimates and 95% CIs were calculated (30). Telephone Survey We conducted a telephone survey to determine the proportion of individuals who could accurately recall a history of atopic dermatitis or eczema for themselves, their children, or another household member. We selected an additional group of patients with more remote diagnoses for this survey so that we could assess the relationship between recall of skin disease and time elapsed since the most recent diagnosis. Current MESA residents were eligible for this survey if they had a history of atopic dermatitis diagnosis (ICD-9 code, 691.8) on two or more occasions separated by at least 60 days since 1979. Eligible patients with atopic dermatitis were divided into three groups. The first group comprised children younger than 18 years of age on 1 July 2002. The telephone survey was administered to a parent or guardian of these children. The second group was composed of adult patients with atopic dermatitis who were the sole adult listed on their Marshfield Clinic billing accounts. The third group consisted of adult household contacts of adult patients with atopic dermatitis

A multicenter study of bacterial vaginosis in women with or at risk for human immunodeficiency virus infection

Background: Bacterial vaginosis is a common gynecologic infection that has been associated with a variety of gynecologic and obstetric complications, including pelvic inflammatory disease, postabortal infection and premature delivery. Recent studies suggest that bacterial vaginosis may increase a woman’s risk for human immunodeficiency virus (HIV). We undertook this study to assess whether the prevalence and characteristics of bacterial vaginosis differed according to HIV status in high-risk US women. Methods: Prevalence of bacterial vaginosis was assessed by Gram’s stain and clinical criteria for 854 HIV-infected and 434 HIV-uninfected women enrolled in the HIV Epidemiology Research (HER) Study.Multiple logistic regression techniques were used to determine whether HIV infection independently predicted bacterial vaginosis. Results: Almost half (46%) the women had bacterial vaginosis by Gram’s stain. The prevalence of bacterial vaginosis was 47% in the HIV-positive women compared with 44% in the HIV-negativewomen; this difference was not statistically significant (p = 0.36). After adjustment for other covariates, HIV-positive women were more likely than HIV-negative women to have bacterial vaginosis (odds ratio (OR) 1.31; 95% confidence interval (CI) 1.01-1.70) by Grams stain but not by clinical criteria (OR 1.16; CI 0.87-1.55). Among HIV-positive women, use of antiretroviral drugs was associated with a lower prevalence of bacterial vaginosis (adjusted OR 0.54; Cl 0.38 -0.77). Conclusions: In this cross-sectional analysis of high-risk US women, HIV infection was positively correlated with bacterial vaginosis diagnosed by Gram’s stain.

Clinician Knowledge and Beliefs after Statewide Program to Promote Appropriate Antimicrobial Drug Use

In 1999, Wisconsin initiated an educational campaign for primary care clinicians and the public to promote judicious antimicrobial drug use. We evaluated its impact on clinician knowledge and beliefs; Minnesota served as a control state. Results of pre- (1999) and post- (2002) campaign questionnaires indicated that Wisconsin clinicians perceived a significant decline in the proportion of patients requesting antimicrobial drugs (50% in 1999 to 30% in 2002; p<0.001) and in antimicrobial drug requests from parents for children (25% in 1999 to 20% in 2002; p = 0.004). Wisconsin clinicians were less influenced by nonpredictive clinical findings (purulent nasal discharge [p = 0.044], productive cough [p = 0.010]) in terms of antimicrobial drug prescribing. In 2002, clinicians from both states were less likely to recommend antimicrobial agent treatment for the adult case scenarios of viral respiratory illness. For the comparable pediatric case scenarios, only Wisconsin clinicians improved significantly from 1999 to 2002. Although clinicians in both states improved on several survey responses, greater overall improvement occurred in Wisconsin.