Health after Legionnaires' disease: A description of hospitalizations up to 5 years after Legionella pneumonia.

BACKGROUND AND OBJECTIVES: Research on Legionnaires' Disease (LD) suggests there may be long-term health complications, but data are limited. This study investigated whether Intensive Care Unit (ICU) admission during LD hospitalization may be associated with adverse health outcomes and characterized subsequent discharge diagnoses in patients with LD up to 5 years post-LD. METHODS: We conducted a retrospective case series study with follow up for 5 years among patients hospitalized at a Department of Veterans Affairs (VA) Medical Center between 2005 and 2010 with LD. Data were collected from medical records on health history, LD severity (including ICU admission), and discharge diagnoses for 5 years post-LD or until death. We used ordinal logistic regression to explore associations between ICU admission and hospitalizations post-LD. Frequency counts were used to determine the most prevalent discharge diagnoses in the 5 years post-LD. RESULTS: For the 292 patients with laboratory-confirmed LD, those admitted to the ICU during LD hospitalization were more likely to have a greater number of hospitalizations within 5 years compared to non-ICU patients (ORHosp 1.92 CI95% 1.25, 2.95). Fifty-five percent (161/292) had ≥ 1 hospitalization within 5 years post-LD. After accounting for pre-existing diagnosis codes in patients with at least one hospitalization in the 2 years prior to LD (n = 77/161 patients, 47.8%), three of the four most frequent new diagnoses in the 5 years post-LD were non-chronic conditions: acute renal failure (n = 22, 28.6%), acute respiratory failure (n = 17, 22.1%) and unspecified pneumonia (n = 15, 19.5%). CONCLUSIONS: Our findings indicate that LD requiring ICU admission is associated with more subsequent hospitalizations, a factor that could contribute to poorer future health for people with severe LD. In addition to chronic conditions prevalent in this study population, we found new diagnoses in the 5-year post-LD period including acute renal failure. With LD incidence increasing, more research is needed to understand conditions and factors that influence long term health after LD.

Preventing hospital-acquired Legionnaires' disease: A snapshot of clinical practices and water management approaches in US acute-care hospitals.

In 2017, we surveyed 101 SHEA Research Network hospitals regarding Legionnaires' disease (LD). Of 29 respondents, 94% have or are developing a water management plan with varying characteristics and personnel engaged. Most LD diagnostic testing is limited to urine antigen testing. Many opportunities to improve LD prevention and diagnosis exist.

Implementation of a Legionella Ordinance for Multifamily Housing, Garland, Texas.

CONTEXT: The incidence of legionellosis has sharply increased in the United States as a result of contaminated water systems. Jurisdictions across the country are considering whether to develop and implement regulations to protect individuals against Legionnaires' disease with its associated high morbidity and mortality. OBJECTIVE: This article sheds light on the implementation and effectiveness of a 2005 citywide Legionella testing mandate of multifamily housing cooling towers in Garland, Texas. This ordinance has been in place for more than 10 years and represents the first of its kind in the United States to mandate routine testing of cooling towers for Legionella in multifamily housing. DESIGN, SETTING, AND POPULATION: We utilized a mix of both qualitative and quantitative methods to explore the development, adoption, and implementation of the ordinance. Phone interviews were conducted with individuals from the City of Garland Health Department and apartment managers. Quantitative data included public health surveillance data on legionellosis. MAIN OUTCOME MEASURES: Barriers and facilitators of implementation, number and percentage of cooling towers from multifamily housing units that tested positive for Legionella by year, and number of legionellosis cases by year in Garland, Texas. RESULTS: Study outcomes highlight key themes that facilitated the successful implementation of the Legionella testing mandate, including the importance of timing, leadership support, stakeholder engagement, and education and outreach. The number of contaminated cooling towers was reduced over time. CONCLUSION: Mandatory monitoring for legionella in a local jurisdiction may result in reduced risk of legionellosis from cooling towers through raising awareness and education of building owners and managers about the need to prevent, detect, and remediate legionella contamination in their building water systems. Garland, Texas, broke new ground in the United States in moving toward primary prevention of legionellosis. The ordinance may be useful both in serving to educate and increase awareness about the need for Legionella prevention and to monitor effectiveness of maintenance procedures.

Impact of a multi-component antenatal vaccine promotion package on improving knowledge, attitudes and beliefs about influenza and Tdap vaccination during pregnancy.

OBJECTIVE: Understanding whether interventions designed to improve antenatal vaccine uptake also change women's knowledge about vaccination is critical for improving vaccine coverage. This exploratory study evaluates the effectiveness of a multi-component influenza and tetanus, diphtheria, and acellular pertussis (Tdap) vaccine promotion package on improving women's knowledge, attitudes and beliefs toward antenatal vaccination. STUDY DESIGN: In 2012/2013 a cluster-randomized trial was conducted to test the effectiveness of a vaccine promotion package on improving antenatal vaccine coverage. Participants included 325 unvaccinated pregnant women from 11 obstetric practices in Georgia. Eleven health beliefs measures were assessed at baseline and 2-3 months post-partum. Outcomes were differences in proportions of women citing favorable responses to each measure between study groups at follow-up. RESULTS: Women enrolled in their third trimester had a higher probability of asking family members to vaccinate to protect the infant if they were in the intervention group versus the control group (36% vs. 22%; risk ratio [RR] = 1.65, 95% confidence interval [CI]: 1.21, 2.26). A similar association was not observed among women enrolled before their third trimester (39% vs. 44%; RR = 0.93, 95% CI: 0.50, 1.73). There were no other significant differences at follow-up between study groups. CONCLUSIONS: While exposure to the intervention package may have raised awareness that vaccinating close contacts can protect an infant, there is little evidence that the package changed women's attitudes and beliefs toward antenatal vaccination. Future research should ensure adequate exposure to the intervention and consider study design aspects including power to assess changes in secondary outcomes, discriminatory power of response options, and social desirability bias. This study is registered with clinicaltrials.gov, study ID NCT01761799.

Trends in reasons for non-receipt of influenza vaccination during pregnancy in Georgia, 2004-2011.

BACKGROUND: Considerable research has identified barriers to antenatal influenza vaccination, yet no research has explored temporal trends in reasons for non-receipt. PURPOSE: To examine trends in reasons for non-receipt of influenza vaccination during pregnancy. METHODS: Serial cross-sectional analyses using 8 years of Georgia Pregnancy Risk Assessment Monitoring Survey (PRAMS) data were conducted. Weighted logistic regression was used to examine trends in the prevalence of citing reasons for non-receipt over time. RESULTS: Between 2004 and 2011, 8300 women reported no influenza vaccination during or immediately before pregnancy. Proportions of women citing "doctor didn't mention vaccination," "in first trimester during influenza season," and "not pregnant during influenza season" decreased significantly over time (Doctor didn't mention: 48.0% vs. 27.1%, test for trend p<0.001; in first trimester: 26.8% vs. 16.3%, test for trend p<0.001; not influenza season: 24.2% vs. 12.7%, test for trend p=0.001). Safety concerns increased over 2004 proportions in 2010 (concern about side effects for me: 40.2% vs. 28.5%, prevalence ratio (PR): 1.41, 95% confidence interval (CI): 1.16, 1.71; concern about harming my baby: 38.9% vs. 31.0%, PR=1.26, 95% CI: 1.04, 1.53) and 2011 (concern about side effects for me: 39.0% vs. 28.5%, PR=1.37, 95% CI: 1.13, 1.65; concern about harming my baby: 38.8% vs. 31.0%, PR=1.25, 95% CI: 1.04, 1.50). Following the 2009/2010 H1N1 pandemic, more Hispanic women cited concern about vaccination harming their baby than other women; in 2011, their concern remained elevated relative to non-Hispanic white women (63% vs. 35%; adjusted PR=1.79, 95% CI: 1.23, 2.61). CONCLUSION: Examining trends in reasons for non-receipt of antenatal influenza vaccination can reflect successes related to vaccine promotion and areas for improvement. By highlighting differential impacts of the 2009/2010 H1N1 pandemic, we reveal opportunities for additional research on tailoring vaccine promotion efforts to specific types of women.

Lack of Availability of Antenatal Vaccination Information on Obstetric Care Practice Web Sites.

OBJECTIVE: To estimate the proportion of obstetric practice web sites in the United States providing information on antenatal influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination. METHODS: Using www.healthgrades.com, a national random sample of 1,003 obstetric practice web sites was examined for provision of information on antenatal vaccination and other preventive prenatal health topics. Data were collected for this cross-sectional study between September 25, 2014, and November 12, 2014. χ tests and odds ratios were calculated to determine significance and magnitude of associations between provision of antenatal vaccination information and other practice characteristics. RESULTS: Of 1,003 web sites examined, 229 (22.8%) posted information pertaining to antenatal vaccinations. Only 105 web sites (10.5%) provided up-to-date information about both antenatal influenza and Tdap vaccination. Compared with the proportion posting on antenatal vaccination, significantly more web sites posted on safe foods (40.8%; P<.001), safe medications (36.9%; P<.001), and safe exercise (38.5%; P<.001) during pregnancy. When compared with web sites not mentioning these other prenatal health topics, web sites mentioning these topics were more likely to also mention antenatal vaccination (safe foods: 45.7% compared with 7.1%; odds ratio [OR] 11.07, 95% confidence interval [CI] 7.65-16.01; safe medications: 45.4% compared with 9.6%; OR 7.8, CI 5.58-10.89; safe exercise: 45.9% compared with 8.4%; OR 9.2, CI 6.5-13.03). CONCLUSION: A majority of obstetric care practice web sites do not provide information on antenatal vaccinations. Obstetric practices should consider using their web sites to provide reliable information on antenatal vaccinations as many already do for other prenatal health topics.

A Review of Guidelines for the Primary Prevention of Legionellosis in Long-Term Care Facilities.

Legionellosis is an important public health problem in the United States and other countries, and residents of long-term care facilities (LTCFs) are at higher risk for Legionnaires' disease than the general population. In this study, we reviewed published US and international guidelines for the primary prevention of legionellosis in LTCFs, including nursing homes, skilled nursing facilities, assisted living facilities, and aged care facilities. The results of this review indicate that most guidelines emphasize adequate design and maintenance of water systems and water temperatures; however, guidance regarding routine preventative environmental testing for Legionella bacteria is not uniform among various jurisdictions, and facilities are generally left without clear guidance on this issue. In the United States, the Centers for Disease Control and Prevention does not recommend such testing in LTCFs, in contrast to the Veterans Health Administration and Environmental Protection Agency. Internationally, the World Health Organization recommends routine environmental testing, as do Ireland; France; The Netherlands; South Africa; Vienna, Austria; and Queensland, Australia. Among domestic and international guidelines in favor of environmental testing, recommendations on the frequency of testing for Legionella in water systems vary. Further research to inform recommendations on the usefulness of routine environmental testing and other measures for the primary prevention of legionellosis in this setting is needed.

Factors Associated with Intention to Receive Influenza and Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccines during Pregnancy: A Focus on Vaccine Hesitancy and Perceptions of Disease Severity and Vaccine Safety.

BACKGROUND: Improving influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccine coverage among pregnant women is needed. PURPOSE: To assess factors associated with intention to receive influenza and/or Tdap vaccinations during pregnancy with a focus on perceptions of influenza and pertussis disease severity and influenza vaccine safety. METHODS: Participants were 325 pregnant women in Georgia recruited from December 2012 - April 2013 who had not yet received a 2012/2013 influenza vaccine or a Tdap vaccine while pregnant. Women completed a survey assessing influenza vaccination history, likelihood of receiving antenatal influenza and/or Tdap vaccines, and knowledge, attitudes and beliefs about influenza, pertussis, and their associated vaccines. RESULTS: Seventy-three percent and 81% of women believed influenza and pertussis, respectively, would be serious during pregnancy while 87% and 92% believed influenza and pertussis, respectively, would be serious to their infants. Perception of pertussis severity for their infant was strongly associated with an intention to receive a Tdap vaccine before delivery (p=0.004). Despite perceptions of disease severity for themselves and their infants, only 34% and 44% intended to receive antenatal influenza and Tdap vaccines, respectively. Forty-six percent had low perceptions of safety regarding the influenza vaccine during pregnancy, and compared to women who perceived the influenza vaccine as safe, women who perceived the vaccine as unsafe were less likely to intend to receive antenatal influenza (48% vs. 20%; p < 0.001) or Tdap (53% vs. 33%; p < 0.001) vaccinations. CONCLUSIONS: Results from this baseline survey suggest that while pregnant women who remain unvaccinated against influenza within the first three months of the putative influenza season may be aware of the risks influenza and pertussis pose to themselves and their infants, many remain reluctant to receive influenza and Tdap vaccines antenatally. To improve vaccine uptake in the obstetric setting, our findings support development of evidence-based vaccine promotion interventions which emphasize vaccine safety during pregnancy and mention disease severity in infancy.

Legionellosis on the Rise: A Review of Guidelines for Prevention in the United States.

CONTEXT: Reported cases of legionellosis more than tripled between 2001 and 2012 in the United States. The disease results primarily from exposure to aerosolized water contaminated with Legionella. OBJECTIVE: To identify and describe policies and guidelines for the primary prevention of legionellosis in the US. DESIGN: An Internet search for Legionella prevention guidelines in the United States at the federal and state levels was conducted from March to June 2012. Local government agency guidelines and guidelines from professional organizations that were identified in the initial search were also included. SETTING: Federal, state, and local governing bodies and professional organizations. RESULTS: Guidelines and regulations for the primary prevention of legionellosis (ie, Legionnaires' disease and Pontiac fever) have been developed by various public health and other government agencies at the federal, state, and local levels as well as by professional organizations. These guidelines are similar in recommending maintenance of building water systems; federal and other guidelines differ in the population/institutions targeted, the extent of technical detail, and support of monitoring water systems for levels of Legionella contamination. CONCLUSIONS: Legionellosis deserves a higher public health priority for research and policy development. Guidance across public health agencies for the primary prevention of legionellosis requires strengthening as this disease escalates in importance as a cause of severe morbidity and mortality. We recommend a formal and comprehensive review of national public health guidelines for prevention of legionellosis.

Distribution of A(H1N1)pdm09 Influenza Vaccine: Need for Greater Consideration of Smaller Jails.

To identify factors associated with vaccine receipt among correctional facilities during the A(H1N1)pdm09 influenza pandemic, this study surveyed one third of U.S. correctional facilities. Analysis of the association of average daily population (ADP) on A(H1N1)pdm09 influenza vaccine receipt found that an ADP increase of 100 inmates resulted in a 32% increased likelihood of receiving influenza vaccine among smaller jails. Zero percent of large jails, 14% of federal prisons, 11% of nonfederal prisons, and 57% of small jails reported never receiving pandemic influenza vaccine. A qualitative assessment identified barriers to vaccine delivery, lessons learned from pandemic response, and recommendations for public health partners. Building stronger relationships between public health entities and correctional facilities to collaborate in influenza pandemic preparedness efforts may help protect correctional and community populations.

Survey of laboratory animal technicians in the United States for Coxiella burnetii antibodies and exploration of risk factors for exposure.

Little is known about the prevalence of zoonotic infections among laboratory animal care technicians (LAT). Q fever, a disease caused by Coxiella burnetii, is a known occupational hazard for persons caring for livestock. We sought to determine the seroprevalence of C. burnetii antibodies among LAT and to identify risk factors associated with C. burnetii seropositivity. A survey was administered and serum samples collected from a convenience sample of 97 LAT. Samples were screened by using a Q fever IgG ELISA. Immunofluorescent antibody assays for phase I and phase II IgG were used to confirm the status of samples that were positive or equivocal by ELISA; positive samples were titered to endpoint. Antibodies against C. burnetii were detected in 6 (6%) of the 97 respondents. In our sample of LAT, seropositivity to C. burnetii was therefore twice as high in LAT as compared with the general population. Age, sex, and working with sheep regularly were not associated with seropositivity. Risk factors associated with seropositivity included breeding cattle within respondent's research facility, any current job contact with waste from beef cattle or goats, and exposure to animal waste during previous jobs or outside of current job duties. Only 15% of responding LAT reported being aware that sheep, goats, and cattle can transmit Q fever. Research facilities that use cattle or goats should evaluate their waste-management practices and educational programs in light of these findings. Additional efforts are needed to increase awareness among LAT regarding Q fever and heightened risk of exposure to infectious materials. Physicians should consider the risk of infection with C. burnetii when treating LAT with potential occupational exposures.

Use, location, and timeliness of clinical microbiology testing in Georgia for select infectious diseases.

OBJECTIVE: Although clinical microbiology testing facilitates both public health surveillance of infectious diseases and patient care, research on testing patterns is scant. We surveyed hospital laboratories in Georgia to assess their diagnostic testing practices. METHODS: Using e-mail, all directors of hospital laboratories in Georgia were invited to participate. The survey focused on timing and location of diagnostic testing in 2006 for 6 reportable diseases: giardiasis, legionellosis, meningococcal disease, pertussis, Rocky Mountain spotted fever, and West Nile virus disease. RESULTS: Of 141 laboratories, 62 (44%) responded to the survey. Hospitals varied widely in their use of diagnostic testing in 2006, with 95.1% testing for meningococcal disease, but only 66.1% and 63.3% testing for legionellosis and West Nile virus disease, respectively. Most laboratories (91%) performed gram stain/culture to diagnose meningococcal disease in-house and 23% performed ova and parasite panels for giardiasis were conducted in-house. Fewer than 11% of laboratories performed in-house testing for the remaining diseases. Laboratories affiliated with small hospitals (≤100 beds) were more likely to send specimens for outside testing compared with laboratories associated with large hospitals (>250 beds). Median turnaround time for ova and parasite panel testing for giardiasis was significantly shorter for in-house testing (1.0 days) than within-system (2.25 days) or outside laboratory (3.0 days) testing (P = .0003). No laboratories reported in-house testing for meningococcal disease, pertussis, or Rocky Mountain spotted fever using polymerase chain reaction. CONCLUSION: Many hospitals did not order diagnostic tests for important infectious diseases during 2006, even for relatively common diseases. In addition, hospital laboratories were unlikely to perform diagnostic testing in-house; sending specimens to an outside laboratory may result in substantial delays in receiving results. These unsettling findings have adverse implications for both patient care and public health surveillance; they indicate an immediate need to study nationally the use and timeliness of clinical microbiologic testing.

Do differences in risk factors, medical care seeking, or medical practices explain the geographic variation in campylobacteriosis in Foodborne Diseases Active Surveillance Network (FoodNet) sites?

BACKGROUND: In the United States, considerable geographic variation in the rates of culture-confirmed Campylobacter infection has been consistently observed among sites participating in the Foodborne Diseases Active Surveillance Network (FoodNet). METHODS: We used data from the FoodNet Population Surveys and a FoodNet case-control study of sporadic infection to examine whether differences in medical care seeking, medical practices, or risk factors contributed to geographic variation in incidence. RESULTS: We found differences across the FoodNet sites in the proportion of persons seeking medical care for an acute campylobacteriosis-like illness (range, 24.9%-43.5%) and in the proportion of ill persons who submitted a stool sample (range, 18.6%-40.7%), but these differences were not statistically significant. We found no evidence of geographic effect modification of previously identified risk factors for campylobacteriosis in the case-control study analysis. The prevalence of some exposures varied among control subjects in the FoodNet sites, including the proportion of controls reporting eating chicken at a commercial eating establishment (18.2%-46.1%); contact with animal stool (8.9%-30.9%); drinking water from a lake, river, or stream (0%-5.1%); and contact with a farm animal (2.1%-12.7%). However, these differences do not fully explain the geographic variation in campylobacteriosis. CONCLUSIONS: Future studies that quantify Campylobacter contamination in poultry or variation in host immunity may be useful in identifying sources of this geographic variation in incidence.

Lessons learned from the 2007 to 2009 Haemophilus influenzae type B vaccine shortage: implications for future vaccine shortages and public health preparedness.

OBJECTIVE: To understand immunization programs' experience managing the 2007 to 2009 Haemophilus influenzae type B (Hib) vaccine shortage and identify ways in which the US immunization system can be improved to assist in responses to future shortages of routine vaccines and large-scale public health emergencies. METHODS: An Internet-based survey was conducted from July 2009 to October 2009 among the 64 city, state, and territorial immunization program managers (IPMs). RESULTS: Fifty-eight percent (37 of the 64) of IPMs responded. Forty percent of responding IPMs indicated not having enough Hib vaccine within their Vaccines for Children program to fulfill the temporary 3-dose recommendation issued in December 2007 in response to the Hib vaccine shortage. While 73% of IPMs indicated success in monitoring provider inventory and 68% indicated success in monitoring doses administered during the shortage, fewer than half indicated success in monitoring providers' compliance with shortage-specific recommendations regarding Hib vaccine. Forty-six percent of IPMs used their immunization information system (IIS) to monitor provider compliance with recommendations regarding Hib vaccine use, and of these, nearly 60% reported success in monitoring provider compliance with recommendations compared with 35% of IPMs who did not use their IIS in this way. Forty-two percent of IPMs felt that the Centers for Disease Control and Prevention (CDC) was successful in determining stockpiled vaccine allocations to their program, and 56% felt that the CDC was successful in communicating its rationale for their immunization program's Hib allocation during the shortage. CONCLUSIONS: Experiences from the 2007 to 2009 Hib vaccine shortage offer insights on how the US immunization system and system-wide response to vaccine shortages can be improved. Results from this survey suggest that improving vaccine transfer between jurisdictions and using IIS to track provider compliance with shortage recommendations are 2 ways that can help the US immunization system respond to future vaccine shortages and large-scale public health emergencies like influenza pandemics.

Perspectives of immunization program managers on 2009-10 H1N1 vaccination in the United States: a national survey.

In June and July 2010, we conducted a national internet-based survey of 64 city, state, and territorial immunization program managers (IPMs) to assess their experiences in managing the 2009-10 H1N1 influenza vaccination campaign. Fifty-four (84%) of the managers or individuals responsible for an immunization program responded to the survey. To manage the campaign, 76% indicated their health department activated an incident command system (ICS) and 49% used an emergency operations center (EOC). Forty percent indicated they shared the leadership of the campaign with their state-level emergency preparedness program. The managers' perceptions of the helpfulness of the emergency preparedness staff was higher when they had collaborated with the emergency preparedness program on actual or simulated mass vaccination events within the previous 2 years. Fifty-seven percent found their pandemic influenza plan helpful, and those programs that mandated that vaccine providers enter data into their jurisdiction's immunization information system (IIS) were more likely than those who did not mandate data entry to rate their IIS as valuable for facilitating registration of nontraditional providers (42% vs. 25%, p<0.05) and tracking recalled influenza vaccine (50% vs. 38%, p<0.05). Results suggest that ICS and EOC structures, pandemic influenza plans, collaborations with emergency preparedness partners during nonemergencies, and expanded use of IIS can enhance immunization programs' ability to successfully manage a large-scale vaccination campaign. Maintaining the close working relationships developed between state-level immunization and emergency preparedness programs during the H1N1 influenza vaccination campaign will be especially important as states prepare for budget cuts in the coming years.