Investigation of an epidemic of invasive aspergillosis: utility of molecular typing with the use of random amplified polymorphic DNA probes.

When seven immunocompromised patients developed invasive aspergillosis during construction at a hospital, new methods were performed to compare fungal isolates and a case-control study was conducted to determine risks for infection. Typing of Aspergillus flavus with the use of restriction endonuclease analysis and restriction fragment length polymorphism using random amplified polymorphic DNA reactions to generate DNA probes revealed different patterns between isolates from two patients and a similar pattern among those from one patient, a health care worker, and an environmental source. Case patients were more likely than controls to have longer periods of hospitalization (median, 83 vs. 24 days; P < 0.01), neutropenia (median, 33 vs. 6 days; P < 0.05), and exposure to broad spectrum antimicrobials (median, 56 vs. 15 days; P = 0.08). No patients restricted to protected areas developed aspergillosis. Risk of exposure of immunocompromised patients to opportunistic organisms stirred up by construction activity may be decreased by admitting these patients to protected areas away from construction activity and by restricting traffic from construction sites to these areas. Although typing of A. flavus isolates did not reveal a single type or source of organism responsible for infection, this method may facilitate epidemiologic investigation of possible nosocomial sources and transmission in similar settings.

Applied epidemiology for the 21st Century.

BACKGROUND: Critics argue that the modern epidemiologist seems more concerned with intricately modelling complex relationships among risk factors than understanding their origins and their implications for public health. Indeed, some contend that epidemiology has reached its limits as a discipline. To address such concerns, alternatives have been proposed that integrate biological, analytical, and social approaches to epidemiological practice and training. METHODS: The published literature was reviewed to examine critical issues in current epidemiological practice and training. In addition, we reviewed records of training programmes in applied epidemiology established in 20 countries. RESULTS: We describe an existing approach to preparing epidemiologists for the emerging challenges of public health in which epidemiological research and practice are applied toward the end of improving public health and health care. Training in applied epidemiology is based on a philosophy of 'learning while doing'. Under the supervision of an experienced epidemiologist, trainees conduct field investigations, analyse large data bases, evaluate surveillance systems, publish and present scientific research, and respond to public enquiries. More than 3000 people have received intensive formal training over the past 50 years in programmes in more than 20 countries; most graduates continued to use the tools of applied epidemiology in their work. CONCLUSION: Training in applied epidemiology anchors the discipline in population-based, relevant public health practice.

Epidemic keratoconjunctivitis in a chronic care facility: risk factors and measures for control.

OBJECTIVE: To study patterns of transmission of epidemic keratoconjunctivitis (EKC) in a chronic care facility and to assess control measures and prevent future outbreaks in this setting. DESIGN: A retrospective cohort study. SETTING: A 120-bed, four-unit, skilled nursing facility. PATIENTS: Residents and employees of the above facility. INTERVENTIONS: Increased frequency of cleaning; use of bleach disinfectant; universal precautions in handling eye secretions from residents with conjunctivitis; cohorting residents by unit; suspension of new admissions; closure of common gathering areas. MEASUREMENTS: Resident demographics; possible risk factors for infection among residents (including mobility, underlying illness, medications, involvement in social activity, level of confusion) and among employees (including co-morbid illnesses and eye conditions, exposures to persons with conjunctivitis, visits to eye care specialists, use of contact lenses or glasses); testing of conjunctival specimens from symptomatic persons for viral and bacterial agents. RESULTS: Of 95 residents on three chronic care units, 47 (attack rate 49%) had onset of eye symptoms consistent with EKC between September 14 and December 7, 1990. Thirty-eight (81%) of these had onset following the onset of symptoms in a resident with dementia who, despite habitual eye-rubbing and wandering into other residents' rooms, was not isolated or restricted in any way. Attack rates were higher (though not statistically significant) among more mobile residents (60% for ambulatory residents) and among those considered by staff to be confused (56%). Rapid antigen detection and culture confirmed adenovirus type 37 as the etiologic agent. CONCLUSIONS: Transmission of infection with adenovirus type 37 was successfully interrupted following strict infection control, suspension of new admissions, cohorting of residents by unit, and change to a disinfectant that inactivates adenovirus. Recognition of conjunctivitis as an appropriate reason for restricting movement of an infected resident may have prevented extensive viral transmission in this outbreak.

Nonmedical doctoral-level scientists in the Centers for Disease Control and Prevention's Epidemic Intelligence Service, 1964-1997.

INTRODUCTION: Although historically a training program in applied epidemiology for physicians, veterinarians, and dentists, CDC's Epidemic Intelligence Service (EIS) has been attracting an increasing number of other doctoral-level scientists with prior experience and training in advanced analytic methods. METHODS: Using data from alumni records, we studied the participation of these nonmedical scientists in the EIS program and their subsequent employment. RESULTS: 160 nonmedical doctoral level scientists enrolled in EIS from 1964 through 1997; 135 had completed EIS as of July 1997. Of 160 enrolled, 94 (59%) had an advanced degree in epidemiology; other degrees included demography, anthropology, behavioral sciences, statistics, and other health areas; 66% were women. Most (112; 70%) were assigned to work in noninfectious disease areas. After completion of EIS, 113 (84%) of 135 officers continued to work in public health activities: 75 (56%) remained employed at CDC; 17 (13%) in academic institutions; 14 (10%) in local or state health departments; 3 (2%) in international health agencies; 2 (1%) in other federal health agencies; and 2 (1%) in public health foundations. Compared with trainees recruited during 1964-1989, greater proportions of those recruited during 1990-1995 remained employed at CDC (44/74 [59%] versus 31/61 [51%]) or at state or local health departments (10 [14%] versus 4 [7%]). Those training during EIS at a state or local health department (15/20, 75%) or in occupational health (17/24, 71%) were more likely than those in other assignments to work outside CDC following EIS. CONCLUSION: There is increasing participation and collaboration of persons trained in nonmedical sciences with those trained in traditional medical areas in the EIS training program and in careers in public health at all levels: local, state, and federal.

An elective rotation in applied epidemiology with the Centers for Disease Control and Prevention (CDC), 1975-1997.

INTRODUCTION: To increase awareness of and interest in public health and epidemiology, CDC initiated an elective in epidemiology and public health for senior medical students in 1975 and for veterinary students in 1982. METHODS: A review of CDC records to describe participation in the elective, to assess whether students subsequently enrolled in another CDC training program, the Epidemic Intelligence Service (EIS), and, if enrolled, employment status following EIS. A review of documentation of board certification in preventive medicine to determine how many participants later chose this specialty, one indicator of public health and prevention as a career choice. RESULTS: From 1975 through 1997, 632 students participated in the elective. Of these, 438 (69%) were assigned to infectious disease areas, 95 (15%) to environmental health, 59 (9%) to chronic disease, and 40 (7%) to other areas. Students participated in at least 278 official investigations of important public health problems including infectious disease outbreaks, natural disasters, chronic disease problems and access to health care. Of 530 students who had completed the elective through June 1995, 91 (17%) were enrolled in EIS by July 1997. Of 83 completing EIS by July 1997, 65 (78%) had continued in public health careers: 35 with CDC; 17 with local or state health departments; 7 with other federal agencies; 4 in academic public health; and 2 in international health. Of those not enrolling in EIS, at least 5% were certified by the American Board of Preventive Medicine, compared with 34% of those completing EIS. CONCLUSION: An elective rotation in public health and applied epidemiology is valuable in introducing future physicians and veterinarians to the practice of public health, and can provide important role models for encouragement to pursue careers in public health.

An investigation of the relationship between psychopathic traits and malingering on the psychopathic personality inventory.

This study employed a repeated-measures simulation design to examine (a) the specific effects of malingering on a recently developed measure of psychopathy, the Psychopathic Personality Inventory (PPI), and (b) the broader association between psychopathic traits and dissimulation. One hundred and forty-three participants completed the PPI twice (both under standard instructions and with instructions to feign psychosis), and also completed post-test questionnaires assessing their attitudes toward engaging in malingering across several hypothetical settings. When attempting to feign psychosis, participants produced elevated scores on a validity scale designed to identify deviant responding, and use of a cross-validated cutoff score with this scale produced high sensitivity and specificity rates across the honest and malingering conditions. Furthermore, PPI scores (in the honest condition) were significantly correlated with a willingness to engage in dissimulation across various hypothetical forensic/correctional scenarios. Results are discussed in terms of the "fakability" of the PPI, as well as the relationship between psychopathic personality features and malingering more generally.

Achievable influenza immunization rates in the elderly.

We sought to determine achievable rates of influenza immunization in a large internal medicine practice in which free vaccination was vigorously promoted. A list of 1,230 patients over 65 years of age constituted the target population. Seven hundred ninety patients (64%) were immunized in the office from September to December 1989. In early 1990, questionnaires were sent to 67 patients who had refused vaccination and to an equal number of age- and sex-matched controls who had either accepted the vaccine or whose immunization status was unknown. Seventy-four percent returned the questionnaires. Of the 67 unimmunized patients, 39 (53%) reported that they might be persuaded to accept immunization, whereas 22 (33%) said that nothing could convince them to be immunized. When we added persons who might accept influenza vaccine and persons who had received the vaccine in public clinics to the total number of patients immunized in the office setting, we reached a total of 1,059 patients (86.1% of the total), which we would propose as the maximal achievable immunization rate in this setting.

Resolution of sick building syndrome in a high-security facility.

The main objective of this article is to serve as a case study for other industrial hygiene (IH) professionals' review as a "real world" effort in responding to a facility perceived as "sick" by its occupants. As many industrial hygienists do not have extensive backgrounds in evaluating microbial air contaminants or the mechanical function of building HVAC units, the overall intent is to provide "lessons learned" to IH generalists who may be asked to participate in indoor environmental quality (IEQ) surveys. In September 1994, a suspected case of "sick building syndrome" was investigated (with significant airborne fungal loads confirmed) at a communications center after numerous occupants reported upper respiratory disease and/or allergy-type symptoms. The setting was a two-story structure approximately 30 years old, with a normal occupancy load of 350 to 400 persons. In addition to continual structural modifications, the central HVAC air conditioning systems had poor maintenance histories. Inspection of HVAC components revealed visible fungal growth on air filters and air ducts and in cooling fan condensate drip pans. Fungal air samples were collected with an Anderson N6 air sampler and Sabouraund dextrose agar media. Over a study period of 23 months, three rounds of 26 air samples were collected for 5 minutes each at 28.3 liters/minute airflow. Cultures exhibited fungi such as Aspergillus, Penicillium, Alternaria, and Cladosporium. Certain strains of these fungi produce mycotoxins that may cause a variety of deleterious health effects such as those described by occupants. Initial 1994 airborne fungal concentrations ranged from 85 to 6157 colony forming units (CFUs) per cubic meter of sampled air (CFU/m3). Some investigators have reported fungal concentrations as low as 245 CFU/m3 associated with complaint sites in other buildings. Remediation efforts involved hiring a dedicated mechanic to implement a HVAC preventive maintenance program (including regular replacement of all HVAC air filters and cleaning of accessible components with water/bleach solution). Post-abatement January 1996 re-sampling revealed a significant drop in airborne fungal colonies up to 97 percent (range = 21 to 1092 CFUs/m3)--which also coincided with physicians at the local hospital sensing a qualitative reduction in patient visits from facility workers. To address seasonal bias, a final August 1996 air sample round revealed a range of 14 to 500 CFUs/m3. Of the 21 workspaces sampled in all three rounds, nine continued to show a decline in CFUs/m3 from September 1994 baseline counts. These results demonstrate the critical role of an ongoing HVAC maintenance program for reducing potential reservoirs of fungal organisms in indoor work environments. Building renovations (especially those involving major changes to building layout and usage) can adversely affect IEQ if plans do not include coordinated updates and regular preventive maintenance of HVAC systems. Eventual negative outcomes can be reduced occupant productivity and deleterious health effects.

A target-based model for increasing influenza immunizations in private practice. Genesee Hospital Medical Staff.

OBJECTIVE: To measure the impact of a population-based tracking system on influenza immunization rates. DESIGN: Thirteen practices with 45 physicians were randomized to a control and two intervention groups. SETTING: Private practices. PATIENTS: All patients aged 65 years and over who were seen in participating physicians' practices within the preceding two years. INTERVENTION: In both intervention groups influenza immunization rates for physicians were recorded weekly as cumulative percentages of their target populations, using a specially prepared poster. In addition, postcard reminders were sent to all the patients in one of the intervention groups. MEASUREMENTS AND MAIN RESULTS: Immunization rates in the two intervention groups were 30% higher than in the control group; the control group immunized 50% (2,405/4,772) of its target population, while the poster and poster/postcard groups immunized 66% (1,420/2,149) and 67% (2,427/3,604), respectively. CONCLUSION: A population-based strategy that monitors performance can significantly improve rates of influenza immunization in private practices.

Pneumococcal bacteremia in Monroe County, New York.

OBJECTIVES: Knowledge of the epidemiology of pneumococcal disease is critical for public health planning, evaluation of preventive strategies, and development of immunization recommendations. METHODS: We studied the incidence and case-fatality rates of pneumococcal bacteremia as a proxy for pneumococcal disease in Monroe County, New York, from 1985 through 1989 by reviewing the laboratory and clinical care records of all cases occurring among residents. RESULTS: There were 671 cases identified, for an overall yearly rate of 18.8 per 100,000. The rates were highest in the very young, in the very old, and in non-White populations. Age-specific rates were consistently higher in Blacks than in Whites. Predisposing medical conditions were present in 61% of cases. Case-fatality rates were 15% overall, 27% in those with predisposing medical conditions, and approximately 30% in Blacks older than 55 years and Whites older than 65 years. CONCLUSIONS: This study documents the incidence of and mortality from pneumococcal bacteremia. It supports previous observations that Black populations have an increased risk of invasive pneumococcal infection and suggests that immunization should be considered for Blacks older than 55 years.

Do family physicians make good sentinels for influenza?

OBJECTIVE: To determine whether volunteer family physician reports of the frequency of influenza-like illness (ILI) usefully supplement information from other influenza surveillance systems conducted by the Centers for Disease Control and Prevention. DESIGN: Evaluation of physician reports from five influenza surveillance seasons (1987-88 through 1991-92). SETTING: Family physician office practices in all regions of the United States. PARTICIPANTS: An average of 140 physicians during each of five influenza seasons. INTERVENTIONS: None. OUTCOME MEASURES: An office visit or hospitalization of a patient for ILI, defined as presence of fever (temperature > or = 37.8 degrees C) and cough, sore throat, or myalgia, along with the physician's clinical judgment of influenza. A subset of physicians collected specimens for confirmation of influenza virus by culture. RESULTS: Physicians attributed 81,408 (5%) of 1,672,542 office visits to ILI; 2754 (3%) patients with ILI were hospitalized. Persons 65 years of age and older accounted for 11% of visits for ILI and 43% of hospitalizations for ILI. In three of five seasons, physicians obtained influenza virus isolates from a greater proportion of specimens compared with those processed by World Health Organization laboratories (36% vs 12%). Influenza virus isolates from sentinel physicians peaked from 1 to 4 weeks earlier than those reported by World Health Organization laboratories. Physicians reported peak morbidity 1 to 4 weeks earlier than state and territorial health departments in four of five seasons and 2 to 5 weeks earlier than peak mortality reported by 121 cities during seasons with excess mortality associated with pneumonia and influenza. CONCLUSIONS: Family physicians provide sensitive, timely, and accurate community influenza morbidity data that complement data from other surveillance systems. This information enables monitoring of the type, timing, and intensity of influenza activity and can help health care workers implement prevention or control measures.

Morphology and ultrastructure of fungi in extended-wear soft contact lenses.

Filamentous fungi of the genera Acremonium, Aspergillus, Alternaria, Cladosporium, Curvularia, and Fusarium penetrated the matrix of soft contact lenses both during normal usage and in laboratory studies. Growth of the fungi within the lens matrix increased with increasing water content of the lens. Hyphae within the lens were coiled. Some species penetrated completely through the lens within 96 h. More frequent cleaning and disinfection of extended-wear soft contact lenses is recommended.

Effects of positive impression management on the Psychopathic Personality Inventory.

The Psychopathic Personality Inventory (PPI; S. O. Lilienfeld & B. P. Andrews, 1996) is a self-report test that has shown considerable promise as a screening measure for psychopathy. A current limitation of the PPI is that no data exist regarding the impact of response sets such as positive impression management. Although the PPI contains a validity scale (Unlikely Virtues) designed to identify response biases such as "faking good," its utility has not yet been assessed. In this study a repeated measures analogue design was employed in which 186 respondents completed the PPI both under standard conditions and with specific instructions to create a favorable impression of themselves. In the "fake good" condition, participants were able to appear significantly less psychopathic, with those who obtained higher scores in the standard instruction condition showing the largest decreases in their PPI scores. Receiver Operating Characteristic analyses indicated that, although the Unlikely Virtues scale significantly differentiated between "fake good" and honest protocols (area under the curve = .73), a considerable number of misclassifications occurred. The clinical and forensic implications of these findings are discussed.

Factors differentiating successful versus unsuccessful malingerers.

Relatively little is known about the processes in which "successful" malingerers engage to avoid detection. This study summarizes the response strategies used by participants (N = 540) instructed to feign a specific mental disorder while completing various self-report instruments designed to detect faking. Postexperiment questionnaires indicated that those who were able to appear symptomatic while avoiding being detected as feigning (n = 60) were more likely to endorse a lower rate of legitimate symptoms, to avoid overly unusual or bizarre items, and to base their responses on their own personal experiences.

Multiple unconfirmed-reactive screening tests for viral antibodies among blood donors.

BACKGROUND: In December 1991, the United States Food and Drug Administration received reports of blood donations with unconfirmed reactivity on screening tests for antibodies to human immunodeficiency virus, human T-lymphotropic virus type I, and hepatitis C virus (HCV). Of 91 donors with these test results, 57 (63%) reported a recent influenza vaccination. STUDY DESIGN AND METHODS: To determine the extent of unconfirmed reactivity, the time at which it began, and its association or nonassociation with specific manufacturers' tests, a nationwide survey of blood centers was conducted. A case-donation was defined as a blood donation that was repeatedly reactive, but not confirmed positive, on at least two of the three tests from May 1990 through December 1991. RESULTS: Among 14 million donations screened by 110 centers, 582 case-donations were identified. An increase in case-donations was evident in the fall of 1990 (2.8/100,000 donations). In 1991, rates increased from 0.9 per 100,000 donations in the first quarter to 1.3, 3.2, and 19.7 in subsequent quarters. A significantly higher rate of case-donations was observed among donations tested with one of the two available anti-HCV screening tests (8.0 vs. 1.2/100,000 donations; risk ratio = 6.8; 95% CI = 5.4-8.5). CONCLUSION: Although unconfirmed reactivity on multiple screening tests appeared to be seasonal, its documentation prior to the availability of influenza vaccine in 1991 and higher rates among donations tested with one manufacturer's anti-HCV test indicated that test-specific factors were also involved.

Multiple false reactions in viral antibody screening assays after influenza vaccination.

In December 1991, US blood centers reported an unusual increase in donations that tested falsely reactive for antibodies to two or more (multiple false positive) of the following viruses: human immunodeficiency virus type 1 (HIV-1), human T-cell lymphotrophic virus type I (HTLV-I), and hepatitis C virus. Many of these donations were from people who had recently received the 1991-1992 influenza vaccine, raising the possibility that this vaccine had somehow specifically caused the problem of multiple false reactivity. A case-control study of 101 affected donors and 191 matched controls found that recent receipt of any brand of influenza vaccine was significantly associated with testing multiple false positive (p < 0.05), as was a history of recent acute illness (p < 0.05) and of allergies (p < 0.05). Surveillance for monthly rates of multiple reactive donations from May 1990 through December 1992 linked the seasonal cluster of multiple false-positive donations to the use of viral screening test kits thought to react nonspecifically to donor immunoglobulin M. There was no similar increase in multiple false-positive donations during the 1992-1993 influenza vaccination season after the HIV-1 and hepatitis C virus tests were replaced; however, the number of donations that were falsely reactive for only HTLV-I almost doubled, indicating that false reactivity was not specifically associated with the 1991-1992 influenza vaccine. Retesting of affected donors found that the duration of HTLV-I and hepatitis C virus false reactivity was 3-6 months. The cluster of multiple false-positive donations in 1991 was most likely caused by the test kits used, rather than by the influenza vaccine.

Ebola hemorrhagic fever, Kikwit, Democratic Republic of the Congo, 1995: risk factors for patients without a reported exposure.

In 1995, 316 people became ill with Ebola hemorrhagic fever (EHF) in Kikwit, Democratic Republic of the Congo. The exposure source was not reported for 55 patients (17%) at the start of this investigation, and it remained unknown for 12 patients after extensive epidemiologic evaluation. Both admission to a hospital and visiting a person with fever and bleeding were risk factors associated with infection. Nineteen patients appeared to have been exposed while visiting someone with suspected EHF, although they did not provide care. Fourteen of the 19 reported touching the patient with suspected EHF; 5 reported that they had no physical contact. Although close contact while caring for an infected person was probably the major route of transmission in this and previous EHF outbreaks, the virus may have been transmitted by touch, droplet, airborne particle, or fomite; thus, expansion of the use of barrier techniques to include casual contacts might prevent or mitigate future epidemics.