Rocky mountain spotted fever characterization and comparison to similar illnesses in a highly endemic area-Arizona, 2002-2011.

BACKGROUND: Rocky Mountain spotted fever (RMSF) has emerged as a significant cause of morbidity and mortality since 2002 on tribal lands in Arizona. The explosive nature of this outbreak and the recognition of an unexpected tick vector, Rhipicephalus sanguineus, prompted an investigation to characterize RMSF in this unique setting and compare RMSF cases to similar illnesses. METHODS: We compared medical records of 205 patients with RMSF and 175 with non-RMSF illnesses that prompted RMSF testing during 2002-2011 from 2 Indian reservations in Arizona. RESULTS: RMSF cases in Arizona occurred year-round and peaked later (July-September) than RMSF cases reported from other US regions. Cases were younger (median age, 11 years) and reported fever and rash less frequently, compared to cases from other US regions. Fever was present in 81% of cases but not significantly different from that in patients with non-RMSF illnesses. Classic laboratory abnormalities such as low sodium and platelet counts had small and subtle differences between cases and patients with non-RMSF illnesses. Imaging studies reflected the variability and complexity of the illness but proved unhelpful in clarifying the early diagnosis. CONCLUSIONS: RMSF epidemiology in this region appears different than RMSF elsewhere in the United States. No specific pattern of signs, symptoms, or laboratory findings occurred with enough frequency to consistently differentiate RMSF from other illnesses. Due to the nonspecific and variable nature of RMSF presentations, clinicians in this region should aggressively treat febrile illnesses and sepsis with doxycycline for suspected RMSF.

Risk factors for fatal outcome from rocky mountain spotted Fever in a highly endemic area-Arizona, 2002-2011.

BACKGROUND: Rocky Mountain spotted fever (RMSF) is a disease that now causes significant morbidity and mortality on several American Indian reservations in Arizona. Although the disease is treatable, reported RMSF case fatality rates from this region are high (7%) compared to the rest of the nation (<1%), suggesting a need to identify clinical points for intervention. METHODS: The first 205 cases from this region were reviewed and fatal RMSF cases were compared to nonfatal cases to determine clinical risk factors for fatal outcome. RESULTS: Doxycycline was initiated significantly later in fatal cases (median, day 7) than nonfatal cases (median, day 3), although both groups of case patients presented for care early (median, day 2). Multiple factors increased the risk of doxycycline delay and fatal outcome, such as early symptoms of nausea and diarrhea, history of alcoholism or chronic lung disease, and abnormal laboratory results such as elevated liver aminotransferases. Rash, history of tick bite, thrombocytopenia, and hyponatremia were often absent at initial presentation. CONCLUSIONS: Earlier treatment with doxycycline can decrease morbidity and mortality from RMSF in this region. Recognition of risk factors associated with doxycycline delay and fatal outcome, such as early gastrointestinal symptoms and a history of alcoholism or chronic lung disease, may be useful in guiding early treatment decisions. Healthcare providers should have a low threshold for initiating doxycycline whenever treating febrile or potentially septic patients from tribal lands in Arizona, even if an alternative diagnosis seems more likely and classic findings of RMSF are absent.

Response to importation of a case of Ebola virus disease--Ohio, October 2014.

On September 30, 2014, the Texas Department of State Health Services reported a case of Ebola virus disease (Ebola) diagnosed in Dallas, Texas, and confirmed by CDC, the first case of Ebola diagnosed in the United States. The patient (patient 1) had traveled from Liberia, a country which, along with Sierra Leone and Guinea, is currently experiencing the largest recorded Ebola outbreak. A nurse (patient 2) who provided hospital bedside care to patient 1 in Texas visited an emergency department (ED) with fever and was diagnosed with laboratory-confirmed Ebola on October 11, and a second nurse (patient 3) who also provided hospital bedside care visited an ED with fever and rash on October 14 and was diagnosed with laboratory-confirmed Ebola on October 15. Patient 3 visited Ohio during October 10-13, traveling by commercial airline between Dallas, Texas, and Cleveland, Ohio. Based on the medical history and clinical and laboratory findings on October 14, the date of illness onset was uncertain; therefore, CDC, in collaboration with state and local partners, included the period October 10-13 as being part of the potentially infectious period, out of an abundance of caution to ensure all potential contacts were monitored. On October 15, the Ohio Department of Health requested CDC assistance to identify and monitor contacts of patient 3, assess the risk for disease transmission, provide infection control recommendations, and assess and guide regional health care system preparedness. The description of this contact investigation and hospital assessment is provided to help other states in planning for similar events.

Achievement of healthy people 2010 objective for adult pneumococcal vaccination in an American Indian community.

OBJECTIVE: Streptococcus pneumoniae (S. pneumoniae) causes significant mortality throughout the United States and greater mortality among American Indian/Alaska Natives. Vaccination reduces S. pneumoniae illness. We describe the methods used to achieve the Healthy People 2010 coverage rate goals for adult pneumococcal vaccine among those at high risk for severe disease in this population. METHODS: We implemented a pneumococcal vaccination project to bolster coverage followed by an ongoing multidisciplinary program. We used community, home, inpatient, and outpatient vaccinations without financial barriers together with data improvement, staff and patient education, standing orders, and electronic and printed vaccination reminders. We reviewed local and national coverage rates and queried our electronic database to determine coverage rates. RESULTS: In 2007, pneumococcal vaccination coverage rates among people > or = 65 years of age and among high-risk people aged 18-64 years were 96.0% and 61.2%, respectively, exceeding Healthy People 2010 goals. Government Performance and Results Act analyses reports revealed a 2.7-fold increase (36.0% to 98.0%) of coverage from 2000 to 2007 among people > or = 65 years of age at Whiteriver Service Unit in Whiteriver, Arizona. CONCLUSIONS: We achieved pneumococcal vaccination rates in targeted groups of an American Indian population that reached Healthy People 2010 goals and were higher than rates in other U.S. populations. Our program may be a useful model for other communities attempting to meet Healthy People 2010 goals.

Acute care for alcohol intoxication. Be prepared to consider clinical dilemmas.

The clinical assessment of an acutely intoxicated patient should be performed with meticulous care and include repetitive examinations to properly determine the patient's condition. Multiple factors, such as trauma and concomitant use of other drugs, can confuse the diagnostic picture and affect the choice of therapy. In this article, Dr Yost reviews the diagnostic considerations, appropriate treatment, and clinic discharge for the intoxicated patient.