Robert A. Gunn

Hemolytic uremic syndrome and diarrhea associated with Escherichia coli 0157:H7 in a day care center

Three cases of hemolytic uremic syndrome with bloody diarrhea occurred during an outbreak of diarrheal illness in children aged 4 months to 9 years who attended a day care center. Thirty-six (34%) of 107 had diarrhea (three or more loose or watery stools in 24 hours) lasting ≧3 days. Thirty-one (48%) of 64 children younger than 4 years of age but only (12%) of 43 in the older classes became ill (relative risk 4.0, P Escherichia coli 0157:H7 was detected in two of eight stool specimens from children who had bloody diarrhea (one with hemolytic uremic syndrome), two of seven with nonbloddy diarrhea, and none of nine who remained well. All three stool specimens obtained at ≦6 days compared with one of nine obtained at ≧6 days after onset yielded this organism (P E. coli 0157:H7 can cause hemolytic uremic syndrome and both nonbloody and bloody diarrhea, and can spread within families and through modes other than foodborne transmission.

Hypersensitivity reactions associated with botulinal antitoxin

During an 11-year period (1967 through 1977) CDC monitored reactions of hypersensitivity to botulinal antitoxin of equine origin. Of 268 persons given botulinal antitoxin, 24 (9.0 percent) had nonfatal acute (5.3 percent) or delayed (3.7 percent) hypersensitivity reactions to a skin test or therapeutic dose. The over-all rate of reaction did not differ with the age or sex of the recipient or with the type (AB or ABE) of antitoxin administered. Serum sickness occurred significantly more frequently in persons who received more than 40 ml of serum antitoxin (p < 0.02). The over-all reaction, rate was higher than that associated with other equine serum products and probably cannot be substantially reduced. This risk, however, would be substantially reduced if not eliminated by using botulinal immune globulin obtained from hyperimmunized human donors.

Screening for chronic hepatitis B and C virus infections in an urban sexually transmitted disease clinic: rationale for integrating services.

Background and Objectives Clients attending sexually transmitted disease (STD) clinics are at risk for multiple infections (e.g., STDs, HIV, and infectious viral hepatitis). Risk assessment and serosurveys can document the need for hepatitis screening and vaccination services. Goal To determine hepatitis C and B virus seroprevalence, identify predictive risk factors, and provide a rationale for integrating hepatitis services in an STD clinic. Methods During various periods in 1998, consecutive clients completed a self-administered risk assessment and were offered screening for markers of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection (HBV core antibody and anti-HCV [enzyme-linked immunosorbent assay 3.0, confirmed by recombinant immunoblot assay 2.0]). Results Sixteen percent of 300 clients tested for an anti-HBV core were positive, with injecting-drug users (IDUs) and men who have sex with men (MSM) having higher prevalences (50% and 37%, respectively). Of 615 clients tested for anti-HCV, 21 (3.4%) were positive. Injecting-drug users (n = 34) had a 38% anti-HCV prevalence compared with 1.1% for non-IDUs. Of 66 non-IDU MSM tested, none was HCV infected. IDUs had a high prevalence of past STDs (> 50%) and unsafe sexual behavior. Conclusions Injecting drug users and MSM are at high risk for STDs, HIV, and hepatitis infections and could benefit from a “one-stop” STD clinic that included hepatitis prevention services.

Screening High-Risk Adolescent Males for Chlamydia trachomatis Infection: Obtaining Urine Specimens in the Field

Background and Objectives: Reported case data suggest that few men are being tested for Chlamydia trachomatis (CT) infection (female:male reported case ratio is >5:1) partially because men seek preventive health services less frequently than women and, until recently, obtaining a CT specimen from men required a urethral swab, which has low patient acceptability. A study was conducted in San Diego, CA, to determine whether urine specimens could be obtained from high‐risk teen males in the field using a peer teen outreach approach. Goals: Identify teen males infected with CT and provide treatment and partner management services. Study Design: Prevalence survey of 261 teen males and a program cost evaluation. Results: During the 6.5‐month study period (Dec 15, 1995 to June 30, 1996) an estimated 1,860 teen males were approached and 261 submitted a urine specimen; 16 (6.1%) were positive by polymerase chain reaction. All positive males were treated with azithromycin, 1 gm, in the field, and 9 female sex partners were treated, 7 of whom were CT positive. The cost per specimen obtained and per CT infection identified was

Sexually transmitted disease clinic clients at risk for subsequent gonorrhea and chlamydia infections: possible 'core' transmitters.

103 and

An outbreak of furunculosis among high school athletes

1,677, respectively. The annual cost for adding a peer teen outreach service to an existing STD program using existing staff and adding 1.2 full‐time equivalents of outreach time is approximately

Prevalence of and Associated Risk Factors for Fluoroquinolone-Resistant Neisseria gonorrhoeae in California, 2000–2003

25,000. Conclusion: Peer teen outreach and in‐field collection of urine specimens appear to be an acceptable alternative for screening teen males for CT and should be further evaluated in other communities.

Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: Results from the San Diego viral hepatitis integration project

Background: From an sexually transmitted disease (STD) intervention perspective, developing a practical way to identify persons in core transmitter groups has been difficult. However, persons who have repeated STD infections may be in such groups. Goal: To evaluate a self‐administered risk assessment approach that would identify STD clinic clients who were at an increased risk of being involved in gonorrhea (GC) or chlamydia (CT) transmission in the subsequent year. Study Design: Prospective cohort of consecutive STD clinic clients with a 1‐year follow‐up period. Results: During a 6‐month period in 1995, 2576 STD clinic clients in San Diego completed a risk assessment. Of those clients, 204 (7.9%) had a subsequent STD and 79 (3.1%) had a subsequent GC or CT infection during the 1‐year follow‐up period. The strongest predictor of a subsequent GC/CT was having a recent history or current clinic visit diagnosis of GC or CT (6.1% subsequent GC/CT rate). The more past episodes of GC or CT, the higher the subsequent GC/CT rate. Unsafe sexual behavior had little effect on further increasing subsequent GC/CT risk. Conclusion: STD clinic clients with a recent history of GC or CT and a high risk of subsequent GC/CT may be core transmitters who could likely benefit from risk reduction, periodic screening for GC/CT, symptom recognition counseling, and preventive treatment‐the essential elements of STD‐prevention case management.

The syphilis epidemic in Connecticut: relationship to drug use and prostitution.

Furuncles (boils) are common among teenagers; how ever, few outbreaks have been documented. We inves tigated an outbreak of furuncles that occurred among male athletes of a Kentucky high school during the 1986 to 1987 school year. The overall attack rate was 25% (31/124). The risk of developing a furuncle in creased two to three times in those who had skin injury. Athletes who sustained abrasions more than twice per week ( P < 0.01), who had a cut that required bandaging (P = 0.01), or had an unspecified injury causing a missed practice or game (P = 0.04) were at increased risk. The risk of developing furunculosis did not appear to be related to contact with fomites, but rather, to contact with furuncles. Although athletes shared com mon areas (showers, locker rooms, practice areas), the attack rates for varsity football (36%) and varsity bas ketball (33%) were four times greater than for nonvars ity teams (P < 0.01). Players who had a friend with a furuncle were more than twice as likely to also have had a furuncle (P < 0.01). Exposure to furuncles ap peared to increase the risk of furunculosis independ ently of reported skin injury. Control and prevention should, therefore, focus on both reducing skin injury and reducing exposure to furuncles, rather than at tempting to sterilize inanimate objects.

Syphilis in San Diego County 1983–1992: Crack Cocaine, Prostitution, and the Limitations of Partner Notification

BACKGROUND Rates of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) are increasing worldwide and in California. METHODS As a supplement to established surveillance, the investigation of QRNG in California included expanded surveillance in southern California, with in-depth interviews of patients (who had QRNG during the period of January 2001-June 2002) and a cross-sectional study of patients at 4 sexually transmitted diseases clinics with gonococcal isolates that underwent susceptibility testing (for the period of July 2001-June 2002). RESULTS The rate of QRNG increased from <1% in 1999 to 20.2% in the second half of 2003. The 2001-2002 expanded surveillance demonstrated that 66 (4.9%) of 1355 isolates were resistant to fluoroquinolones; the majority of these infections occurred after August 2001. Cross-sectional analysis of 952 patients with gonorrhea revealed that the prevalence of QRNG varied geographically during 2001-2002, with the highest rate being in southern California (8.9%) and the lowest being in San Francisco (3.6%). The QRNG prevalence was 8.6% among men who have sex with men (MSM), 5.1% among heterosexual men, and 4.3% among women. Although risk factors for QRNG varied by clinic, multivariate analysis demonstrated independent associations with race/ethnicity, recent antibiotic use, and MSM. CONCLUSIONS The emergence and spread of QRNG in California appeared to evolve from sporadic importation to endemic transmission among both MSM and heterosexuals. Monitoring of both the prevalence of and risk factors for QRNG infections is critical for making treatment recommendations and for developing interventions to interrupt transmission.