Robert H. Hutcheson

Ehrlichiosis in a Golf-Oriented Retirement Community

BACKGROUND Ehrlichiosis due to Ehrlichia chaffeensis usually occurs sporadically or in small clusters, with an annual incidence estimated at 3 to 5 cases per 100,000 population in areas of endemic disease. The putative principal vector is the Lone Star tick (Amblyomma americanum). We investigated an outbreak of ehrlichiosis that occurred in June 1993 among members of a golf-oriented retirement community (community A) in Tennessee. The community is densely wooded and borders a wildlife-management area where deer are numerous. METHODS We conducted a case-control study, using medical-history reviews, serologic testing, and testing with the polymerase chain reaction for E. chaffeensis infection. We also surveyed a sample of 10 percent of the households in community A and in another golf-oriented community (community B) more than 20 miles (32 km) from the wildlife-management area. Survey participants completed a questionnaire and provided specimens for serologic testing. In both communities, searches for ticks were undertaken. RESULTS Eleven cases of symptomatic ehrlichiosis were identified in the case-control study, 10 of which were in community A (attack rate, 330 per 100,000). Of 311 surveyed residents of community A, 12.5 percent had serologic evidence of past E. chaffeensis infection, as compared with 3.3 percent of 92 in community B (relative risk in community A as compared with community B, 3.9; 95 percent confidence interval, 1.2 to 12.2). The risk of infection was associated with tick bites, exposure to wildlife, golfing, and among golfers, retrieving lost golf balls from the rough. Persons who never used insect repellent were more likely to have had infection than persons who did. In community A, thousands of Lone Star ticks were found; in community B, only three ticks were found. CONCLUSIONS The high rate of E. chaffeensis infection in community A resulted from its proximity to a wildlife reserve. When outdoor recreational activities are common and concentrations of ticks are high, outbreaks of arthropod-borne zoonoses can be anticipated.

NOSOCOMIAL TRANSMISSION OF SALMONELLA GASTROENTERITIS TO LAUNDRY WORKERS IN A NURSING HOME

BACKGROUND Outbreaks of salmonella gastroenteritis in nursing homes are common. Person-to-person transmission to nursing home personnel occurs occasionally, but infection of laundry staff as a result of handling soiled linen rarely has been reported. OBJECTIVE To examine the nosocomial transmission of infection to laundry staff during an outbreak of salmonellosis in a nursing home. SETTING A 250-bed nursing home in a rural Tennessee county. METHODS Residents and staff of the nursing home were interviewed and cultures of stool samples examined for enteric pathogens. RESULTS Stool cultures from 32 residents and 8 employees were positive for Salmonella hadar. Infection among the residents was food-borne, but infection among employees likely represented secondary transmission, as none of the employees ate food prepared in the kitchen and their onset of symptoms occurred seven to 10 days after that of ill residents. Three laundry personnel who had no contact with residents were infected. Most of the ill residents (81%) were incontinent, which led to an increase in both the degree of fecal soiling and the amount of soiled linen received by the laundry during the outbreak. Laundry personnel regularly ate in the laundry room, did not wear protective clothing, and did not wear gloves consistently while handling soiled laundry. CONCLUSIONS This investigation implicates linen soiled with feces as the source of nosocomial S hadar infection in laundry workers and underscores the importance of using appropriate precautions when handling linen.

Salmonella enteritidis Gastroenteritis Transmitted by Intact Chicken Eggs

OBJECTIVE To determine the source and to describe the clinical importance of a large outbreak of Salmonella enteritidis gastroenteritis in Tennessee, which is outside the geographic focus of the S. enteritidis pandemic. DESIGN A case-control study and tracing of the source eggs. SETTING A Tennessee community and a large layer farm in Indiana. PATIENTS Case patients ate at the implicated restaurant and subsequently developed S. enteritidis gastroenteritis; controls ate with the case patients, but did not develop gastroenteritis. MEASUREMENTS Eighty-one case patients were identified; 73 (90%) had eaten egg-containing sauces at a local restaurant on a given evening. The eggs were traced to their farm of origin in Indiana. The farm was inspected 5 weeks after the outbreak. MAIN RESULTS Of 24 patients with culture-proved cases, 11 were hospitalized. Hollandaise and bernaise sauces prepared with intact, extra-large, grade-A eggs were strongly associated with illness (P less than 0.001). Salmonella enteritidis was isolated from specimens collected from chickens and the farm. Antimicrobial susceptibility patterns, phage typing, and plasmid profiles of isolates from the farm and from patients were indistinguishable. CONCLUSIONS Salmonella enteritidis infection is a large and growing public health problem that is spreading beyond the northeastern United States. This study shows a direct link between infected poultry flocks and an outbreak of human illness.

Acute histoplasmosis: Clinical, epidemiologic and serologic findings of an outbreak associated with exposure to a fallen tree

Abstract An outbreak of acute histoplasmosis occurred among 42 people who gathered for two days in May 1977 to cut and clear a fallen oak tree near Nashville (Williamson County), Tennessee. Thirty-two (76 per cent) of the participants had serologic evidence of infection; 20 (48 per cent) had acute pulmonary disease and of these, three required hospitalization. Frequent symptoms of acute pulmonary disease included fever, malaise, chest pain, headache, cough, myalgia, weight loss (≥ 5 pounds) and stomach cramps. Chest roentgenograms revealed abnormalities in 87 per cent of the ill participants. The disease developed in two dogs that were also present at the activities. Illness began an average of 14 days after exposure. Risk of illness was associated with sawing the tree, and loading wood and bark into a truck, as well as the length of the time spent near the tree. Tests for fungal antibodies in serum obtained from the participants and community controls, (those who lived in the county but did not have symptoms of respiratory illness) were used to establish criteria for serologic diagnosis. Immunodiffusion tests with initial serum samples were most useful for diagnosis; the presence of an M precipitin band was 75 per cent sensitive and was 97 per cent specific as judged by data from community controls. Similarly, the mycelial form antigen Histoplasma capsulatum complement fixation test at a titer ≥ 1:8 was 55 per cent sensitive and 97 per cent specific, and the yeast-form antigen complement fixation test at a titer of ⩾ 1:16 was 75 per cent sensitive and 77 per cent specific. When serum obtained four weeks after exposure (one to two weeks after onset of symptoms) was compared with serum obtained eight weeks after exposure, a fourfold increase in complement fixation antibodies was detected in 28 per cent of those infected.

Outbreak of acute pulmonary hîstoplasmosis in members of a wagon train.

In August 1980, an outbreak of acute pulmonary histoplasmosis occurred among participants in a wagon train as it traveled through eastern Tennessee. Of the 85 people on the train 69 (81 percent) had evidence of infection with Histoplasma capsulatum. Fifty-four people had symptomatic disease. The source of infection was traced to the site of a former winter blackbird roost in Charleston, Tennessee, that had been partially cleared five years earlier to make a park. Fourteen of 25 soil samples from this site were culture-positive for H. capsulatum. This is the first reported outbreak to involve a large migrant group. The outbreak is unusual in that exposure occurred without excavation, construction or tree-cutting at the site.

Rubella among the amish : resurgent disease in a highly susceptible community

Although the Amish make up less than 0.05% of the United States population, nearly all rubella reported in the United States in 1991 occurred in this population. In early 1991 a large rubella outbreak in a Tennessee Amish community that had experienced no rubella for 17 years afforded an opportunity to describe the epidemiology of rubella in this unique population. Structured interviews were conducted with 54 Amish families. Of 383 persons in the sample 85 (22%) had rubella. Illnesses were mild; 16% of cases lacked fever and 20% of cases reported no symptoms except rash. Children < 17 years of age were 7 times more likely than older individuals to be affected (77 of 214 vs. 8 of 165). All pregnant women in the community were > 20 years of age; none developed rubella. No congenital rubella syndrome was recognized. Although rubella is increasingly a disease of adolescents and young adults, in this outbreak, rubella was again a childhood disease. Illness in this community-based investigation was mild; rubella may be difficult to diagnose and report. Immunity after remote natural infection was durable since the communitys last outbreak. Pregnant women probably were protected by the age distribution of immunity; this age distribution may not occur in other Amish populations. If preventable morbidity from rubella and other vaccine preventable diseases is to be avoided in this group, increased attention should be directed to encouraging vaccinations among Amish persons.

Statewide survey of the antimicrobial susceptibilities of Haemophilus influenzae producing invasive disease in Tennessee.

Between October 1, 1980, and September 30, 1981, a prospective statewide study of Haemophilus influenzae infections identified 220 culture-proved systemic infections. Of these, 92% were caused by H. influenzae type b. Antimicrobial susceptibility testing of the type b isolates showed that 17% were resistant to ampicillin, but virtually all were susceptible to chloramphenicol, trimethoprim-sulfamethoxazole, cefaclor and rifampin. Ampicillin resistance is common in all parts of Tennessee and chloramphenicol remains the drug of choice for initial therapy of systemic H. influenzae infections.

A statewide characterization of hospital infection control practices and practitioners.

Selected features of infection control programs among the 163 general hospitals in Tennessee were surveyed in 1976 and 1979. Each hospital but one had a designated infection control practitioner. Three-fourths of the hospitals had fewer than 200 beds and most were in rural areas. The practitioners in these small hospitals worked in an isolated professional milieu: few (4%) had attended a basic training course or were members of a national (11%) or local (16%) infection control association. They also had significantly less access to standard infection control resource publications than did practitioners in large hospitals. Use of aqueous quaternary ammonium compounds for disinfection was reported by 37% of all hospitals in 1979; 68% of hospitals routinely performed bacteriologic cultures of personnel or the environment. In contrast, only 3% of hospitals did not have a policy specifying the use of sterile closed-system drainage of indwelling bladder catheters. Although these practices varied somewhat by hospital size, the differences were not statistically significant. Modest improvement in each parameter was noted since 1976. Pathology was the most common medical specialty (34%) among chairman of infection control committees; internal medicine and pediatrics accounted for only 13%. The practice of routine microbiologic monitoring was significantly more common among hospitals with chairmen who were pathologists. The implications of these findings for national priorities in hospital infection control are discussed.