Injuries from the wichita falls tornado: implications for prevention.

We examined the circumstances of death and injury among victims of the tornado that struck Wichita Falls, Texas, on 10 April 1979. We also assessed the protective measures taken by a representative sample of community residents who suffered no major injury in order to estimate the relative risk of injury to people directly in the tornado's path. Twenty-six (60 percent) of the 43 traumatic deaths and 30 (51 percent) of the 59 serious injuries occurred in people who, despite ample warning, went to their cars to drive out of the storm's path. These people had a risk of serious or fatal injury of 23 per 1000. People who remained indoors and in stationary homes were at relatively low risk (3 per 1000) if they took simple precautions; people in mobile homes were at greatest risk (85 per 1000). Current safety recommendations and housing codes for single family homes and mobile homes need to be amended to decrease the impact of future tornadoes on human health.

Plague and tularemia.

Human plague is a local or systemic flea-transmitted infection caused by Yersinia pestis. It is maintained in well established enzootic foci among wild rodents. This article discusses the clinical findings in plague, diagnosis, treatment, and prevention of plague, and management of contacts of human plague cases and of exposures to epizootic plague. Tularemia shares many features with plague but is widespread in animal and arthropod vector populations and essentially throughout the United States.

Outbreak of tick-borne relapsing fever at the north rim of the Grand Canyon: evidence for effectiveness of preventive measures.

An outbreak of tick-borne relapsing fever (TBRF) originating at the North Rim of Grand Canyon National Park was investigated in 1990. To determine risk factors for the disease, almost 7,000 parties of visitors were surveyed; over half responded, representing > 10,000 people. Fifteen cases of confirmed or probable TBRF were identified in visitors and 2 in employees. All patients except one experienced symptoms after overnight stays in a group of cabins that had not been rodent-proofed after a TBRF outbreak in 1973 (relative risk for visitors [RR] 8.2, 95% confidence interval [CI] 1.1-62). Seven cases of TBRF were associated with a single cabin (RR 98, 95% CI 30-219). Structural flaws and rodent nests were common in the implicated cabins and rare in unaffected cabins. This investigation suggests that measures to rodent-proof cabins at sites where TBRF is endemic prevent reinfestation of cabins by infected rodents and tick vectors, thereby preventing the spread of disease in humans.

Limitations of the complement-fixation test for distinguishing naturally acquired from vaccine-induced yellow fever infection in flavivirus-hyperendemic areas.

On the basis of previous studies, it has long been stated that 17D yellow fever (YF) vaccine generally does not induce complement-fixing (CF) antibodies, and that the presence of CF antibodies could be used in epidemiological studies to distinguish individuals infected with wild YF virus from vaccinated persons. In January 1979, seroepidemiological investigations were conducted during a YF epidemic in The Gambia, West Africa. Since a mass vaccination campaign was also in progress, it was important to confirm that the CF test could be used for serodiagnosis and determination of the incidence of natural YF infections. The serological responses of 58 individuals who received 17D YF vaccine were studied. The vaccinees fell into three gorups: 1) those with prevaccination YF neutralizing (N) antibodies; 2) immunological virgins without prevaccination YF-N antibody or hemagglutination-inhibiting (HI) antibodies to heterologous flaviviruses (Zika, West Nile, dengue 1, Uganda S, Spondweni, or Ntaya; and 3) those without prevaccination YF-N antibodies but with heterologous flaviviral HI antibodies. Vaccination of persons without prior flaviviral immunological experience resulted in monotypic YF HI and/or N antibody seroconversions, but no CF antibody response. The presence of prevaccination YF N antibodies blocked serological response to the vaccine in a high proportion of the cases; however, 24% of vaccinees in this group had a marked rise in log2 YF CF antibody titer (mean increase of 3.9). Thirteen (46%) of 28 persons without prevaccination YF N, but with heterologous flaviviral HI antibodies demonstrated YF CF antibody seroconversion or increase in titer following vaccination; in this group the mean increase in log2/ YF CF antibody titer was 2.1. The CF antibody response was generally broadly cross-reactive; but in a few individuals, the YF CF antibody response was homotypic. Nine different patterns of HI and CF homologous and heterologous antibody responses were defined and are discussed. The practical significance of these studies is that they demonstrate that in a high percentage of persons with prior flavivirus exposure, anamnestic serological responses to YF vaccine result in CF antibodies similar to those induced by natural YF virus infection. In Africa and tropical America, where the background of flaviviral immunity is high, it is imperative that seroepidemiologic investigations during or after YF outbreaks be conducted prior to vaccination.

Yellow fever in the Gambia, 1978--1979: epidemiologic aspects with observations on the occurrence of orungo virus infections.

An epidemic of yellow fever (YF) occurred in the Gambia between May 1978 and January 1979. Retrospective case-finding methods and active surveillance led to the identification of 271 clinically suspected cases. A confirmatory or presumptive laboratory diagnosis was established in 94 cases. The earliest serologically documented case occurred in June 1978, at the extreme east of the Gambia. Small numbers of cases occurred in August and September. The epidemic peaked in October, and cases continued to occur at a diminishing rate through January, when a mass vaccination campaign was completed. The outbreak was largely confined to the eastern half of the country (MacCarthy Island and Upper River Divisions). In nine survey villages in this area (total population 1,531) the attack rate was 2.6--4.4%, with a mortality rate of 0.8%, and a case fatality rate of 19.4%. If these villages are representative of the total affected region, there may have been as many as 8,400 cases and 1,600 deaths during the outbreak. The disease incidence was highest in the 0- to 9-year age group (6.7%) and decreased with advancing age to 1.7% in persons over 40 years. Overall, 32.6% of survey village inhabitants had YF complement-fixing (CF) antibodies. The prevalence of antibody patterns indicating primary YF infection decreased with age, in concert with disease incidence. The overall inapparent:apparent infection ratio was 12:1. In persons with serological responses indicating flaviviral superinfection, the inapparent:apparent infection ratio was 10 times higher than in persons with primary YF infection. Sylvatic vectors of YF virus, principally Aedes furcifer-taylori and Ae. luteocephalus are believed to have been responsible for transmission, at least at the beginning of the outbreak. Eighty-four percent of wild monkeys shot in January 1979 had YF neutralizing antibodies, and 32% had CF antibodies. Domestic Aedes aegypti were absent or present at very low indices in many severely affected villages (see companion paper). In January, however, aegypti-borne YF 2.5 months into the dry season was documented by isolation of YF virus from a sick man and from this vector species in the absence of sylvatic vectors. Thus, in villages where the classical urban vector was abundant, interhuman transmission by Ae. aegypti occurred and continued into the dry season. A mass vaccination campaign, begun in December, was completed on 25 January, with over 95% coverage of the Gambian population. A seroconversion rate of 93% was determined in a group of vaccinees. This outbreak emphasizes the continuing public health importance of YF in West Africa and points out the need for inclusion of 17D YF vaccination in future programs of multiple immunication.

Studies on the control of plague in the western United States: laboratory trials of six insecticide dust formulations applied to soil for the control of the plague vector Oropsylla montana (Siphonaptera: Ceratophyllidae).

In this study, six insecticide dust formulations were laboratory-tested in soil mixtures ranging in concentration from 40 to 1,280 parts per million (ppm) against a proven vector of bubonic plague, Oropsylla montana (Baker). Pulicidal effects of the six insecticides, which included three organophosphates, two carbamates, and a pyrethroid, were compared by LD(50) values at both ambient and 75% RH. Permethrin (Pyraperm 455 dust), a pyrethroid with a LD(50) less than 40 ppm, demonstrated the most effective pulicidal action for the 13-wk trial period, followed in order by chlorpyrifos, bendiocarb, propetamphos, diazinon, and carbaryl.

Reported cases of human plague infections in the United States, 1970-1991.

From 1970 to 1991, 295 indigenous cases and one imported case of human plague were reported in the United States. Eighty-two percent of the total indigenous cases occurred in New Mexico, Arizona, and Colorado. Ninety-three percent of these cases had onset in the months of April through November. Most cases (89%) presented as bubonic or septicemic plague, or both. Cases were reported more frequently in males (58%), and male mortality exceeded that of females (17 versus 11%). Ground squirrels were the most frequently implicated sources of infection in cases associated with flea bites, and domestic cats were found to play an increasingly important role in transmission of disease to humans during these decades.

Laboratory and field trials of permethrin-treated cotton used as nesting material to control fleas (Insecta: Siphonaptera) on cricetid rodents.

Upholstery cotton treated with four different concentrations (0.25-2.0%) (2,500-20,000 ppm) of an aqueous permethrin solution, used as nesting material by white mice, was laboratory-tested against the potential plague vectors Oropsylla montana (Baker), Thrassis bacchi (Rothschild), and Orchopeas howardi (Baker) and found highly effective (P less than 0.001) for 1 yr. Similarly treated cotton gauze was tested under ambient and 75% RH and was found to be highly effective (P less than 0.001) in both environments for 1 yr. A separate test determined that the LD50 of permethrin-treated cotton was less than 10 ppm. Cotton tested with 0.5% permethrin and distributed under field conditions to cricetid rodents for use as nesting material was found to be highly effective (P less than 0.001 as a pulicide for greater than 4 mo when tested during winter in Larimer County, Colo. Permethrin-treated cotton was less successful in controlling fleas on cricetid rodents during the summer months in a New Mexico hyperendemic plague area.

Response to and efficacy of vaccination against eastern equine encephalomyelitis virus in emus.

OBJECTIVE: To evaluate humoral immune responses of emus vaccinated with commercially available equine polyvalent or experimental monovalent eastern equine encephalomyelitis (EEE) virus and western equine encephalomyelitis (WEE) virus vaccines and to determine whether vaccinated emus were protected against challenge with EEE virus. DESIGN: Cohort study. ANIMALS: 25 emus. PROCEDURE: Birds were randomly assigned to groups (n = 5/group) and vaccinated with 1 of 2 commercially available polyvalent equine vaccines, a monovalent EEE virus vaccine, or a monovalent WEE virus vaccine or were not vaccinated. Neutralizing antibody responses against EEE and WEE viruses were examined at regular intervals for up to 9 months. All emus vaccinated with the equine vaccines and 2 unvaccinated control birds were challenged with EEE virus. An additional unvaccinated bird was housed with the control birds to assess the possibility of contact transmission. RESULTS: All 4 vaccines induced detectable neutralizing antibody titers, and all birds vaccinated with the equine vaccines were fully protected against an otherwise lethal dose of EEE virus. Unvaccinated challenged birds developed viremia (> 10(9) plaque-forming units/ml of blood) and shed virus in feces, oral secretions, and regurgitated material. The unvaccinated pen-mate became infected in the absence of mosquito vectors, presumably as a result of direct virus transmission between birds. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicate that emus infected with EEE virus develop a high-titer viremia and suggest that they may serve as important virus reservoirs. Infected emus shed EEE virus in secretions and excretions, making them a direct hazard to pen-mates and attending humans. Commercially available polyvalent equine vaccines protect emus against EEE virus infection.

Importation of Aedes albopictus and other exotic mosquito species into the United States in used tires from Asia.

Between May 18 and December 4, 1986, 79 seagoing containers and their contents of 22,051 used tires were inspected for adult mosquitoes as well as eggs and larvae. Of the total inspected, 5,507 tires (25%) contained significant amounts of water. No adults or eggs were found. Fifteen tires contained mosquito larvae that were identified as Ae. albopictus, Ae. togoi, Culex pipiens complex, Tripteroides bambusa and Uranotaenia bimaculata. The infestation rate for all species was 6.8 infested tires per 10,000 tires (wet and dry) inspected. Aedes albopictus larvae were most frequently collected, occurring at a rate of 20 infested wet tires per 10,000 inspected.

A prospective study of maternal and fetal outcome in acute Lassa fever infection during pregnancy.

Several viral infections have been reported to result in more severe disease in pregnant than non-pregnant women, but the relative risks have not been well characterised. This has now been done for Lassa fever in a prospective study of 68 pregnant and 79 non-pregnant women who were admitted to hospital in Sierra Leone with confirmed Lassa fever. Lassa fever was the main cause of maternal mortality in the hospital, accounting for 25% of maternal deaths. Twelve of 40 patients in the third trimester died, compared with two of 28 in the first two trimesters and 10 of 79 non-pregnant women. The odds ratio for death in the third trimester compared with the first two trimesters was 5.57 (95% confidence intervals 1.02 to 30.26). The condition of the mother improved rapidly after evacuation of the uterus, whether by spontaneous abortion, evacuation of retained products of conception, or normal delivery; 10 of 26 women without uterine evacuation died, but only four of 39 women with evacuation died (p = 0.0016). The odds ratio for death with pregnancy intact was 5.47 (95% confidence interval 1.35 to 22.16). Fetal and neonatal loss was 87%. The risk of death from Lassa fever in the third trimester is significantly higher than that in the first two trimesters and higher than that for non-pregnant women, but evacuation of the uterus can significantly improve the mother's chance of survival.

The Russian flu. Its history and implications for this year's influenza season.

From November 1977 through mid-January 1978 the population younger than 25 years in the Union of Soviet Socialist Republics experienced a widespread epidemic of mild influenza (Russian flu) caused by an H1N1 virus similar to the virus that circulated worldwide during the early 1950s. Outbreaks of Russian flu occurred in school populations and military recruits in the United States starting in mid-January. Many other countries reported outbreaks of H1N1 virus in the winter of 1978. Predictions of influenza activity are always hazardous, but most experts believe that the Russian flu may occur again in the fall and winter of 1978. Other type A and B strains may also circulate; therefore, a trivalent vaccine containing A/USSR, A/Texas, and B/Hong Kong virus strains will be available. It is recommended that the chronically ill and those 65 years and older be the target populations for annual vaccination.

Minimizing tuberculosis risk to hospital personnel and students exposed to unsuspected disease.

A 15-month prospective study of the personnel and students exposed to initially unsuspected active cases of tuberculosis was undertaken to define the risk of their acquiring infection. Eight of 484 (1.65%) personnel exposed to 17 initially unsuspected tuberculosis patients and 5 of 2013 (0.25%) unexposed personnel with similar risk but no known exposures developed positive tuberculin skin tests. This greater than sixfold increase in conversion rate for the exposed group was significant (chi-2=14.83; P=0.0003). Delay in making the diagnosis in these patients was associated with failure to apply a tuberculin skin test on admission in 14 patients and radiologic misinterpretation in 15. A comprehensive surveillance method involving the Employee and Student Health Departments as well as the Public Health Department is suggested to minimize the risk of undiagnosed tuberculosis.

Gas chromatography in the identification of microorganisms and diagnosis of infectious diseases.

Gas-liquid chromatography (GLC) continues to find increasing applications in the characterization of microorganisms and the diseases associated with them. GLC has been used to characterize microorganisms through qualitative and quantitative analyses of cellular structural components and soluble extracts and metabolic by-products. Chromatographic patterns, or fingerprints, can be used to differentiate between very closely related microorganisms, even strain differences, and provides a potentially powerful tool for future taxonomic studies and more precision in definitive microbial classification. However, the most valuable use of GLC is in the identification of disease through patterns obtained by direct analysis of body fluids. Chromatographic fingerprints of microbial metabolites and compounds associated with the host response to infection and even noninfectious disease can be used to develop relatively simple GLC diagnostic methods. These methods are specific, sensitive, and rapid. This review examines the use of GLC for identification of infectious diseases through the analysis of body fluids, spent culture media, and cellular materials and suggest other clinical areas where its diagnostic potential has yet to be developed.

Use of recombinant OspC from Borrelia burgdorferi for serodiagnosis of early Lyme disease.

Infection with Borrelia burgdorferi, the etiologic agent of Lyme disease, is associated with an early and dominant humoral response to the spirochete's 23-kDa outer surface protein C (OspC). We have cloned and expressed OspC as a fusion protein in Escherichia coli and have shown that patient serum samples react with it in an enzyme-linked immunosorbent assay (ELISA) (S. J. Padula, A. Sampieri, F. Dias, A. Szczepanski, and R. W. Ryan, Infect. Immun. 61:5097-5105, 1993). Now we have compared the detection of B. burgdorferi-specific immunoglobulin M antibodies in 74 individuals with culture-positive erythema migrans by a whole-cell ELISA, immunoblot, and the recombinant OspC (rOspC) ELISA. Seventy-six negative controls were also studied. With all of the tests, there was a statistically significant association between the duration of disease and the frequency of a positive result. With the rOspC ELISA, the predictive value of a positive test was 100% and the predictive value of a negative test was 74%. Similar results were obtained with the whole-cell ELISA and with the immunoblot using as the source of test antigen a strain of B. burgdorferi which expresses abundant levels of OspC. We conclude that the use of rOspC in an ELISA is a convenient, readily automated, and easily standardized test for the serodiagnosis of early Lyme disease.

Hematologic dysfunction in Lassa fever.

Lassa fever is widespread in West Africa, where the case fatality is about 16% in hospitalized adult patients. The clinical course is highly variable, with a few patients developing severe disease with bleeding, adult respiratory distress syndrome, encephalopathy and hypovolemic shock. We studied 70 patients admitted with suspected Lassa fever to a hospital in Sierra Leone, West Africa. Fourteen patients classified as having severe Lassa fever on the basis of serum aspartate amino transferase (AST) greater than 150 IU/L or viremia of greater than 10(3.6) tissue culture infective dose (TCID) 50/ml were found to have statistically significantly depressed lymphocyte counts when compared with patients with mild Lassa fever (AST less than 150 IU/L or viremia, less than 10(3.6)TCID50/ml), (P less than 0.0001) and with febrile control patients, in whom Lassa infection had been excluded by laboratory criteria (P less than 0.0008). Maximum depression occurred a mean of 10.9 days post onset. Patients with severe Lassa fever also had moderate thrombocytopenia, which was statistically significant when compared with febrile control patients (P less than 0.0003) and this occurred a mean of 10.8 days postonset. The most significant changes were in platelet function, which was markedly depressed in patients with severe Lassa fever (P less than 0.0035 in response to ADP and P = 0.0081 for collagen) when compared with patients with mild Lassa fever, and when compared with febrile controls, (P = 0.0013 for ADP and P less than 0.00001 for collagen). This abnormality was usually maximal on admission to hospital, and probably is an early event, preceding hospitalization in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies of metabolic changes in cell cultures infected with four serotypes of dengue fever viruses by frequency-pulsed electron-capture gas-liquid chromatography.

Monkey kidney cell cultures were infected with four serotypes of dengue viruses, and the supernatant fluids of the cell cultures were extracted for amines, alcohols, carboxylic acids, and hydroxy acids. The derivatized extracts were then analyzed by frequency-pulsed electron-capture gas-liquid chromatography (FPEC-GLC). FPEC-GLC profiles of the hydroxy acids showed peaks that were different for different serotypes and the FPEC-GLC carboxylic acid profiles differed from the control medium. These differences were reproducible when the same lot for medium was used. There were differences in profiles between lots of control media due apparently to different fetal bovine sera used in the growth medium. Therefore, the same lot of medium was necessary to reproduce profiles. The data obtained from the study indicate that FPEC-GLC can be used to detect changes in cellular metabolism caused by viral infection, and that these metabolic changes might be useful in detection of genetic differences in viruses as reflected by detectable changes in the metabolism of the infected cell.

Possible use of frequency-pulse-modulated electron capture gas-liquid chromatography to identify septic and aseptic causes of pleural effusions.

Frequency-pulse-modulated electron capture gas-liquid chromatography was used in conjunction with appropriate derivatization procedures to obtain chromatograms from extracts of pleural effusions. These chromatograms were used to rapidly classify the various types of pleural effusions. With this method we have been able to distinguish among a limited number of effusions caused by congestive heart failure, Mycobacterium tuberculosis, and some other types of bacterial empyemas and pleural effusions.

Evaluation of the potency and safety of inactivated Japanese encephalitis vaccine in US inhabitants.

In 1981 and 1982, two US citizens died from Japanese encephalitis (JE) acquired in China. In 1983, the Centers for Disease Control initiated an evaluation of a purified, inactivated, mouse-brain-derived JE vaccine produced and used in Japan since 1966. Two doses of this vaccine given 1-2 weeks apart evoked neutralizing antibody titers greater than or equal to 8 in only 77% of recipients. After three JE vaccine doses administered 1-2 weeks apart, 99% developed titers greater than or equal to 8. When a third dose was given to 29 participants 6-12 months after the primary series, all developed titers greater than or equal to 16. Reported adverse reactions included injection site tenderness (18%), erythema (6%), or swelling (3%); headache (9%); and dizziness, fatigue, sleepiness, nausea, chills, fever, or lower back pain (less than or equal to 5%). On the basis of this study, three doses of BIKEN JE vaccine are recommended for US citizens who may be at risk of exposure to JE virus.