David W. Fleming

Recommendations for preventing the spread of vancomycin resistance: Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC)

A rapid increase in the incidence of infection and colonization with vancomycin-resistant enterococci (VRE) has been reported from U.S. hospitals in the last 5 years. This increase poses several problems, including a) the lack of available antimicrobials for therapy of infections due to VRE, since most VRE are also resistant to multiple other drugs, e.g., aminoglycosides and ampicillin, previously used for the treatment of infections due to these organisms, and b) the possibility that the vancomycin resistance genes present in VRE may be transferred to other gram-positive microorganisms such as Staphylococcus aureus. An increased risk of VRE infection and colonization has been associated with previous vancomycin and/or multi-antimicrobial therapy, severe underlying disease or immunosuppression, and intra-abdominal surgery. Because enterococci can be found in the normal gastrointestinal or female genital tract, most enterococcal infections have been attributed to endogenous sources within the individual patient. However, recent reports of outbreaks and endemic infections due to enterococci, including VRE, have shown that patient-to-patient transmission of the microorganisms can occur either via direct contact or indirectly via hands of personnel or contaminated patient-care equipment or environmental surfaces.(ABSTRACT TRUNCATED AT 250 WORDS)

A Swimming-Associated Outbreak of Hemorrhagic Colitis Caused by Escherichia coli O157:H7 and Shigella Sonnei

BACKGROUND In the summer of 1991, simultaneous outbreaks of bloody diarrhea and hemolytic-uremic syndrome caused by Escherichia coli O157:H7 and of bloody diarrhea caused by Shigella sonnei were traced to a lakeside park near Portland, Oregon. METHODS We identified cases primarily from routine surveillance reports. In case-control studies, the activities of persons with park-associated E. coli O157:H7 or S. sonnei infections were compared independently with those of three sets of controls. We also evaluated environmental conditions at the park and subtyped the bacterial isolates. RESULTS We identified 21 persons with park-associated E. coli O157:H7 infections (all of them children; median age, six years) and 38 persons with S. sonnei infections (most of them children). These 59 people had visited the park over a 24-day period. Their illnesses were not associated with food or beverage consumption. All the case patients reported swimming, however, and in case-control studies swimming was strongly associated with both types of infection (P = 0.015 or less). The case patients were more likely than the controls to report having swallowed lake water, and they had spent more time in the lake. Numbers of enterococci indicative of substantial fecal contamination (geometric mean, > 50 per deciliter) were detected in the swimming area during some but not all of the outbreak period. Park-associated E. coli O157:H7 isolates were identical by pulsed-field gel electrophoresis and were distinguishable from other isolates in the Portland area. CONCLUSIONS Lake water that was fecally contaminated by bathers was the most likely vehicle for the transmission of both the E. coli O157:H7 and the S. sonnei infections. The unusually prolonged outbreak suggests both the survival of these enteric organisms in lake water and a low infectious dose.

Tobacco smoke as a risk factor for meningococcal disease

BACKGROUND Since 1992 the US Pacific Northwest has experienced a substantial increase in the incidence of serogroup B meningococcal disease. The current meningococcal polysaccharide vaccine is poorly immunogenic in young children and does not protect against N. meningitidis serogroup B. Defining alternative approaches to the prevention and control of meningococcal disease is of considerable public health importance. METHODS We performed a case-control study comparing 129 patients in Oregon and southwest Washington with 274 age- and area-matched controls. We used conditional logistic regression analysis to determine which exposures remained associated with disease after adjusting for other risk factors and confounders and calculated the proportion of disease attributable to modifiable exposures. RESULTS After adjustment for all other significant exposures identified, having a mother who smokes was the strongest independent risk factor for invasive meningococcal disease in children < 18 years of age [odds ratio (OR), 3.8; 95% confidence interval (CI) 1.6 to 8.9)], with 37% (CI 15 to 65) of all cases in this age group potentially attributable to maternal smoking. Adult patients were more likely than controls to have a chronic underlying illness (OR 10.8, CI 2.7 to 43.3), passive tobacco smoke exposure (OR 2.5, CI 0.9 to 6.9) and to smoke tobacco (OR 2.4, CI 0.9 to 6.6). Dose-response effects were seen for passive smoke exposure and risk of disease in all age groups. CONCLUSION Tobacco smoke exposure independently increases the risk of developing meningococcal disease.

Primary invasive Haemophilus influenzae type b disease: A population-based assessment of risk factors

We performed a population-based case-control study of risk factors for primary invasive Haemophilus influenzae type b (Hib) disease in metropolitan Atlanta from July 1, 1983, through June 30, 1984. Active surveillance identified 102 cases in children less than 5 years of age, 89 of whom lived in households with telephones. We used random digit dialing to select 530 controls who were postmatched to cases by age. Multivariate analysis showed a significant association between Hib disease and two independent exposure factors, household crowding (odds ratio (OR) 2.7, 95% confidence limits (CL) 1.3 to 5.6) and day-care attendance. For day-care attendance, relative risk was highest in 2- to 5-month-old infants (OR 17.7, 95% CL 5.8 to 54.4) and declined to 9.4 (4.3 to 20.9) at ages 6 to 11 months, 5.0 (2.7 to 9.3) at 12 to 23 months, 2.7 (1.3 to 5.5) at 24 to 35 months, and 1.4 (0.5 to 4.0) in 36- to 59-month-old children. Fifty percent of all invasive Hib disease that occurred during the study period was attributable to exposure to day-care; the attributable risk for household crowding was 18%. Dose-response effects were observed for hours per week of day-care attendance and extent of household crowding. Breast-feeding was protective for infants less than 6 months of age (OR 0.08, 95% CL 0.01 to 0.59). After controlling for socioeconomic and other confounding factors, we could demonstrate no effect of black race on cumulative risk of invasive Hib disease. Our study defines high-risk groups and provides a population-based model of the interrelationship between risk factors associated with invasive Hib disease.

Menu Labeling Regulations and Calories Purchased at Chain Restaurants

BACKGROUND The federal menu labeling law will require chain restaurants to post caloric information on menus, but the impact of labeling is uncertain. PURPOSE The goal of the current study was to examine the effect of menu labeling on calories purchased, and secondarily, to assess self-reported awareness and use of labels. DESIGN Single-community pre-post-post cross-sectional study. Data were collected in 2008-2010 and analyzed in 2011-2012. SETTING/PARTICIPANTS 50 sites from 10 chain restaurants in King County, Washington, selected through stratified, two-stage cluster random sampling. A total of 7325 customers participated. Eligibility criteria were: being an English speaker, aged ≥ 14 years, and having an itemized receipt. The study population was 59% male, 76% white non-Hispanic, and 53% aged<40 years. INTERVENTION A regulation requiring chain restaurants to post calorie information on menus or menu boards was implemented. MAIN OUTCOME MEASURES Mean number of calories purchased. RESULTS No significant changes occurred between baseline and 4-6 months postregulation. Mean calories per purchase decreased from 908.5 to 870.4 at 18 months post-implementation (38 kcal, 95% CI=-76.9, 0.8, p=0.06) in food chains and from 154.3 to 132.1 (22 kcal, 95% CI=-35.8, -8.5, p=0.002) in coffee chains. Calories decreased in taco and coffee chains, but not in burger and sandwich establishments. They decreased more among women than men in coffee chains. Awareness of labels increased from 18.8% to 61.7% in food chains and from 4.4% to 30.0% in coffee chains (both p<0.001). Among customers seeing calorie information, the proportion using it (about one third) did not change substantially over time. After implementation, food chain customers using information purchased on average fewer calories compared to those seeing but not using (difference=143.2 kcal, p<0.001) and those not seeing (difference=135.5 kcal, p<0.001) such information. CONCLUSIONS Mean calories per purchase decreased 18 months after implementation of menu labeling in some restaurant chains and among women but not men.

Emergence of Antimicrobial-Resistant Shigellosis in Oregon

Ampicillin and trimethoprim-sulfamethoxazole (TMP-SMZ) are currently considered acceptable empirical therapy for shigellosis in developed countries. However, there are few recently reported studies on antimicrobial resistance among shigellae isolated in the United States. We examined the epidemiology of shigellosis and the antimicrobial susceptibility of Shigella species isolated in Oregon from July 1995 through June 1998. Of 430 isolates, 410 were identified to the species level: Shigella sonnei accounted for 55% of isolates, and Shigella flexneri, for 40%. The overall annual incidence of shigellosis was 4.4 cases per 100,000 population. Children aged <5 years (annual incidence, 19.6 cases per 100,000 population) and Hispanics (annual incidence, 28.4 cases per 100,000 population) were at highest risk. Of 369 isolates tested, 59% were resistant to TMP-SMZ, 63% were resistant to ampicillin, 1% were resistant to cefixime, and 0.3% were resistant to nalidixic acid; none of the isolates were resistant to ciprofloxacin. Thirteen percent of the isolates had multidrug resistance to ampicillin, chloramphenicol, streptomycin, sulfisoxazole, and tetracycline. Infections due to multidrug-resistant shigellae are endemic in Oregon. Neither ampicillin nor TMP-SMZ should be considered appropriate empirical therapy for shigellosis any longer; when antibiotics are indicated, a quinolone or cefixime should be used.

Partner Notification: Can It Control Epidemic Syphilis?

STUDY OBJECTIVE During 1987, the rate of syphilis among heterosexual adults in Oregon increased 159%, yet the number of cases of gonorrhea remained stable. Our study was done to evaluate why the same control measures contained gonorrhea but not syphilis in this population. DESIGN Exploratory case-control study. SETTING Public health clinics in Portland, and Salem, Oregon. PATIENTS All 146 heterosexual adults with early syphilis and all 164 heterosexual adults with acute gonorrhea reported to the public health clinics during April to July 1988. INTERVENTION A questionnaire was administered to all syphilis case-patients and control patients (those with gonorrhea) at the beginning of the routine, sexually transmitted disease (STD), investigative interview. MEASUREMENTS AND MAIN RESULTS Syphilis case-patients had contact with an average of 5.0 sex partners for whom they could not supply locating information sufficient to initiate partner notification. In contrast, patients with gonorrhea had contact with an average of 0.4 sex partners for whom they could not supply locating information (P less than 0.005). The 28% (41 of 146) of syphilis case-patients who reported having exchanged sex for drugs or money accounted for 72% (527 of 729) of the unlocatable partners exposed to syphilis. In contrast, the 17% (28 of 164) of patients with gonorrhea who reported having exchanged sex for drugs or money accounted for 36% (25 of 69) of the unlocatable partners exposed to gonorrhea. CONCLUSIONS Because patients infected with syphilis have relatively large numbers of anonymous sexual encounters, prevention strategies that supplement partner notification are urgently needed to control the syphilis epidemic among adults.

TRIAL OF ANONYMOUS VERSUS CONFIDENTIAL HUMAN IMMUNODEFICIENCY VIRUS TESTING

Before December, 1986, all public human immunodeficiency virus (HIV) testing in Oregon was done confidentially (using names). In December, clients were offered the option of either anonymous or confidential services. As judged by questionnaire responses, the availability of anonymity increased overall demand for testing by 50%: 125% for homosexual/bisexual (gay) men, 56% for female prostitutes, 17% for intravenous drug users, and 32% for other clients. The number of gay clients who had tests increased from a mean of 42 per month during the 4 months before anonymity was available to 108 per month during the 4 months after, whereas, at public sites in Colorado or California and private sites in Oregon, the number of gay clients tested did not increase. Twice as many seropositive persons were identified during the 3 1/2 months after anonymity became available (n = 85) as in the 3 1/2 months before (n = 36). Thus, availability of anonymous HIV testing and counselling drew gay men who had not sought services under a confidential testing system.

Scope and organization of the guide to community preventive services

BACKGROUND The diverse nature of the target audience (i.e., public health decision-makers) for the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) dictates that it must be broad in scope. In addition, for the Guide to be most useful for its target audience, its organization and format must be carefully considered. DETERMINING THE SCOPE OF THE GUIDE Healthy People objectives and actual causes of death were used to determine the contents of the Guide. A priority setting exercise resulted in the selection of 15 topics for systematic reviews using the following criteria: burden of the problem, preventability, relationship to other public health initiatives, usefulness of the package of topics selected and level of current research and intervention activity in public and private sectors. Interventions within each topic target state and local levels and include population-based strategies, individual strategies in other than clinical settings and group strategies. ORGANIZATION OF THE GUIDE The Guide is organized into: Introduction, Reviews and Recommendations (three sections: Changing Risk Behaviors, Reducing Diseases, Injuries, or Impairments, and Addressing Environmental and Ecosystem Challenges), Appendixes, and Indexes. DISCUSSION The scope and organization of the Guide were determined using relevant public health criteria and expert opinion to provide a useful and accessible document to a broad target audience. While the final contents of the Guide may change during development, the working table of contents described in this paper provides a framework for development of the Guide and conveys its scope and intention.

Dermatitis in Grocery Workers Associated with High Natural Concentrations of Furanocoumarins in Celery

Abstract A vesicular, peeling rash characteristic of a phytophototoxic dermatitis developed on the hands and arms of 30 of 127 grocery workers. The rash subsequently healed with residual hyperpigme...