Underutilization of pneumococcal vaccine in nursing home in Washington State: report of a serotype-specific outbreak and a survey.

PURPOSE: To describe an outbreak of pneumococcal disease in a Washington state nursing home and to report a survey of pneumococcal vaccine utilization in Washington nursing homes. PATIENTS AND METHODS: Outbreak. Data were collected from nursing home residents' records. Nasopharyngeal cultures were obtained from residents and staff. Survey. Fifty-four randomly selected Washington nursing homes were surveyed about pneumococcal vaccine utilization and policies. RESULTS: Outbreak. Three confirmed and 4 possible cases of pneumococcal disease occurred over 9 days among 94 residents; 5 patients (71%) died. Cases were identified among 6 of 42 residents on 1 wing, compared with 1 of 52 on the other 2 wings (relative risk 7.4, 95% confidence interval 1.0, 398.5). Streptococcus pneumoniae serotype 9V was cultured from the blood of 3 confirmed case-patients and the nasopharynx of 2 of 73 residents. Only 7% of residents had received pneumococcal vaccine, including one case-patient who had received 14-valent vaccine without serotype 9V. Survey. Only 22% of residents were reported to have received pneumococcal vaccine; vaccination status was unknown for 66%. Physician discretion determined pneumococcal vaccination in 49 (91%) nursing homes; 9 (17%) had a written policy. Two major barriers to pneumococcal vaccination were cited: low priority among physicians (43%) and difficulty in determining residents' vaccine history (37%). CONCLUSIONS: A pneumococcal disease outbreak among undervaccinated nursing home residents probably resulted from person-to-person transmission. Pneumococcal vaccine appears to be underutilized in Washington state nursing homes.

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.

Infections with Escherichia coli O157:H7 in Washington State. The first year of statewide disease surveillance.

In 1987, Washington became the first state to require that infection with Escherichia coli serotype O157:H7 be reported. In the first year of surveillance, 93 cases were reported, yielding an annual incidence of 2.1 cases per 100,000 population. The median age of case patients was 14 years (range, 11 months to 78 years), with the highest attack rate among children younger than 5 years (6.1 cases per 100,000 population per year). Bloody diarrhea was present in 95% of reported cases, 12% of patients developed either hemolytic-uremic syndrome or thrombotic thrombocytopenic purpura, and one patient died. Suspected secondary cases were seen in 5% of households. Fifty-six (60%) cases occurred during June through September, as did 73% of the cases of hemolytic-uremic syndrome or thrombotic thrombocytopenic purpura. Cases reported during the summer months were more likely than cases reported at other times of the year to be in children younger than 10 years. Medications, including antimicrobial medications, did not influence the duration of symptoms, nor did they appear to alter the risk of developing hemolytic-uremic syndrome or thrombotic thrombocytopenic purpura. This newly established surveillance system in Washington demonstrates that E coli O157:H7 is an important and common cause of bloody diarrhea in the United States.

Risk factors for fireworks-related injury in Washington State.

To determine the frequency and effects of and risk factors for fireworks -related injury, we identified all 146 persons who were injured by fireworks and sought emergency care during the 1983 July 4 holiday in the Seattle area. The mean charge for medical care for the injuries received was +562; 7.1% of those injured required hospitalization. In a matched-pair case-control study, use of either of two fireworks types-- firecrackers or aerial devices--was significantly associated with injury (odds ratios [ORs], 3.3 and 2.9, respectively; 95% confidence intervals [CI], 1.2, 8.5, and 1.2, 6.6, respectively). Also associated with injury were several fireworks misuse behaviors, including lack of adult supervision of children (OR, 11.5; CI, 2.8, 100.6). We conclude that fireworks cause serious injuries that theoretically could be prevented by behavioral changes or decreased availability of high-risk fireworks devices.

Screening for hepatitis B during pregnancy. Awareness of current recommendations among Washington hospitals.

Acute care hospitals in Washington State that reported births (n = 77) were surveyed regarding their awareness of and compliance with the Centers for Disease Control recommendations for hepatitis B screening of pregnant women. Of these, 62 hospitals (81%) were aware of the recommendations and 39 (51%) routinely screened pregnant women who did not have a history of prenatal care at the time of delivery. In all, 68 hospitals (88%) had hepatitis B vaccine and 54 (70%) had hepatitis B immune globulin available on site. Despite awareness of the current recommendations for hepatitis B screening, barriers exist that prevent many hospitals from fully implementing them.

Reactive arthritis and Reiter's syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis.

Reactive arthritis and Reiter's syndrome have been reported following gastroenteritis. Prevalence studies for these conditions are uncommon, and the prevalence of Reiter's syndrome after Salmonella enteritidis infection has not been previously reported. After a large outbreak of S. enteritidis gastroenteritis, a survey of persons exposed to the implicated food source was conducted, and those with reactive arthritis were evaluated for possible risk factors. Among 481 persons responding to the questionnaire, 217 cases of S. enteritidis gastroenteritis were identified (31 confirmed and 186 clinical cases; attack rate, 45%). Twenty-nine percent of the cases had symptoms of reactive arthritis, 3% had symptoms of Reiter's syndrome, and 10% had reactive arthritis with oral ulcers. Markers for severe illness (diarrhea > or =7 days, emergency room visit or hospitalization, and antibiotic treatment) were statistically significant but colinear factors associated with reactive arthritis. Increased awareness of postdysenteric reactive arthritis and Reiter's syndrome is recommended.

Transmission of hepatitis B virus from adopted Asian children to their American families.

In 1985, 6,991 Asian children were adopted by Americans. To estimate the risk that such children may transmit hepatitis B virus to their adoptive families, we conducted a cumulative-incidence follow-up study in the State of Washington. We examined the association between having adopted a hepatitis B surface antigen (HBsAg)-seropositive Asian child and serologic evidence of past or present hepatitis B virus infection in adoptive family members. Seven (9 per cent) of 77 family members exposed to an HBsAg-seropositive child had evidence of past or present infection compared with four (2 per cent) of 232 nonexposed (relative risk = 5.3; 90% confidence limits [CL] = 2.0-13.9). The risk was higher for those with prolonged exposure and was entirely restricted to parents.

Hospital charges for people with AIDS in Washington State: utilization of a statewide hospital discharge data base.

We analyzed Washington State inpatient hospital utilization for 165 AIDS (acquired immunodeficiency syndrome) cases with 344 hospitalizations from July 1984 through December 1985. We found that mean charges per hospitalization were $9,166 and mean length of stay was 13.3 days. In addition, evaluation of two diagnosis-related groups (DRGs 079 and 398) commonly used for AIDS hospitalizations showed that AIDS hospitalizations were substantially more expensive than non-AIDS hospitalizations within the same diagnosis-related group. AIDS-specific diagnosis-related groups may be necessary to achieve a balance between inpatient charges and reimbursements.

Predictors of hemolytic uremic syndrome in children during a large outbreak of Escherichia coli O157:H7 infections.

OBJECTIVE: To evaluate risk factors for progression of Escherichia coli O157:H7 infection to the hemolytic uremic syndrome (HUS). STUDY DESIGN: We conducted a retrospective cohort study among 278 Washington State children <16 years old who developed symptomatic culture-confirmed E coli O157:H7 infection during a large 1993 outbreak. The purpose of the study was to determine the relative risk (RR) of developing HUS according to demographic characteristics, symptoms, laboratory test results, and medication use in the first 3 days of illness. RESULTS: Thirty-seven (14%) children developed HUS. In univariate analysis, no associations were observed between HUS risk and any demographic characteristic, the presence of bloody diarrhea or of fever, or medication use. In multivariate analysis, HUS risk was associated with, in the first 3 days of illness, use of antimotility agents (odds ratio [OR] = 2.9; 95% confidence interval [CI] 1.2-7.5) and, among children <5.5 years old, vomiting (OR = 4. 2; 95% CI 1.4-12.7). Among the 128 children tested, those whose white blood cell (WBC) count was >/=13 000/microL in the first 3 days of illness had a 7-fold increased risk of developing HUS (RR 7. 2; 95% CI 2.8-18.5). Thirteen (38%) of the 34 patients with a WBC count >/=13 000/microL developed HUS, but only 5 (5%) of the 94 children whose initial WBC count was <13 000/microL progressed to HUS. Among children who did not develop HUS, use of antimotility agents in the first 3 days of illness was associated with longer duration of bloody diarrhea. CONCLUSIONS: Prospective studies are needed to further evaluate measures to prevent the progression of E coli O157:H7 infection to HUS and to assess further clinical and laboratory risk factors. These data argue against the use of antimotility agents in acute childhood diarrhea. Our finding that no intervention decreased HUS risk underscores the importance of preventing E coli O157:H7 infections.

Cryptosporidiosis in Washington State: an outbreak associated with well water.

In 1994, an outbreak of cryptosporidiosis occurred in a rural community in Washington State where water was supplied by two deep unchlorinated wells. Confirmed case-patients had a stool specimen containing Cryptosporidium parvum oocysts. Probable case-patients had diarrhea lasting > or = 5 days. Sixty-two households (68.1% of 91) responded to a survey. Eighty-six cases (15 confirmed, 71 probable) were identified, for an attack rate of 50.9% (86/169 residents). Drinking unboiled well water was associated with being a case-patient (relative risk, 1.84; 95% confidence interval, 0.89-3.82), and a significant dose-response relationship was found between water consumption and illness (P = .004). Water that was presumed to be treated wastewater from a piped irrigation system was found dripping along one well's outer casing, which was extensively rusted. Presumptive Cryptosporidium oocysts were found in well water and in treated wastewater. This investigation demonstrates that even underground water systems are vulnerable to contamination.

Natural history of the eosinophilia-myalgia syndrome.

OBJECTIVE: To describe the natural history and disease progression of the eosinophilia-myalgia syndrome and to assess the therapeutic effects of orally administered steroids on the disorder as of October 1990. DESIGN: Case-series analysis. A cohort of 45 patients with the eosinophilia-myalgia syndrome was followed prospectively by periodic telephone interviews and medical examinations for an average of 14 months after onset of illness. SETTING: Washington state. PATIENTS: The cases of 47 patients were reported to the Washington State Department of Health from 1 July to 12 December 1989. Two patients were unavailable for follow-up, and the remaining 45 completed the study. MAIN RESULTS: Patients were predominantly non-Hispanic white women (87%) with an average age of 49 years. Symptoms typically progressed from early onset of myalgia and fatigue to later development of neurologic and scleroderma-like skin changes. Six (13%) patients recovered completely within 2 to 5 months of symptom onset. After 14 months of illness, over half of the patients who initially presented with myalgia, fatigue, or scleroderma-like skin changes remained symptomatic. The average severity of each major symptom was measured using interviews and patient self-reports and has improved subjectively by at least 40%. Statistical analyses showed no significant difference in long-term symptom duration or severity between patients treated and those not treated with prednisone. CONCLUSIONS: The eosinophilia-myalgia syndrome is a long-term illness characterized by progressive improvement during the first 25 weeks after symptom onset, followed by a protracted phase of symptom resolution. We could not show a clear-cut benefit of prednisone in reducing the long-term severity or duration of the disease.

Toxin genotypes and plasmid profiles as determinants of systemic sequelae in Escherichia coli O157:H7 infections.

In 1987, 93 Escherichia coli O157:H7 isolates were collected during routine surveillance for this pathogen in the state of Washington. Toxin genotypes and plasmid profiles were correlated with the clinical sequelae of illness in 88 of the 93 patients from whom these strains were isolated. Thirteen plasmid patterns were observed among the 88 tested isolates; four patterns accounted for 82% of the isolates. Genetic probing for Shiga-like toxins (SLT) I and II demonstrated the presence of both genes in 67 (76%), SLT I alone in three (3%), and SLT II alone in 18 (20%). The hemolytic uremic syndrome or thrombotic thrombocytopenic purpura developed in seven (39%) of 18 patients infected with isolates having only the SLT II gene, while these complications occurred in only four (6%) of 70 patients infected with isolates having the other two genotypes (relative risk, 6.8; 95% confidence interval, 1.9, 26.4). This study shows that E. coli O157:H7 isolates systematically collected from a single geographic region over a defined time period exhibit considerable diversity in plasmid content and toxin genotype and that the toxin genotype of the infecting strain may influence the risk of developing microangiopathic sequelae.

Escherichia coli O157:H7, an emerging gastrointestinal pathogen. Results of a one-year, prospective, population-based study.

To examine the incidence of Escherichia coli O157:H7 enteric infections in the United States and to evaluate the vehicles of transmission for sporadic cases, we conducted a one-year, population-based study at a large health maintenance organization (HMO) in the Puget Sound area of Washington State. All stool specimens submitted for culture to the HMO laboratory were screened for E coli O157:H7; the organism was identified in 25 (0.4%) of 6485 stool specimens. All patients with E coli O157:H7 identified had diarrhea; 24 patients (96%) had bloody diarrhea. Exposure histories demonstrated that rare ground beef was consumed more often by patients (21%) than by age-matched control subjects (4%) in the week before onset of illness. Raw milk also was consumed by two patients but by none of the control subjects. Incidence rates for laboratory-confirmed enteric infections in the HMO population were as follows: Campylobacter, 50/100,000 person-years; Salmonella, 21/100,000 person-years; E coli O157:H7, 8/100,000 person-years; and Shigella, 7/100,000 person-years. The organism is a more common pathogen in the United States than is generally recognized, and the diagnosis should be considered for patients with suspected enteric infection.

The low risk of hepatitis B in rural hospitals. Results of a seroepidemiologic survey.

To determine the risk of hepatitis B virus infection for rural hospital employees, we obtained serum and a completed questionnaire from each of 2,064 employees of 11 rural hospitals. Only 96 (4.7%) employees had hepatitis B virus markers. Increased marker prevalence was significantly associated with prior residence in a city with a population of greater than 100,000 (odds ratio, 2.9; 95% confidence interval, 1.6 to 5.2) and increasing blood contact (odds ratio, 1.6; confidence interval, 1.2 to 2.3); however, the association with blood contact was not significant when we limited analysis to the 836 employees who had never lived in a city. We conclude that the risk of hepatitis B virus infection for these rural hospital employees is low, probably because the incidence of hepatitis B in rural areas is low.

Characteristics of antibiotic-resistant Escherichia coli O157:H7 in Washington State, 1984-1991.

The resistance of Escherichia coli O157:H7 to amoxicillin/clavulanic acid, ampicillin, ceftazidime, ceftriaxone, cefuroxime, cephalothin, chloramphenicol, ciprofloxacin, gentamicin, streptomycin, sulfisoxazole, tetracycline, ticarcillin, tobramycin, and trimethoprim-sulfamethoxazole was examined, and resistant strains were characterized. All 56 isolates collected between 1984 and 1987 were susceptible to all antibiotics tested; 13 (7.4%) of 176 strains isolated between 1989 and 1991 were resistant to streptomycin, sulfisoxazole, and tetracycline. lambda-restriction fragment length polymorphism analysis suggested that the 13 resistant strains belonged to nine different clones. The emerging resistance of E. coli O157:H7 to antibiotics could portend an increased prevalence of this pathogen in food animals that receive antibiotics. Antimicrobial resistance of E. coli O157:H7 could be useful as a rapid epidemiologic marker and as a way to select this pathogen from suspected vehicles of transmission, but this resistance could also complicate therapeutic trials with sulfa-containing antibiotics.

A statewide outbreak of Escherichia coli O157:H7 infections in Washington State.

In November 1986, a statewide outbreak of Escherichia coli O157:H7 infections in Washington State was identified after a physician in an eastern Washington community hospitalized three patients with hemorrhagic colitis which progressed to thrombotic thrombocytopenic purpura. Epidemiologic investigation identified 37 cases in this community and linked the illnesses to a local restaurant which had served ground beef that was the suspected initial vehicle of transmission. The plasmid profile and toxin production pattern (Shiga-like toxin II alone) of the outbreak strain provided a unique strain marker. E. coli O157:H7 infections caused by this strain were simultaneously seen in other parts of the state among nursing home residents and in patients with the hemolytic-uremic syndrome, and an increase in sporadic cases of hemorrhagic colitis was noted at a Seattle health maintenance organization. It is suspected that a contaminated product, probably ground beef distributed statewide, was the common source. Tracing of this meat led to farms where rectal swabs from six (1%) of 539 cattle tested yielded E. coli O157:H7, although the plasmids and toxin production patterns of these isolates differed from the human outbreak strain. Introduction of a single strain of E. coli O157:H7 has the potential to cause widespread concurrent outbreaks. Such outbreaks are likely to escape recognition until heightened screening and surveillance for E. coli O157:H7 is established.

Babesiosis in Washington State: a new species of Babesia?

OBJECTIVE: To characterize the etiologic agent (WA1) of the first reported case of babesiosis acquired in Washington State. DESIGN: Case report, and serologic, molecular, and epizootiologic studies. SETTING: South-central Washington State. PATIENT: A 41-year-old immunocompetent man with an intact spleen who developed a moderately severe case of babesiosis. MEASUREMENTS: Serum specimens from the patient were assayed by indirect immunofluorescent antibody (IFA) testing for reactivity with seven Babesia species and with WA1, which was propagated in hamsters inoculated with his blood. A Babesia-specific, ribosomal-DNA (rDNA) probe was hybridized to Southern blots of restriction-endonuclease-digested preparations of DNA from WA1, Babesia microti, and Babesia gibsoni. Serum specimens from 83 family members and neighbors were assayed for IFA reactivity with WA1 and B. microti. Small mammals and ticks were examined for Babesia infection. RESULTS: The patient's serum had very strong IFA reactivity with WA1, strong reactivity with B. gibsoni (which infects dogs), but only weak reactivity with B. microti. DNA hybridization patterns with the rDNA probe clearly differentiated WA1 from B. gibsoni and B. microti. Four of the patient's neighbors had IFA titers to WA1 of 256. The tick vector and animal reservoir of WA1 have not yet been identified, despite trapping 83 mammals and collecting 235 ticks. CONCLUSIONS: WA1 is morphologically indistinguishable but antigenically and genotypically distinct from B. microti. Some patients elsewhere who were assumed to have been infected with B. microti may have been infected with WA1. Improved serodiagnostic and molecular techniques are needed for characterizing Babesia species and elucidating the epidemiology of babesiosis, an emergent zoonosis.