Clinician judgement as a tool for targeting HIV counseling and testing in North Carolina state mental hospitals, 1994.

HIV infection increasingly affects populations that may not appear at high risk based on the use of some traditional targeting strategies. To shed some light on how to more sensitively/effectively identify people who need routine HIV testing and counseling, the objective of this study is to determine the prevalence of HIV infection in North Carolina state mental hospitals and to evaluate clinician judgment as a tool for targeting HIV counseling and testing. The design used is a blinded seroprevalence study. The study population includes all patients admitted to North Carolina state mental hospitals between March 1st and May 31st, 1994. The main outcome measures are the HIV seroprevalence, demographic and diagnostic features, and clinician assessment of the likelihood of HIV infection. The results of the study find that of 2159 study subjects, 35 persons (1.6%) were infected with HIV; of these, 14 (40%) were not previously known to be infected. All 35 HIV infections occurred in persons aged 13-59 years. Within this age group, infection rates were significantly higher for Blacks, males, persons who had a diagnosis of organic brain disease, and persons who had multiple psychiatric diagnoses. However, testing strategies that targeted any of the higher risk groups were insensitive. The rate of HIV infection for persons judged by the admitting clinician to have a high or intermediate likelihood of HIV infection was 26.4 times higher than the rate for those judged to have a low likelihood of infection (2.1 vs. 0.1%, 95% confidence intervals: 3.5-201.3). Of the 14 previously undiagnosed HIV-infected persons, 13 were judged by clinicians to have a high or intermediate likelihood of HIV infection. Moreover, 1258 persons were correctly assessed to have a low likelihood of infection. Conclusions from this study are that an HIV counseling and testing strategy targeting persons (in this setting aged 13-59 years) who were judged by clinicians to have a high or intermediate likelihood of infection, would have identified more than 90% of previously undetected infections while substantially reducing the number of negative HIV tests performed.

Acute effects of nitrogen dioxide after accidental release.

OBJECTIVES: Following an accidental release of nitrogen dioxide from a railroad tank car containing nitrous tetroxide, the authors undertook a study of the health effects of the release, measuring the association between acute low level exposure and pulmonary symptoms. METHODS: The authors reviewed the records of three emergency departments, surveyed 80 emergency department patients, 552 community residents, 21 chemical plant workers, and 29 emergency workers, and conducted a case-control study. Pulmonary case status was defined as having an objective pulmonary finding noted on the emergency department record, reporting that the onset of symptoms was subsequent to the release, and being within the city limits at the time of the release. Self-reported case status was defined as reporting one or more symptoms consistent with exposure to nitrogen dioxide in the week after the release and having been within the city limits at the time of the release. Control subjects were survey respondents who reported no symptoms in the week after the release and had been within the city limits at the time of the release. Chemical exposure was characterized by proximity to, direction from, and being outdoors within one hour after the release. Duration of potential exposure was not measured. Logistic regression was used to estimate odds ratios and 95% confidence interval for symptoms by exposure level, adjusted for age, sex, smoking, and preexisting pulmonary conditions. RESULTS: Local emergency department visits increased fivefold in the week after the release. The most common complaints recorded in a systematic sample of 528 visits in the first 30 hours after the release were headache (31%), burning eyes (30%), and sore throat (24%). Objective pulmonary findings were recorded for 41 (5%) patients in the week before and 165 (4%) in the week after the release. The odds of being a pulmonary case increased by 40% for each quarter-mile increment in proximity to the release (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.1, 1.7), while the odds of being a self-reported case increased by 20% for each quarter-mile increment in proximity (OR 1.2, 95% CI 1.1, 1.4). People who met the pulmonary case definition were 2.5 times (CI 1.3, 4.8) more likely than control subjects to have been outdoors and 6.4 times (CI 3.2, 12.6) more likely to report a preexisting pulmonary condition. Self-reported cases were 2.6 times (95% CI 1.8, 3.8) more likely than control subjects to have been outdoors and 1.9 times (95% CI 1.1, 3.1) more likely to report a preexisting pulmonary condition. CONCLUSIONS: Emergency department visits increased five-fold, but serious acute health effects were uncommon. People who met the pulmonary case definition were six times more likely to report pulmonary symptoms than those without preexisting conditions. This study was not designed to determine any potential long-term effects of exposure.

HIV vaccine acceptance among heterosexual clients of a sexually transmitted diseases clinic.

We evaluated the willingness of clients at a large urban sexually transmitted diseases (STD) clinic in the southeastern United States to participate in future trials of preventive vaccines for HIV type 1 (HIV-1). A single trained interviewer administered an oral survey instrument to STD clinic clients over a 4-week enrollment period. The participants were 167 randomly selected clients (90 men and 77 women), most of whom were young, African-American heterosexuals. Risk behaviors for HIV-1 infection were highly prevalent. Overall, 67% of clients expressed willingness to consider participation in an HIV-1 vaccine trial. By univariate analysis, prior HIV-1 testing was significantly associated with willingness to participate (P = 0.04). Multivariate analysis revealed that female gender (P = 0.05) and prior HIV-1 testing (P = 0.03) were significant predictors of willingness to participate.

Eliminating access to anonymous HIV antibody testing in North Carolina: effects on HIV testing and partner notification.

Anonymous HIV testing may attract persons who might otherwise not be tested but may hinder partner notification. We evaluated the effects on North Carolina's HIV testing and partner notification programs of policy changes that eliminated and later restored anonymous testing in 82 counties. We used an interrupted time-series design to compare counties eliminating with counties retaining anonymous testing. We analyzed HIV testing and partner notification data from before, during, and after elimination of anonymous testing. After elimination of anonymous testing in 82 counties, the mean monthly level of testing (+/- SE) increased by 45%, or 548 (+/- 123) tests per month, while in 18 counties that retained anonymous testing, there was a 63% increase, or 802 (+/- 162) tests per month (p > .05). Among men of all races, testing increased by 16%, or 155 (+/- 35) tests per month, in counties that eliminated anonymous testing; and by 51%, or 305 (+/- 42) tests per month (p < .05), in counties that retained anonymous testing. After elimination of anonymous testing, both county types experienced similar increases in the rate of partners notified. However, partner notification was more successful if the index patient was tested confidentially; 2.7 times as many partners per index patient were notified and counseled. There was no effect on testing or on partner notification rates following restoration of anonymous testing. Substantial community opposition to eliminating anonymous testing was encountered. The policy change appeared to result in a slight decrease in testing among men and a slight increase in partners notified. Programs considering the elimination of anonymous testing should weigh these potential gains and losses, as well as the impact on relationships between the public health and advocacy communities

Erythema migrans-like rash illness at a camp in North Carolina: a new tick-borne disease?

BACKGROUND: Borrelia burgdorferi, the causative agent of Lyme disease, has never been isolated from a patient thought to have acquired Lyme disease in any southeastern state. OBJECTIVE: To investigate 14 cases of an erythema migrans (EM)-like rash illness that occurred during 2 summers at an outdoor camp in central North Carolina in an effort to determine the etiologic, epidemiological, and clinical aspects of this illness. METHODS: Using active surveillance, we identified cases of clinically diagnosed EM in residents and staff of the camp. We collected clinical and demographic information; history of exposure to ticks; acute and convalescent serum antibodies to B. burgdorferi, Rickettsia rickettsii, and Ehrlichia chaffeensis; and cultures for spirochetes from biopsy specimens of skin lesions. Serum samples from a group of residents and staff who did not develop rashes were tested for the same antibodies. We speciated ticks removed from people and collected from vegetation. RESULTS: We identified 14 cases of EM-like rash illness during the 2 summers. Of the 14 case-patients, 10 had associated mild systemic symptoms and 1 had documented fever. All 14 case-patients had removed attached ticks, and 8 remembered having removed a tick from the site where the rash developed a median of 12 days earlier (range, 2-21 days). One tick removed from the site where a rash later developed was identified as Amblyomma americanum, the Lone Star tick; 97% of ticks collected from vegetation and 95% of ticks removed from people were A. americanum. No spirochetes were isolated from skin biopsy specimens. Paired serum samples from 13 case-patients did not show diagnostic antibody responses to B. burgdorferi or other tick-borne pathogens. CONCLUSIONS: This investigation suggests the existence of a new tick-associated rash illness. We suspect that the disease agent is carried by A. americanum ticks. In the southern United States, EM-like rash illness should no longer be considered definitive evidence of early Lyme disease.

Steaming oysters does not prevent Norwalk-like gastroenteritis.

OBJECTIVES: To determine whether steaming oysters prevents gastroenteritis caused by small round structured (Norwalk-like) viruses and to identify risk factors for illness. METHODS: The authors interviewed all 48 people who ate oysters at two church suppers that were followed by outbreaks of gastroenteritis from a Norwalk-like virus. Data were collected on demographics, clinical illness, number of oysters eaten, and the extent to which they were cooked. RESULTS: Among the 48 persons, the attack rate was 56%. The risk of illness increased with the number of oysters eaten (chi-square for trend = 5.7, P = 0.02). There was no decrease in attack rates among persons who ate oysters that were better done (chi-square for trend = 1.1, P = 0.29). CONCLUSIONS: In these outbreaks, the risk of illness increased with the number of oysters eaten. Steaming oysters did not appear to prevent illness, suggesting that steaming may not be adequate to inactivate small round structured viruses. Public health messages that have emphasized the role of raw shellfish in the transmission of enteric viruses should be altered to increase the public's awareness that eating steamed oysters may also pose health risks.

Cardiac effects of standard-dose halofantrine therapy.

The antimalarial drug halofantrine hydrochloride has been associated with cardiac arrhythmias. This is a report of a study on the cardiac effects of standard-dose halofantrine (24 mg/kg) on a sample of 48 patients selected from a group of 402 Dega (Montagnard) refugees treated for Plasmodium falciparum infection. Prolongation of the rate-corrected QT interval (QTc) on the electrocardiogram (ECG) was used as an indicator of risk for halofantrine-associated cardiac arrhythmias. We found that standard-dose halofantrine was associated with a lengthening of the mean QTc from 0.04 sec(1/2) to 0.44 sec(1/2). Two patients had a QTc increase of greater than 25%, but none had a follow-up QTc of more than 0.55 sec(1/2), an interval length generally considered to be a risk factor for ventricular arrhythmias. Regression analysis indicated that pretreatment ECGs were poorly predictive of QTc lengthening during therapy, although pretreatment ECGs may be useful to evaluate patients with pre-existing cardiac conditions. The manufacturer has recommended that the halofantrine dose not exceed 24 mg/kg and revised the list of medication contraindications to include some cardiac conditions. Clinicians should weigh a patient's risk, including history of cardiac disease and availability of alternative therapy before use of halofantrine.

Imported malaria in Montagnard refugees settling in North Carolina: implications for prevention and control.

In the winter of 1992, some 402 Southeast Asian refugees were resettled in North Carolina. They received very limited medical screening before immigration and many arrived in the United States with significant health problems, including several tropical infectious diseases. These refugees had lived for many years in remote areas along the Vietnam-Cambodia border, where there is intense transmission of malaria, including Plasmodium falciparum resistant to most antimalarial drugs available in the United States. Of 322 refugees screened after arrival in North Carolina, 187 (58%) were infected: 33% with P. falciparum, 23.5% with P. vivax, 23.5% with P. malariae, and 2.1% with P. ovale. Most infected persons were asymptomatic and infections with multiple species were common. Because of the documented high infection prevalence and the probable presence of many subpatent infections, all nonpregnant refugees were treated with halofantrine; those with P. vivax or P. ovale infections were given primaquine as well. This group accounted for the largest cluster of malaria cases reported in the United States in the last 50 years. Their rapid relocation, with minimal medical screening prior to arrival, resulted in a significant burden to the refugees and to the health-care system. Coordination between immigration agencies, the public health community, and medical workers in communities where the refugees are settled is critical for U.S.-based management of imported tropical diseases.

Blueprint for a national public health surveillance system for the 21st century.

This article lays out a blueprint for public health surveillance and assessment for the year 2000 and beyond. The blueprint defines the roles of local, state, and national public health agencies and partners in the medical care system in conducting surveillance and assessment activities. It proposes a new over-arching National Public Health Surveillance System to be the conceptual framework for all public health surveillance and assessment activities into the 21st century.

Impediments to public health surveillance in the 1990s: the lack of resources and the need for priorities.

With the increased demand for public health surveillance data comes the development of new surveillance systems and the expansion of existing systems. A corresponding increase in financial and personnel resources to support data collection, particularly at the local public health department level, has been documented. Adequate and timely surveillance data are critical to both overall public health program design and evaluation and to meet emerging surveillance needs. Without an emphasis placed on priorities and resources for public health surveillance, the foundation upon which public health decisions are based is threatened.

Factors responsible for immunizations referrals to health departments in North Carolina.

BACKGROUND: Despite the existence of Medicaid and other programs designed to eliminate cost as a barrier to immunization in physicians' offices, referrals to local health departments for immunizations are common. Many children leave their physicians' offices without receiving needed immunizations. PURPOSE: To determine: 1) the frequency and determinants of immunization referrals to health departments in North Carolina, and 2) the factors associated with private physicians' decisions to immunize Medicaid children in their offices and participate in the state-funded vaccine replacement program. METHODS: The 2537 pediatricians and family physicians licensed in North Carolina were surveyed by mail using a 23-item, self-administered questionnaire. RESULTS: Seventy-two percent of physicians responded; 93% referred at least some children to local health departments for immunizations. Concern regarding parents' ability to pay for immunizations was the most important reason for referral for 93% of respondents. Forty percent referred all or some of their Medicaid patients; excessive paperwork, inadequate reimbursement, and parental preferences were the most common reasons. Only 33% of physicians had participated in the state's vaccine replacement program. Family physicians, and physicians in solo or two-physician practices in rural counties, and in practices caring for a small number of children on Medicaid were most likely to refer children covered by Medicaid and not participate in the state's existing vaccine replacement program. CONCLUSIONS: Medicaid and North Carolina's vaccine replacement program are not preventing large numbers of immunization referrals to health departments. Future programs designed to increase the proportion of children immunized in physicians' offices will not succeed if more effective incentives for physician participation are not developed.

Inpatients with AIDS and AIDS-related complex: economic inpact on hospitals in North Carolina.

To determine the economic impact of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) cases on North Carolina hospitals, we collected inpatient data from all North Carolina hospitals on charges and number of patients discharged with these diagnoses. More than 97% of the state's hospitals responded to the survey for the study year (1987-1988). There were 540 AIDS/ARC discharges from 58 North Carolina general hospitals and 125 AIDS/ARC discharges from 13 other types of hospitals, for a statewide total of 665 patients. The total general hospital charges for AIDS/ARC inpatients in North Carolina were approximately $7.7 million per year, and almost $2 million of these charges were uncompensated by any insurance. The greatest burden of cost for this care was borne disproportionately by 15 of the 58 general hospitals, accounting for 82% of the discharges.

A large outbreak of antibiotic-resistant shigellosis at a mass gathering.

In July 1987, a large outbreak of shigellosis occurred among attendees at a mass gathering in a national forest, the annual Rainbow Family Gathering. Sanitation in the campsite was poor, allowing widespread transmission of disease, probably by food, water, and person-to-person spread. The attack rate may have been greater than 50% among the estimated 12,700 attendees. The outbreak was caused by Shigella sonnei, resistant to ampicillin, tetracycline, and trimethoprim-sulfamethoxazole; the organism was of colicin type 9 and contained a 90-kilobase plasmid not found in non-outbreak-related strains. The dispersal of the group resulted in nationwide dissemination of the organism, and outbreaks in three states were linked to transmission from attendees at the Gathering. This outbreak demonstrates the potential for rapid dissemination of disease in such a setting and the necessity for careful planning of mass gatherings.

Control of a non-foodborne outbreak of salmonellosis: day care in isolation.

We report an outbreak of Salmonella typhimurium in the infant room of a day care center. Time between onset dates, clustering of cases in the room, lack of a common food exposure, lack of illness among other children and staff, and lack of community-wide infection suggested person-to-person or continuing-common-source transmission. Successful preventive measures included instruction of personnel in proper handwashing and diaper-changing procedures and cohorting of infected and non-infected children. This is the second description of a non-foodborne outbreak of salmonellosis in a day care center, and the first involving S. typhimurium.