Estimating the True Burden of Legionnaires' Disease.

Over the past decade, the reported incidence of Legionnaires' disease (LD) in the northeastern United States has increased, reaching 1-3 cases per 100,000 population. There is reason to suspect that this is an underestimate of the true burden, since LD cases may be underdiagnosed. In this analysis of pneumonia and influenza (P&I) hospitalizations, we estimated the percentages of cases due to Legionella, influenza, and respiratory syncytial virus (RSV) by age group. We fitted mixed-effects models to estimate attributable percents using weekly time series data on P&I hospitalizations in Connecticut from 2000 to 2014. Model-fitted values were used to calculate estimates of numbers of P&I hospitalizations attributable to Legionella (and influenza and RSV) by age group, season, and year. Our models estimated that 1.9%, 8.8%, and 5.1% of total (all-ages) inpatient P&I hospitalizations could be attributed to Legionella, influenza, and RSV, respectively. Only 10.6% of total predicted LD cases had been clinically diagnosed as LD during the study period. The observed incidence rate of 1.2 cases per 100,000 population was substantially lower than our estimated rate of 11.6 cases per 100,000 population. Our estimates of numbers of P&I hospitalizations attributable to Legionella are comparable to those provided by etiological studies of community-acquired pneumonia and emphasize the potential for underdiagnosis of LD in clinical settings.

Association Between Sporadic Legionellosis and River Systems in Connecticut.

Background: There has been a dramatic increase in the incidence of sporadic legionnaires' disease in Connecticut since 1999, but the exact reasons for this are unknown. Therefore, there is a growing need to understand the drivers of legionnaires' disease in the community. In this study, we explored the relationship between the natural environment and the spatial and temporal distribution of legionellosis cases in Connecticut. Methods: We used spatial models and time series methods to evaluate factors associated with the increase and clustering of legionellosis in Connecticut. Stream flow, proximity to rivers, and residence in regional watersheds were explored as novel predictors of disease, while controlling for testing intensity and correlates of urbanization. Results: In Connecticut, legionellosis incidence exhibited a strong pattern of spatial clustering. Proximity to several rivers and residence in the corresponding watersheds were associated with increased incidence of the disease. Elevated rainfall and stream flow rate were associated with increases in incidence 2 weeks later. Conclusions: We identified a novel relationship between the natural aquatic environment and the spatial distribution of sporadic cases of legionellosis. These results suggest that natural environmental reservoirs may have a greater influence on the spatial distribution of sporadic legionellosis cases than previously thought.

Assessment of postarrival tuberculosis examinations among immigrants and refugees screened overseas.

BACKGROUND: Immigrants and refugees screened overseas and found to have Mycobacterium tuberculosis infection (TB arrivers) are either treated fortuberculosis (TB) or, if disease is not found these arrivers are given a TB classification of latent TB infection (LTBI) and are referred for reexamination after arriving in the United States. METHODS: A retrospective cohort analysis was performed of TB arrivers in Connecticut to determine the proportion of TB arrivers documentedwith their postarrival domestic medical examination and to determine the proportion of TB arriverswho started and completed LTBI treatment. RESULTS: Of 184TB arrivers, 109 (59%) were evaluated for TB after arrival and four (4%) were diagnosed withTB. Of 105 personswith LTBI,49 (47%) started treatment, and of those 15(30%) completedtreatment. CONCLUSION: The majority of TB cases in Connecticut are among foreign-born individuals. Improving TB control overseas is a crucial step in the reduction of TB in the United States. Improvements are still needed to ensure timely, postarrival medical examinations that ensure treatment for high-risk persons with LTBI to reduce TB in Connecticut's foreign-born populations.

Opportunities to improve colorectal cancer screening in Connecticut through Medicare claims data.

Colorectal cancer represents a serious public-health problem in the United States, with important geographic differences and disparities of care evident in its detection and treatment. While effective screening tests exist, Connecticut lacks current data about rates of colorectal cancer screening. The Connecticut Department of Public Health commissioned Qualidigm, the federally designated Quality Improvement Organization, to conduct an analysis of 2008 fee-for-service Medicare claims data to determine screening rates. This article reports the findings of this analysis to increase awareness of opportunities for improvement in colorectal cancer screening and to highlight demographic and geographic variations that may require particular attention in Connecticut.

A 2009 varicella outbreak in a Connecticut residential facility for adults with intellectual disability.

We investigated a varicella outbreak in a residential facility for adults with intellectual disabilities. A case of varicella was defined as a generalized maculopapular rash that developed in a facility resident or employee. Immunoglobulin M testing was conducted on serologic samples, and polymerase chain reaction testing was performed on environmental and skin lesion samples. Eleven cases were identified among 70 residents and 2 among ∼145 staff. An unrecognized case of herpes zoster was the likely source. Case patients first entered any residential facility at a younger age than non-case residents (9.5 vs 15.0 years; P < .01). Varicella zoster virus DNA was detected 2 months after the outbreak in environmental samples obtained from case patients' residences. This outbreak exemplifies the potential for at-risk pockets of varicella-susceptible adults, especially among those who have lived in residential facilities from a young age. Evidence of immunity should be verified for all adults and healthcare staff in similar residential settings.

Agritourism and Kidding Season: A Large Outbreak of Human Shiga Toxin-Producing Escherichia coli O157 (STEC O157) Infections Linked to a Goat Dairy Farm-Connecticut, 2016.

The objective of this study was to determine sources of Shiga toxin-producing Escherichia coli O157 (STEC O157) infection among visitors to Farm X and develop public health recommendations. A case-control study was conducted. Case-patients were defined as the first ill child (aged <18 years) in the household with laboratory-confirmed STEC O157, or physician-diagnosed hemolytic uremic syndrome with laboratory confirmation by serology, who visited Farm X in the 10 days prior to illness. Controls were selected from Farm X visitors aged <18 years, without symptoms during the same time period as case-patients. Environment and animal fecal samples collected from Farm X were cultured; isolates from Farm X were compared with patient isolates using whole genome sequencing (WGS). Case-patients were more likely than controls to have sat on hay bales at the doe barn (adjusted odds ratio: 4.55; 95% confidence interval: 1.41-16.13). No handwashing stations were available; limited hand sanitizer was provided. Overall, 37% (29 of 78) of animal and environmental samples collected were positive for STEC; of these, 62% (18 of 29) yielded STEC O157 highly related by WGS to patient isolates. STEC O157 environmental contamination and fecal shedding by goats at Farm X was extensive. Farms should provide handwashing stations with soap, running water, and disposable towels. Access to animal areas, including animal pens and enclosures, should be limited for young children who are at risk for severe outcomes from STEC O157 infection. National recommendations should be adopted to reduce disease transmission.

Multistate analysis of prospective Legionnaires' disease cluster detection using SaTScan, 2011-2015.

Detection of clusters of Legionnaires' disease, a leading waterborne cause of pneumonia, is challenging. Clusters vary in size and scope, are associated with a diverse range of aerosol-producing devices, including exposures such as whirlpool spas and hotel water systems typically associated with travel, and can occur without an easily identified exposure source. Recently, jurisdictions have begun to use SaTScan spatio-temporal analysis software prospectively as part of routine cluster surveillance. We used data collected by the Active Bacterial Core surveillance platform to assess the ability of SaTScan to detect Legionnaires' disease clusters. We found that SaTScan analysis using traditional surveillance data and geocoded residential addresses was unable to detect many common Legionnaires' disease cluster types, such as those associated with travel or a prolonged time between cases. Additionally, signals from an analysis designed to simulate a real-time search for clusters did not align with clusters identified by traditional surveillance methods or a retrospective SaTScan analysis. A geospatial analysis platform better tailored to the unique characteristics of Legionnaires' disease epidemiology would improve cluster detection and decrease time to public health action.

Tryptophan hydroxylase 2 gene and alcohol use among college students.

Genes that regulate serotonin activity are regarded as promising predictors of heavy alcohol use. Tryptophan hydroxylase (TPH2) plays an important role in serotonergic neurotransmission by serving as the rate-limiting enzyme for serotonin biosynthesis in the midbrain and serotonergic neurons. Despite the link between TPH2 and serotonergic function, TPH2's role in the pathogenesis of alcohol-use disorders remains unclear. The goal of this study was to examine whether a variation in the TPH2 gene is associated with risky alcohol consumption. Specifically, this study examined whether the TPH2 G-703T polymorphism predicted alcohol consumption among college students. In two successive years, 351 undergraduates were asked to record their alcohol use each day for 30 days using an Internet-based electronic diary. Participants' DNA was collected and polymerase chain reaction genotyping was performed. Results show that alcohol consumption was not associated with the TPH2 G-703T polymorphism alone, or the interaction of TPH2 with two other candidate polymorphisms (TPH1 C218A and the SLC6A4 tri-allelic 5-HTTLPR), or negative life events. In conclusion, this study supports recent null findings relating TPH2 to drinking outcomes. It also extends these findings by showing null interactions with the TPH1 C218A polymorphism, the SLC6A4 tri-allelic 5-HTTLPR polymorphism and environmental stressors in predicting sub-clinical alcohol use among Caucasian American young adults.