Missed opportunities for tuberculosis prevention.

BACKGROUND: With the recent resurgence of tuberculosis in the United States, it is unclear whether existing prevention strategies can successfully control and eliminate the disease. We determined the extent to which opportunities for prevention were missed among patients with tuberculosis. METHODS: For all patients with active tuberculosis reported to the Oregon Health Division, Portland, from July 1991 through June 1992, we determined previous history of tuberculosis therapy, previous tuberculin skin test status, the presence of medical conditions for which skin testing is recommended, and previous health care. We then determined whether they had undergone preventive procedures in accordance with current recommendations of the Advisory Council for the Elimination of Tuberculosis. RESULTS: Of 153 patients with active tuberculosis, 90 (59%) had indications for--but had not previously undergone--recommended procedures. Ten patients (7%) did not complete therapy for previous disease; two (1%) did not complete preventive therapy; 12 (8%) with known previous positive tuberculin skin tests and an indication for preventive therapy never received it; and 66 (43%) with known indications for screening never received a skin test. Indications for skin testing included exposure to active tuberculosis (44%), predisposing medical conditions (83%), previous residence in an institution (24%), and birth in a country with a high prevalence of tuberculosis (29%). CONCLUSIONS: Based on their known effectiveness, a major reduction in tuberculosis morbidity could occur if preventive measures were fully implemented. Appropriate skin testing is a prevention strategy of major importance. Priorities should include working to change provider practice to better ensure that persons with indications routinely receive tuberculin skin tests.

Where's the beef? The role of cross-contamination in 4 chain restaurant-associated outbreaks of Escherichia coli O157:H7 in the Pacific Northwest.

BACKGROUND: From March through August 1993, outbreaks of Escherichia coli O157:H7 occurred at 4 separate Oregon and Washington steak and salad bar restaurants affiliated with a single national chain. OBJECTIVE: To determine the cause of outbreaks of E coli O157:H7 at 4 chain restaurants. METHODS: Independent case-control studies were performed for each outbreak. Available E coli O157:H7 isolates were subtyped by pulse-field gel electrophoresis and by phage typing. RESULTS: Infection was not associated with beef consumption at any of the restaurants. Implicated foods varied by restaurant but all were items served at the salad bar. Among the salad bar items, no single item was implicated in all outbreaks, and no single item seemed to explain most of the cases at any individual restaurant. Molecular subtyping of bacterial isolates indicated that the first 2 outbreaks, which occurred concurrently, were caused by the same strain, the third outbreak was caused by a unique strain, and the fourth was multiclonal. CONCLUSIONS: Independent events of cross-contamination from beef within the restaurant kitchens, where meats and multiple salad bar items were prepared, were the likely cause of these outbreaks. Meat can be a source of E coli O157:H7 infection even if it is later cooked properly, underscoring the need for meticulous food handling at all stages of preparation.

Childhood upper respiratory tract infections: to what degree is incidence affected by day-care attendance?

Risk factors for acute upper respiratory tract disease in childhood were evaluated in a population-based sample of the Atlanta metropolitan area. Mothers from 449 households containing 575 children less than 5 years of age were selected by random-digit dialing and questioned about upper respiratory tract infection and ear infection occurring in their children during the preceding 2 weeks. Household demographic and socioeconomic characteristics, maternal smoking history and child day-care attendance and breast-feeding information were also obtained. For children less than 5 years of age, the reported incidence of upper respiratory tract infection was 24%, and of ear infection, 6%. Controlling for the other variables measured, day-care attendance was associated with a significantly increased risk of both illnesses. For upper respiratory tract infection, increased risk was present for all children attending day care (P = .02, odds ratio = 1.6), whereas for ear infection, risk could be demonstrated only for full-time attendees (P = .005, odds ratio = 3.8). Maternal smoking was a second independent risk factor for a child's having upper respiratory tract infection (odds ratio = 1.7, P = .01). Thirty-one percent of all upper respiratory tract infection among day-care attendees and 66% of all ear infections among full-time day-care attendees were attributable to day-care attendance. Given the proportion of children in day care, 9% to 14% of the total burden of upper respiratory tract disease in this population was day care related.(ABSTRACT TRUNCATED AT 250 WORDS)

An evaluation of measles revaccination among school-entry-aged children.

BACKGROUND: A two dose measles vaccination schedule is recommended routinely for all school-entry-aged children. We evaluated this recommendation by determining both measles antibody seroprevalence and the response to revaccination in seronegative children in this age group. METHODS: Children 4 to 6 years of age who had received a single dose of measles vaccine between the ages of 15 to 17 months were tested for measles antibody by using enzyme-linked immunosorbent assay (ELISA) microneutralization technique. Seronegative children were revaccinated and again tested for measles antibody (immunoglobulin M [IgM] and neutralizing). RESULTS: Of 679 children tested, 37 (5.4%) were seronegative. Seronegativity was not significantly associated with age, sex, race, age at initial vaccination, time since vaccination, or maternal year of birth. However, children mothers with a college degree were 12 times more likely to be seronegative than children of mothers who never attended college (P < .01). Of the 37 seronegative children, 36 seroconverted after revaccination--33 producing IgM measles antibody, suggestive of a primary immune response. The cost per seroconversion would have been an estimated $415 if all 679 children had been revaccinated. CONCLUSIONS: Revaccination reduces the pool of children who are susceptible to measles. Although the cost per seroconversion is high, a two-dose schedule should reduce the substantial costs of controlling measles out breaks by reducing the number of outbreaks.

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.

Vancomycin in Oregon: who's using it and why.

OBJECTIVE: To determine the proportion of vancomycin orders that are appropriate according to national guidelines and to identify targets for educational messages. DESIGN: Population-based study of vancomycin use in Oregon during a 3-week period. Survey of pharmacists, prospective flagging of vancomycin orders, and data abstraction from patient charts using standardized forms. SETTING: Nonpsychiatric hospitals in Oregon. RESULTS: Four (6%) of the 66 Oregon hospitals had pharmacy restrictions on initial vancomycin orders. Sixty-four (97%) of the hospitals participated in the study of indications for use; 293 vancomycin orders were reported; 3.8 courses were initiated per 1,000 patient-days. Indications for use were determined for 266 (91%); of these, 159 (60%) were deemed appropriate. Of uses for prophylaxis, empirical treatment of suspected gram-positive infection, and treatment of documented gram-positive infection, 57%, 56%, and 65%, respectively, were appropriate. Of hospitals with <250, 251-475, and >475 licensed beds, 65%, 58%, and 57% of vancomycin orders were appropriate. No single medical specialty accounted for >16% of inappropriate vancomycin use. CONCLUSIONS: Vancomycin was used inappropriately by physicians of many different specialties, in hospitals of all sizes, and in sundry clinical situations. The problem of inappropriate vancomycin use does not lend itself to solution by educational strategies targeted at specific subgroups; restrictions by hospital pharmacies may be required.

Patient-care directives and infection control: the potential conflict of interest during epidemics in long-term care facilities.

Patient-care directives in long-term care facilities ensure that the aggressiveness of diagnostic and therapeutic interventions accurately reflects the desires of the patient. The results of our investigation of two outbreaks of fatal respiratory illness in long-term care facilities illustrate how patient-care directives may have delayed response to the outbreaks. Despite a cluster of deaths in each facility, staff delayed collection of laboratory specimens until patients with no directives restricting the medical workup became ill. Directives focus on the needs of the individual patient and family, but when an outbreak occurs, they may conflict with community needs. The challenge for the infection control practitioner is to recognize when community needs outweigh individual desires so that appropriate laboratory investigations can identify the cause of the illness.

Health care reform in Oregon: the impact of the Oregon Health Plan on utilization of mammography.

BACKGROUND: In 1994, Oregon implemented the Oregon Health Plan (OHP), extending health care coverage under a system of capitated managed care to uninsured citizens living below the Federal Poverty Level (FPL). We conducted a study to measure receipt of clinical preventive services among women newly enrolled in the OHP. METHODS: Six hundred and sixty six women aged 52-64, and living below the FPL in Oregon were randomly selected from OHP enrollment rosters and interviewed by telephone. A follow-up survey was conducted 1 year later. The main outcome of interest was receipt of a screening mammogram during the first year in the OHP. RESULTS: At enrollment 17% (65/383) of participants had never had health care coverage. Sixty-six percent of the women (220/333) were overdue for a mammogram. Fifty-five percent (121/220) reported cost as the main reason they had not had this procedure. Mammography rates doubled under the OHP (21% to 52%, 95% CI = 0.25-0.38, p < 0.001). Among women who were overdue for a mammogram at the time they enrolled, an expressed plan to get a mammogram (OR3.0, 95% CI = 1.1-8.7, p = 0.04), citing cost as the main reason for being overdue (OR3.0, 95% CI = 1.3-7.2, p = 0.014), receipt of a routine checkup (OR9.5, 95%CI = 3.7-24.9, p < 0.001), and health care provider's (HCP's) recommendation for mammography (OR8.1,95% CI = 2.9-23.0, p < 0.001) were independently associated with receipt of a mammogram. CONCLUSION: The OHP enrolled and successfully delivered clinical preventive services to a medically under served population. Even after removing the financial barrier, obstacles to mammography remain. These may be overcome by health systems changes to insure receipt of routine checkups and appropriate provider recommendations.

A community-wide outbreak of cryptosporidiosis associated with swimming at a wave pool.

OBJECTIVE: To determine the cause of a community-wide outbreak of cryptosporidiosis. DESIGN: A matched case-control study. SETTING: General community of Lane County, Oregon. PATIENTS AND OTHER PARTICIPANTS: Persons with Cryptosporidium detected in their stool from June to October 1992 were identified by contacting laboratories serving the area. Exposures of the first 18 case patients identified were compared with those of 18 age- and neighborhood-matched controls selected from a reverse telephone directory. MAIN OUTCOME MEASURES: Reported exposures to risk factors for cryptosporidiosis and abatement of cryptosporidiosis outbreak. RESULTS: Fifty-five patients with cryptosporidiosis were detected, including 37 who were the first individuals ill in their households. The case-control study involving the first 18 case patients showed no association between illness and attendance at day care or drinking municipal water or drinking untreated surface waters (river or lake water) in the 2 weeks before onset of illness. However, nine of 18 case patients reported swimming at a local wave pool, compared with none of 18 controls. We ultimately identified 17 case patients who reported swimming at the same wave pool during their incubation periods, whose exposure dates spanned a 2-month period. Inspection of the pool's filtration system did not detect any abnormalities. The outbreak subsided after the pool water was drained and replaced. CONCLUSIONS: This prolonged outbreak of cryptosporidiosis was likely caused by exposure to fecally contaminated wave pool water. Since Cryptosporidium is highly chlorine resistant and inadequately removed by sand filters, such outbreaks may represent an unrecognized hazard of wave pools, where the likelihood of inadvertent water ingestion is high. Such outbreaks may go undetected in areas where cryptosporidiosis is not reportable or laboratory screening is infrequent.

Comparison of physician based reporting of tobacco attributable deaths and computer derived estimates of smoking attributable deaths, Oregon, 1989 to 1996.

BACKGROUND: Tobacco use prevention programmes need accurate information about smoking related mortality. Beginning in 1989, Oregon began asking physicians to report on death certificates whether tobacco use contributed to the death. OBJECTIVE: To determine the long term comparability of this method of estimating tobacco attributable mortality to estimates of smoking attributable mortality derived from a computer model. DESIGN: For the period 1989 to 1996, we compared mortality resulting from tobacco use reported by Oregon physicians to estimates of smoking attributable deaths (SADs) derived by "Smoking attributable mortality, morbidity and economic costs" software version 3.0 (SAMMEC 3.0), a widely used software program that estimates SADs on the basis of smoking prevalence and relative risks of specific diseases among current and former smokers. MAIN OUTCOME MEASURES: Numbers of deaths, age, sex, and category of disease. RESULTS: Of 212, 448 Oregon deaths during 1989-1996, SAMMEC 3.0 estimated that 42, 778 (20.1%) were attributable to cigarette smoking. For the same 27 diagnoses, physicians reported that tobacco contributed to 42, 839 (20.2%) deaths-a cumulative difference of only 61 deaths over the eight year period. The age and sex distributions of tobacco and smoking attributable deaths reported by the two systems were also similar. By category of disease, the ratio of SAMMEC 3.0 estimates to physician reported deaths was 1.11 for neoplasms, 0.88 for heart disease, and 1.04 for respiratory disease. CONCLUSIONS: Physician reporting provides comparable estimates of smoking attributable mortality and can be a valuable source of data for communicating the risks of tobacco use to the public.

Legalized physician-assisted suicide in Oregon--the second year.

BACKGROUND AND METHODS: In 1997, Oregon legalized physician-assisted suicide. We have previously reported data on terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. We now report similar data for 1999, obtained from physicians' reports, death certificates, and interviews with physicians. We also report data from interviews with family members. RESULTS: Information on 33 persons who received prescriptions for lethal medications in 1999 was reported to the Oregon Health Division; 26 died after taking the lethal medications, 5 died from their underlying illnesses, and 2 were alive as of January 1, 2000. One additional patient, who received a prescription in 1998, died after taking the medication in 1999. Thus, 27 patients died after ingesting lethal medications in 1999 (9 per 10,000 deaths in Oregon), as compared with 16 patients in 1998 (6 per 10,000). The median age of the 27 patients who died in 1999 after taking lethal medications was 71 years. The most frequent underlying illnesses were cancer (in 17 patients), amyotrophic lateral sclerosis (in 4), and chronic obstructive pulmonary disease (in 4). All 27 patients had health insurance, 21 were receiving hospice care, and 13 were college graduates. According to both physicians and family members, patients requested assistance with suicide for several reasons, including loss of autonomy, loss of control of bodily functions, an inability to participate in activities that make life enjoyable, and a determination to control the manner of death. CONCLUSIONS: In the second as compared with the first year of legalized physician-assisted suicide in Oregon, the number of patients who died after ingesting lethal medications increased, but it remained small in relation to the total number of persons in Oregon who died. Patients who request assistance with suicide appear to be motivated by several factors, including loss of autonomy and a determination to control the way in which they die.

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.

Acquired immunodeficiency syndrome in low-incidence areas. How safe is unsafe sex?

Serum specimens from the cohort of persons who attended sexually transmitted disease clinics in New Mexico during a two-month period were tested for human immunodeficiency virus (HIV) antibody. Twenty-seven (2.0%) of 1374 serum specimens had repeatedly low-positive reactions by enzyme-linked immunosorbent assay testing, and 22 (1.6%) had repeatedly high-positive reactions. All sera (sufficient for testing by Western blot) with low-positive reactions gave negative results, and all sera (sufficient for testing by Western blot) with high-positive reactions gave positive results. All persons whose serum had high-positive reactions were male. Most (86%) had been seen at the only urban sexually transmitted disease clinic in New Mexico, and most (72%) were openly gay or bisexual. Of all gay and bisexual men evaluated, 14% (16/112) had high-positive reactions. Rapid plasma reagin positivity was significantly associated with HIV enzyme-linked immunosorbent assay low (false) positivity. The relatively high rate of HIV seropositivity among gay men with other sexually transmitted diseases indicates that transmission of acquired immunodeficiency syndrome is continuing in this low-incidence area and documents the need for testing and counseling programs in sexually transmitted disease clinics.

Pedestrian and hypothermia deaths among Native Americans in New Mexico. Between bar and home.

OBJECTIVE: To determine the nature of excess injury mortality among Native Americans in New Mexico. DESIGN: Retrospective review of death certificates for deaths from unintentional injuries. SETTING: The state of New Mexico. SUBJECTS: New Mexico residents who died of unintentional injuries between January 1, 1980, and December 31, 1989. MAIN OUTCOME MEASURE: Cause-specific mortality rates. RESULTS: Over half of the excess mortality from all unintentional injuries among Native Americans resulted from hypothermia and from pedestrian-motor vehicle crashes. New Mexico Native Americans were nearly eight times more likely to die in pedestrian--motor vehicle crashes and were 30 times more likely to die of hypothermia compared with other New Mexico residents. At death, 90% of those Native Americans tested were highly intoxicated (median blood alcohol concentrations of 0.24 and 0.18 g/dL [corrected] for pedestrian and hypothermia deaths, respectively). Despite the fact that most Native Americans in New Mexico live on reservations, most deaths occurred at off-reservation sites in border towns and on roads leading back to the reservation. CONCLUSIONS: The possession and sale of alcohol is illegal on many Native American reservations. This policy forces Native Americans who want to drink to travel long distances to obtain alcohol. These data suggest that this policy is also the likely explanation for the markedly increased risk of death from hypothermia and pedestrian-motor vehicle crashes in this population.

Outcome-based management and public health: the Oregon Benchmarks experience.

Oregon is taking major steps toward monitoring health and nonhealth issues through the use of an outcome-based management approach called Benchmarks. Developed through a lengthy statewide consensus-building process, there are currently 272 goals, or Benchmarks, for the years 1995, 2000, and 2010, of which 54 are health related. Major effects on both the state and the local health departments include enhanced assessment activities, increased health planning, and improved collaboration both among health agencies and with other governmental and nongovernmental organizations.

Legalized physician-assisted suicide in Oregon--the first year's experience.

BACKGROUND AND METHODS: On October 27, 1997, Oregon legalized physician-assisted suicide. We collected data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. The data were obtained from physicians' reports, death certificates, and interviews with physicians. We compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. RESULTS: Information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division; 15 died after taking the lethal medications, 6 died from underlying illnesses, and 2 were alive as of January 1, 1999. The median age of the 15 patients who died after taking lethal medications was 69 years; 8 were male, and all 15 were white. Thirteen of the 15 patients had cancer. The case patients and controls were similar with regard to sex, race, urban or rural residence, level of education, health insurance coverage, and hospice enrollment. No case patients or controls expressed concern about the financial impact of their illness. One case patient and 15 controls expressed concern about inadequate control of pain (P=0.10). The case patients were more likely than the controls to have never married (P=0.04) and were more likely to be concerned about loss of autonomy due to illness (P=0.01) and loss of control of bodily functions (P=0.02). At death, 21 percent of the case patients and 84 percent of the controls were completely disabled (P<0.001). CONCLUSIONS: During the first year of legalized physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain or concern about financial loss. In addition, we found that the choice of physician-assisted suicide was not associated with level of education or health insurance coverage.

Isolation of Listeria monocytogenes from raw milk.

During a recent outbreak of listeriosis, we examined 121 raw milk samples and 14 milk socks (filters). Listeria monocytogenes was recovered from 15 (12%) of 121 milk specimens and 2 (14%) of 14 milk socks. The optimal processing method consisted of cold enriching diluted milk for 1 month with culture to selective broth, followed by plating.

Eosinophilia-myalgia syndrome associated with exposure to tryptophan from a single manufacturer.

Although eosinophilia-myalgia syndrome has been linked to use of tryptophan, it has been unclear whether tryptophan itself or a contaminant causes illness. In Oregon, we compared the brand and source of tryptophan used by 58 patients with eosinophilia-myalgia syndrome with the brand and source of tryptophan used by 30 asymptomatic controls identified through a random telephone survey and 63 asymptomatic controls who contacted the Oregon Health Division voluntarily. Although a single brand/retail lot of tryptophan was statistically associated with the development of eosinophilia-myalgia syndrome, there was no common importer, wholesaler, tablet maker, encapsulator, or distributor. However, 45 (98%) of 46 cases had taken a product made by one manufacturer, compared with three (30%) of 10 telephone survey controls and 15 (48%) of 31 volunteer controls. Retail lots of tryptophan from this manufacturer that were associated with cases were significantly more likely to have been produced from January through June 1989 than lots from this manufacturer that were taken by controls. These findings indicate that the recent epidemic of eosinophilia-myalgia syndrome was caused by a contaminant or an alteration in a subset of tryptophan manufactured by a single company in Japan shortly before the outbreak began.