[From genomics to surveillance, prevention and control: new challenges for the African meningitis belt]. / Ceinture africaine de la méningite: de la génomique aux stratégies de surveillance, de lutte et de prévention.

An international conference was held in Niamey, Niger, in November 2005. It aimed at reviewing the current situation in the meningitis belt. This region stretches from Senegal to Ethiopia and is characterized by high levels of seasonal endemicity with large epidemics of meningococcal meningitis occurring cyclically, generally caused by N. meningiditis serogroup A. WHO currently recommends a reactive strategy based on rapid detection of epidemics, intervention with antibiotics to treat cases and mass vaccination with a meningococcal polysaccharide vaccine to halt the outbreak. Epidemiological patterns of the disease in Africa have been changing with the occurrence of outbreaks outside the meningitis belt and with the emergence of serogroup W135, which first caused an epidemic among Hajj pilgrims in 2000 and then a large-scale meningitis outbreak in Burkina Faso in 2002. Consequently enhanced laboratory surveillance and confirmation of the strain responsible for the outbreak are required. New rapid dipstick tests have been developed through a collaboration between Institut Pasteur and CERMES. They are designed for bedside diagnosis and detect meningococcal antigens present in CSF using immunochromatography. The treatment of meningococcal meningitis during epidemics is based on short-course, long-acting oily chloramphenicol. An alternative is the use of ceftriaxone, which is equally effective and can be used in pregnant women and infants. A low-cost, monovalent serogroup A meningococcal conjugate vaccine for large-scale use in Africa is under development. In spite of the emergence of W135 strains in the meningitis belt, N. meningiditis A continues to be the principal strain isolated during the epidemic seasons and elimination of outbreaks of N. meningiditis serogroup A can still be considered as the primary objective of a preventive vaccination strategy.

Serologic studies in suspected visceral candidiasis.

Twenty-six healthy controls and 45 patients with clinically suspected candidiasis were studied utilizing precipitin determination by double immunodiffusion, agglutinin titers, and presence of clumping factor by microscopy. The data are used to evaluate the specificity, reproducibility, and ease of performance of the procedures. Our results indicate that there is considerable overlap in agglutinin titers in patients with or without visceral candidiasis and that determination of clumping factor by microscopy only is inadequate for diagnosis. Precipitin tests were positive in 80% of patients with visceral candidiasis (exceptions were highly immunosuppressed hosts). This test is easily performed, reproducible, and can be applied in any general hospital laboratory. Neither agglutinin nor precipitin determination appears to be applicable to determining duration of therapy.

A coordinated, communitywide program in Monroe County, New York, to increase influenza immunization rates in the elderly.

BACKGROUND: Despite the efficacy of influenza vaccination in preventing complications of influenza, rates of immunization among high-risk populations remain low. The Monroe County (New York) Influenza Vaccination Demonstration was a communitywide, collaborative effort to increase the rates of influenza immunization to greater than 60% in elderly Medicare recipients. METHODS: The local health department, university medical center, and practicing physicians collaborated to develop a communitywide demonstration directed to all Medicare part B enrollees 65 years of age or older, multiple coordinated approaches were used over a 4-year period (1988 to 1992). Most providers, including public agencies, private providers, hospital outpatient facilities, nursing homes, and insurance providers, were enrolled in a comprehensive program that included centralized claims processing, vaccine distribution and promotion, and extensive provider and public education efforts, including a special urban outreach program. An office-based, denominator-driven physician incentive project was also evaluated. RESULTS: The demonstration project resulted in a 1991 influenza immunization rate of 74.3% among 88,811 Medicare enrollees 65 years of age or older. The increase in immunization rate occurred primarily among the patients of private physicians. CONCLUSION: A communitywide, collaborative approach can succeed in achieving high rates of influenza immunization.

A mobile internal medicine clinic.

The Denver Veterans Administration Medical Center (DVAMC) established a mobile internal medicine clinic (MediVAn) to provide access to primary care for veterans living more than fifty miles from the center and to study the costs of such an outreach program. A fully equipped van staffed by an internist visited four Colorado cities weekly for scheduled appointments. In the first two years of operation there were 4,655 visits by 766 veterans with a mean age of 56 years, with 3.9 diagnoses, and receiving 3.0 medicines. The cost per MediVAn visit was $68, compared with $67 per outpatient visit at DVAMC. We conclude that a mobile medical clinic is a convenient method of delivering primary care over distances and is comparable in cost to outpatient hospital visits.

Pulmonary cavitation following pulmonary infarction.

Cavitation following bland pulmonary infarction is not commonly considered in the differential diagnosis of cavitary lung disease. In a 4-year period we have found 10 cases of cavitating pulmonary infarction (CPI) by reviewing serial chest radiographs from autopsies with pulmonary infarction and in all cases with positive ventilation-perfusion lung scans. We have compared these cases to 31 previously reported cases in the English literature that met our criteria for CPI. In our 10 patients, there were 12 radiographic cavities; 5 in the upper lobes, 5 in the lower lobes and 2 in the middle lobe. This distribution was consistent with a relative upper-lobe predominance in the literature review. In nine patients the cavitation appeared rapidly (mean, 5 days) and was associated with fever, purulent sputum, and leukocytosis. Sputum cultures were obtained in eight patients, revealing Pseudomonas aeruginosa and Escherichia coli in three each and Proteus species in two. In four patients, pulmonary infarction was not considered and the diagnosis was made at autopsy, a situation also common in previously reported cases. We have seen a high incidence of CPI in a retrospective review of patients with pulmonary infarction, and we believe that it is important to consider this diagnosis when evaluating cavitary lesions.

Hospital-acquired gram-negative rod pneumonias: an overview.

Because of a high incidence and case fatality rate, nosocomial infections of the lower respiratory tract due to aerobic gram-negative rods are important, particularly in patients bedded in intensive care units. Risk factors include severity of illness, antimicrobial therapy and respiratory tract instrumentation. Respiratory tract colonization, which invariably precedes infection, seems to be a general characteristic of patients with severe illness, whereas normal oral defenses clear gram-negative bacteria very efficiently. Pneumonia follows after failure of pulmonary antibacterial defenses to cope with aspirated inoculums. Attempts to block colonization with local antimicrobials result not only in a transient decrease in colonization and pneumonia but also in the appearance of resistant organisms. Attempts to enhance human lung antibacterial defenses by bacterial interference or immunization have not been well studied. Despite some progress, the general outlook for immediate control of these infections is not encouraging.

Inefficacy of pneumococcal vaccine in a high-risk population.

Use of pneumococcal vaccine remains controversial. To further study this question, 89 patients hospitalized at the Denver Veterans Administration Medical Center with pneumococcal bacteremia were chosen as the case group for a case-control study. The control group was made up of patients matched on the basis of age, date of admission, and comorbid conditions. Vaccination status in the bacteremic patients and control patients was determined, as were pneumococcal serotypes among the bacteremic patients. If the vaccine were protective, vaccination rates should be higher among the control patients, and serotype distribution should be different in vaccinated and nonvaccinated bacteremic patients. There were no differences between vaccination rates among bacteremic patients (29 percent) and control patients (24 percent). Furthermore, 65 percent of the blood isolates from nonvaccinated bacteremic patients were serotypes included in the vaccine, as compared with 69 percent of the isolates in vaccinated bacteremic patients. Pneumococcal vaccine did not appear to be protective in this high-risk population.

Campylobacter enteritis associated with unpasteurized milk.

Campylobacter fetus ss. jejuni has recently been recognized as a human enteric pathogen. Laboratory isolation has been hindered by its fastidious nature. Methods for recovery of this organism from stool culture and a specific serologic test are described. An outbreak is reported in which three members of the same family became simultaneously ill with fever, severe abdominal cramps and diarrhea. C. fetus ss. jejuni was recovered from stool specimens from all three. A fourfold increase in serum immunoglobulin G (IgG) titer to this organism was demonstrated in each patient. All three patients had been consuming unpasteurized milk from a cow whose feces were infected with C. fetus ss. jejuni.

Bacteremic hemophilus influenzae pneumonia in adults. A report of 24 cases and a review of the literature.

Twenty-four cases of Hemophilus influenzae pneumonia diagnosed by positive blood or pleural fluid cultures are compared to 43 cases previously reported in the literatrue. Frequently associated illnesses in both series include alcoholism, chronic airways obstruction and preceding respiratory tract infection. Moderate temperature elevation and slight leukocytosis were common on admission in both groups. Chest roentgenograms in our series revealed both bronchopneumonia (75 per cent) and lobar consolidation (38 per cent). Pleural disease occurred frequently, with two empyemas noted on admission and nine additional effusions developing during therapy. Treatment of choice was ampicillin. All five patients who did not receive ampicillin died, whereas 16 to 19 who received this drug survived. High mortality (33 per cent) in our series may be attributed to the advanced age of the patients and the presence of associated illnesses. In addition, a 10 year review suggests a true increase in the incidence of H. influenzae pneumonia in adults.

Iatrogenic disease in hospitalized elderly veterans.

To help determine whether or not the elderly are at unusually high risk for hospital-related complications, a study was made of consecutive admissions involving 48 patients less than 65 years old (mean 50.3 years) and 174 patients more than 65 years old (mean 73.1 years). They were prospectively followed during their hospital stays, and were monitored daily. According to admission data, they were classified as : Group 1, likely to die soon after admission; Group II, likely to die within a year; Group III, likely to live longer than a year. Complications were listed under the causal factors: trauma, infection, hospital procedures, drugs, and miscellaneous. About 90 per cent of all 222 patients in both age categories were in Group III. The overall complication rates were 29 per cent for patients under 65, and 45 per cent for those over 65 (P less than 0.05). For the under-65 Group III patients, the rates were 17 per cent and 42 per cent for medical and surgical patients, respectively; for the over-65 patients, the rates were 40 per cent (medical) and 43 per cent (surgical). This indicated a major increase in complications among medical patients more than 65 years old. Procedure-related problems were most common among surgical patients under 65. For over-65 patients, the complication rates for procedure-related, trauma, miscellaneous, infection, and drug toxicity categories were fairly evenly distributed within the range of 16.8-12.8 per cent, in that order. Major psychiatric deterioration was observed in 10.7 per cent of patients over 65, but in none of the younger subjects. Drug toxicity and traumatic complications were also more common in the older patients. These data confirm the disproportionately high incidence of iatrogenic diseases in hospital patients over the age of 65. Several of these complications are amenable to control.

Pulmonary aspiration in a long-term care setting: clinical and laboratory observations and an analysis of risk factors.

OBJECTIVE: To determine the incidence and risk factors associated with aspiration in a high risk group in a long-term care setting. DESIGN: A prospective study of demographic, nutritional, clinical, dental, and survival characteristics in 69 patients who suffered 98 aspirations events from May 1, 1990, to December 31, 1990. Demographic and nutritional data from 192 patients who did not aspirate were collected from September 1991 to December 1991. SETTING: A long-term care VA facility. PATIENTS: Long-term care residents, most of whom were neurologically debilitated. MEASUREMENTS: The incidence of aspiration was measured and the clinical and microbiological characteristics of aspiration-associated nosocomial pneumonia described. Mortality and demographic, clinical, and nutritional characteristics were compared between patients who aspirated and those who did not. MAIN RESULTS: Twenty-five percent of the study group aspirated during the 8-month observational period, and 56% of the aspiration events progressed to roentgenographically proven cases of nosocomial pneumonia. Six bacteremic episodes were documented, and results of sputum cultures were consistent with mixed Gram-positive and Gram-negative infections. During the study period, patients who aspirated were at three times the risk of dying compared with patients who did not aspirate. Three years later, only 17% of the original group of patients who aspirated were still alive compared with 60% of the patients who had not aspirated. Multivariate analysis identified tube feeding, presence of a hyperextended neck or contractions, malnutrition, and the use of benzodiazepines and anticholinergics as risk factors. CONCLUSIONS: Pulmonary aspiration is a common and serious event in neurologically impaired long-term care patients. Some risk factors are amenable to change.

A retrospective study of nosocomial pneumonia at a long-term care facility.

BACKGROUND: Results of a passive surveillance system (pneumonia confirmed by x-ray examination) suggested that in 1989 a total of 187 cases of nosocomial pneumonia had occurred at the Canandaigua Veterans Administration Medical Center among 250 long-term care patients. METHODS: A retrospective study was undertaken to validate cases and to enumerate risk factors. A chart review showed that 136 of 187 cases (72%) met predetermined criteria for nosocomial pneumonia. RESULTS: Three nursing units characterized as at high risk had a pneumonia rate of 1.90 per 1000 patient days, as compared with a rate of 0.70 cases per 1000 patient days on the two other units. There were no differences in age, mean white blood cell count, or clinical symptoms between high- and average-risk patients. Two thirds of all patients had a history of chronic aspiration. High-risk patients were more likely to be confined to bed, to have a debilitating neurologic disease, and to require tube feedings. Twenty percent of patients on high-risk units died of nosocomial pneumonia or with nosocomial pneumonia as a contributory factor. CONCLUSIONS: Facility-associated pneumonia is an important cause of morbidity and mortality in long-term care facilities.

Poliomyelitis vaccines. Success and controversy.

The conquest of poliomyelitis by killed and live poliomyelitis vaccines is arguably the most successful American public health project. In 1950, 20,000 cases of paralytic poliomyelitis were reported in the United States, whereas in recent years, fewer than 10 cases were reported. These few cases were largely associated with oral vaccine and despite their small number have led to a reconsideration of killed vaccine as a public health measure in the United States.

Evaluation of respiratory problems.

Respiratory problems are common in international travelers. Most are self-limited and do not result in significant morbidity. Those that are severe enough to result in fever and an abnormal chest roentgenogram may pose diagnostic difficulties. The familiar bacterial respiratory pathogens found worldwide are the most common causes of this syndrome, but less familiar entities also need to be considered. A careful evaluation, including a thorough travel history, should yield the diagnosis.

"McFlu". The Monroe County, New York, Medicare vaccine demonstration.

BACKGROUND: Monroe County (MC) NY was one of 9 original sites for the 1988-1992 Medicare Influenza Vaccine Demonstration, which led to Medicare coverage of annual influenza vaccination. The "McFlu" project involved collaboration among university, health department, and practice community. METHODS: Community-wide systems for promoting and/or documenting influenza vaccine delivery and for conducting laboratory-based influenza surveillance were established in MC and in neighboring Onondaga County (OC), which served as a comparison site without Medicare coverage of vaccination. Vaccination utilization and virologic surveillance data collected from physician practices, hospitals, and nursing homes were furnished to national demonstration evaluators. RESULTS: Influenza vaccination rates among persons > or = 65 years of age increased from 41% to 74% in MC compared to an increase from 46% to 57% in OC. The greatest increase occurred in physician offices utilizing an innovative vaccination promotion and tracking strategy. Community-wide influenza A/H3N2 and B outbreaks were documented in three successive demonstration years, affording investigators the opportunity to better define influenza impact and vaccine effectiveness among the Medicare population. CONCLUSION: The McFlu project exemplifies the potential for linking the academic and public health sectors to complement each others' strengths in planning, implementing and documenting a targeted program for improving community health. This model of medicine and public health collaboration should be applicable to attaining other well articulated goals for the health of the public.

Performance-based physician reimbursement and influenza immunization rates in the elderly. The Primary-Care Physicians of Monroe County.

OBJECTIVE: To investigate the effect of performance-based financial incentives on the influenza immunization rate in primary care physicians' offices. DESIGN: Randomized controlled trial during the 1991 influenza immunization season. SETTING: Rochester, New York, and surrounding Monroe County during the Medicare Influenza Vaccine Demonstration Project. PARTICIPANTS: A total of 54 solo or group practices that had participated in the 1990 Medicare Demonstration Project. INTERVENTIONS: All physicians in participating practices agreed to enumerate their ambulatory patients aged 65 or older who had been seen during the 1990 or 1991 calendar years, and to track the immunization rate on a weekly basis using a specially designed poster from September 1991 to January 1, 1992. Additionally, physicians agreed to be randomized, by practice group, to the control group or to the incentive group, which could receive an additional $.80 per shot or $1.60 per shot if an immunization rate of 70% or 85%, respectively, was attained. MEASUREMENTS: The main outcome measures are the 1991 immunization rate and the improvement in immunization rate from the 1990 to 1991 influenza seasons for each group practice. RESULTS: For practices in the incentive group, the mean immunization rate was 68.6% (SD 16.6%) compared with 62.7% (SD 18.0%) in the control group practices (P = .22). The median practice-specific improvement in immunization rate was +10.3% in the incentive group compared with +3.5% in the control group (P = .03). CONCLUSIONS: Despite high background immunization rates, this modest financial incentive was responsible for approximately 7% increase in immunization rate among the ambulatory elderly.

A performance-based incentive program for influenza immunization in the elderly.

Our objective was to implement and evaluate performance-based reimbursement for influenza immunization of the elderly in physician offices. We performed a community-based quasi-experiment with historic and concurrent comparisons, using primary care physician offices in Monroe County, New York. Participants in the intervention group included 53 primary care physicians admitting to one hospital, and the comparison group included 82 primary care physicians admitting to other hospitals. All physicians participated in a Medicare-sponsored demonstration to increase influenza immunization rates, and, during the 1990-1991 immunization season, used a target-based poster to track immunization rates. Physicians in the intervention group were enrolled in a performance-based financial incentive program that rewarded immunization rates above 70%. A survey concerning influenza immunization practices and opinions was sent to all physicians. The average physician-specific immunization rate in the incentive group was 73.1% versus 55.7% in the comparison practices (P < .001). Eligibility for incentives, practice size, sex of physician, medical specialty, reminder postcards, and practice populations including medically indigent patients were associated with immunization level. Controlling for the above variables, we completed a regression analysis showing that eligibility for the incentive was still significant (P = .003). The survey responses were not predictive of performance or significantly different between the two groups, except for the negative influence of sending postcards. This study in a community setting suggests that linking reimbursement to performance may be a successful strategy to increase influenza immunization levels for the elderly.

Non-pneumococcal Gram-positive coccal meningitis related to neurosurgery.

Thirty-eight of 154 cases (25%) of bacterial meningitis seen by the authors during a 7-year period were due to non-pneumococcal Gram-positive cocci. Thirty cases (80%) resulted from neurosurgical manipulation; half of these were shunt infections and half were early postoperative complications. Only three cases (8%) occurred de novo in patients with presumably normal host defenses. Signs, symptoms, and laboratory data related more to predisposing factors than to infecting microorganisms. Fever, peripheral leukocytosis, abnormal cerebrospinal fluid (CSF), and positive Gram stain were the most reliable indicators of infection. Prognosis was good with antibiotic therapy and removal of CSF shunt equipment when present.

Adverse effects of lidocaine and methylparaben on tracheal ciliary activity.

The effect of standard concentrations of lidocaine HCl and methylparaben (preservative) on the ciliary activity of ferret tracheal rings in organ culture was assessed. Pure lidocaine concentrations as low as 0.5% caused complete ciliostasis which was reversible after removal of the drug. One percent and two percent effects were not completely reversible. Pure methylparaben concentrations as low as 0.06 mg/ml paralyzed cilia; and, at concentrations of 0.5 mg/ml or higher, adverse effects were not completely reversible. When lidocaine and methylparaben were combined at the same ratio used in commercial preparations, their ciliotoxic effects were additive. These data suggest that topical respiratory anesthesia may result in prolonged ciliary paralysis.