Tuberculosis control in New York City hospitals.

OBJECTIVES: To assess the implementation of tuberculosis (TB) control measures in New York City hospitals in 1992 and determine trends during the subsequent 2 years. METHODS: The 22 acute care facilities with the largest number of hospitalized TB patients in 1991 were selected for inclusion in the study. Medical and laboratory records of the 10 most recent acid fast bacilli (AFB) smear-positive patients in each of the selected facilities in 1992, 1993, and 1994 were reviewed by using a standardized questionnaire to determine risk factors for TB, previous history of TB, clinical signs and symptoms, AFB laboratory turnaround times, emergency department contact, timing of isolation, timing of treatment, case reporting, and status on discharge. The patients' rooms were evaluated for TB environmental control measures if the patient was still on respiratory isolation precautions. RESULTS: More than one third of patients were admitted with a previous history of TB, 31% were admitted with a cavitary lesion on chest x-ray examination, and 48% were known to have HIV infection. Eighty-five percent were admitted from the emergency department where they stayed for up to 116 hours (mean stay: 17 hours). The proportion of patients placed in AFB isolation on admission to the floor increased from 75% in 1992 to 84% in 1994. The proportion of patients given a minimum of four anti-TB drugs increased from 88% in 1992 to 94% in 1994. Patients "on isolation" were sharing rooms with up to nine other patients in 1992, whereas no patients were sharing rooms in the 1994 survey. In 1992, 51% of the rooms were under negative air flow with respect to the corridor. During the 1994 survey, 80% of rooms were under negative air flow. Between 1992 and 1994, the proportion of AFB isolation rooms with dust/mist respirators increased from 28% to 76% (p < 0.00001). Approximately 25% of discharged patients left against medical advice (no trend over time). The proportion of medically discharged patients with three negative AFB smears before discharge increased from 26% to 48% (p = 0.03) and the proportion referred for directly observed therapy increased from 15% to 53% (p = 0.00001). CONCLUSION: TB control efforts in New York City hospitals improved dramatically between 1992 and 1994. The ultimate control of TB will continue to depend on the coordinated efforts within and between health care facilities, providers, and the community.

Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services.

When the GUIDE TO COMMUNITY PREVENTIVE SERVICES: Systematic Reviews and Evidence-Based Recommendations (the Guide) is published in 2001, it will represent a significant national effort in encouraging evidence-based public health practice in defined populations (e.g., communities or members of specific managed care plans). The Guide will make recommendations regarding public health interventions to reduce illness, disability, premature death, and environmental hazards that impair community health and quality of life. The Guide is being developed under the guidance of the Task Force on Community Preventive Services (the Task Force)-a 15-member, nonfederal, independent panel of experts. Subject matter experts, methodologists, and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature reviews of evidence of effectiveness, economic efficiency, and feasibility on which to base recommendations for community action. Contributors to the Guide are building on the experience of others to confront methodologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonrandomized designs and diverse measures of outcome and effectiveness. Persons who plan, fund, and implement population-based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors. When the Guide is complete, readers are encouraged to consider critically the value and relevance of its contents, the implementation of interventions the Task Force recommends, the abandonment of interventions the Task Force does not recommend, and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness.

Analysis of Mycobacterium tuberculosis transmission patterns in a homeless shelter outbreak.

SETTING: From July 1997 through May 1998, ten tuberculosis (TB) cases were reported among men in a Syracuse New York homeless shelter for men. OBJECTIVE AND DESIGN: Investigation to determine extent of, and prevent further, transmission of Mycobacterium tuberculosis. RESULTS: Epidemiologic and laboratory evidence suggests that eight of the ten cases were related. Seven cases had isolates with matching six-band IS6110 DNA fingerprints; the isolate from another case had a closely related fingerprint pattern and this case was considered to be caused by a variant of the same strain. Isolates from eight cases had identical spoligotypes. The source case had extensive cavitary disease and stayed at the shelter nightly, while symptomatic, for almost 8 months before diagnosis. A contact investigation was conducted among 257 shelter users and staff, 70% of whom had a positive tuberculin skin test, including 21 with documented skin test conversions. CONCLUSIONS: An outbreak of related TB cases in a high-risk setting was confirmed through the use of IS6110 DNA fingerprinting in conjunction with spoligotyping and epidemiologic evidence. Because of the high rate of infection in the homeless population, routine screening for TB and preventive therapy for eligible persons should be considered in shelters.

Teaching medical students epidemiology: utilizing a state health department.

An epidemiology teaching course for third-year medical students was developed at the University of Vermont's College of Medicine by staff members of the Vermont Department of Health in conjunction with clinical faculty members. The course consists of analyses of actual community health problems encountered by the health department, evaluation of published clinical studies, and design of studies on current public health issues in Vermont. In the course's first year, 54 percent of the students gave it an overall assessment of average or above average. A striking improvement was found in the second year; 98 percent of the students rated their overall assessment as average or better. Sessions rated the best by students were the critical appraisal of clinical studies, followed by sessions on study design and outbreak investigations. The Vermont course communicates epidemiologic concepts to students by stressing their clinical relevance and by putting the concepts into a recognizable public health context. Students are required to grapple with epidemiologic issues as participants. This approach to teaching epidemiology combines faculty having both public health and clinical perspectives, emphasizes relevance to future practice, and requires students to actively work through epidemiologic problems. The Vermont experience has shown that combining health department and clinical faculty resources can result in a useful format for teaching epidemiology to medical students.

False positive tuberculosis skin test results.

The re-emergence of tuberculosis as a significant public health threat has led to greatly renewed activity in tuberculin skin testing to identify infected persons. However, even use of the preferred skin test technique (intradermal injection of purified protein derivative via the Mantoux method) can lead to either false positive or false negative results. Interpretation of a Mantoux test can be influenced by cross reactions with other mycobacteria, intertester variation, host-response variation, and product related problems. At least 25 apparent false positive purified protein derivative skin test reactions in New York State in 1992 appeared to be associated with lots of the derivative produced by one manufacturer. These unexpected skin test results led to examination of a product with an altered appearance that may have caused the unanticipated responses. After announcement of these false positive results to the press, the company removed the product from the market. Food and Drug Administration analysis later revealed particulate matter in vials of the suspected lots of purified protein derivative.

Establishment of an exposure level to tetrachloroethylene in ambient air in Vermont.

Where environmental contaminants pose potential health hazards, health departments are involved in complex and often controversial situations. Often the rapid formation of a threshold exposure level is required to protect public health. A decision making process was implemented in Vermont when it became necessary to have an interim ambient air exposure level to test for tetrachloroethylene contamination in the water, air, and soil of a community. Contamination of public and private drinking water and ambient air in schools and homes was discovered as a result of uncontrolled waste disposal from an industrial uniform laundry and drycleaning plant. A telephone survey was conducted to determine action taken by the other 49 States regarding emission standards for tetrachloroethylene into ambient air. There were no guidelines in 25 States, and there were guidelines in the remaining 25. Vermont's Commissioner of Health convened a multidisciplinary group of public health professionals to review various approaches to the establishment of an ambient air standard. A decision making action using modified Delphi and nominal group consensus methods set the interim standard at 67 micrograms per cubic meter in ambient air. The drycleaning plant had been closed voluntarily before the standard was established, and the interim standard was used to prevent reopening of the plant through a health order issued by the Vermont Health Department. The standard was also useful for guidance during environmental remediation.

New York State's two-dose schedule for measles immunization.

In April 1989, New York became the first State in the United States to adopt a two-dose schedule for routine measles immunization. Although a two-dose schedule had been under discussion for the previous 10 years, this policy change was finally prompted in New York State by widespread measles outbreaks in 1989 among college and high school students who had been appropriately vaccinated with a single dose of measles vaccine. These outbreaks affected 21 college and secondary school campuses with 91 cases of measles and led to the administration of 53,093 doses of vaccine at a cost in excess of $859,000 for vaccine alone. In addition, there were major disruptions of intercollegiate athletic and scholastic events and physician and public confusion over the different recommendations for "outbreak" versus "routine" measles immunization. In response, the New York State Department of Health adopted a policy of two doses of measles vaccine required for entrance into kindergarten and college beginning in the fall of 1990. This report describes the data and process that were used in reaching this policy decision.

Legionella in cooling towers.

Legionellosis (Legionnaires' disease and Pontiac fever) outbreaks have been associated with aerosols ejected from contaminated cooling towers--wet-type heat rejection units (WTHRUs) used to dissipate unwanted heat into the atmosphere. The Vermont Department of Health undertook a program to inventory, inspect, and sample all WTHRUs in Vermont from April 1981 to April 1982. All WTHRUs were sampled for Legionella pneumophila and data were obtained for location, design, construction, and operating characteristics. Of the 184 WTHRUs operating, statistical analyses were performed on those 130 which were sampled for L. pneumophila only once during the study period. Of these, 11 (8.5%) were positive for L. pneumophila. Sources of makeup water and period of operation had significant association with the recovery of L. pneumophila. Five out of 92 towers (5.4%) utilizing surface water sources for cooling were positive for L. pneumophila, in contrast to 6 positive towers of the 38 units (15.8%) which obtained makeup water from ground water sources (p = .054 by chi-square test). Nearly 15% of the 54 units which operated throughout the year were positive, compared to less than 4% of the 76 towers operating seasonally (p = .03 by chi-square test). The mean pH of the cooling water in units where L. pneumophila was recovered (8.3) was significantly higher than the mean pH of 7.9 in units testing negative (p less than .05 by t-test). In addition, the mean log-transformed turbidity of positive towers, 0.03 nephelometric units (ntu), was significantly lower than the mean of log turbidity of negative towers, 0.69 ntu (p less than .02 by t-test).

New York State HIV seroprevalence project: goals, windows, and policy consideration.

In the summer of 1987, the New York State Department of Health embarked on an extensive effort to determine the prevalence of trends of HIV infection in the state. Sero-surveillance for antibody to HIV was undertaken by blind testing of available blood samples. Six populations were selected as windows on the epidemic: newborns, homeless adolescents, prisoners, and clients of family planning, STD, and drug treatment clinics. Testing of all newborns in New York State began in December 1987, and all six study windows were operational by June 1988. As of March 1990 blind testing for HIV antibody had been performed on more than 725,000 blood specimens in these six studies. Collectively these seroprevalence activities are providing invaluable information and impetus to preventive actions and public policy.

HIV seroprevalence surveys: impetus for preventive activities.

Seroprevalence determinations of human immunodeficiency virus are essential for design and implementation of preventive strategies. By demonstrating the severity of HIV infections within communities, New York State surveys have spurred preventive interventions, including information to the public and health care providers and increased counseling and testing of women of reproductive age. In high-prevalence areas the community health workers have been employed in preventive activities. Specific information has been provided to county health departments on zip code areas with high HIV seroprevalence rates. Serosurveys revealed that the magnitude of HIV infection in adolescents is much larger than indicated by case reports. Various seroprevalence studies confirmed higher rates of infection with increasing age and minority status and a strong association with intravenous drug use. Combining data provided by seroprevalence studies in a given community enables planners to assess the extent of infection in that community and in groups important to transmission of the virus.

The contractual model for prison health care.

In New York City, the Department of Health is responsible for providing health services to 8 correctional facilities which receive 60,000 admissions annually. A large component of this prison health system is a contract with Montefiore Hospital, a voluntary institution, to provide medical services to the population on Rikers Island, a penal complex. This contractual agreement is unique in that an operating entity, Monefiore Hospital, has agreed to provide a "package" of health services to a defined prisoner population. The City agreed to reimbruse to the Hospital for the three year term of the contract, a total amount not to exceed +11.7 million. Because of delays in renovation of the prison facilities, for the majority of the period of the three year contract, only two prisons were served via the contractual route. Since 1973, the program has provided a range of services including screening of new prisoners, primary, emergency, infirmary and limited speciality care. Major improvements in laboratory and radiology services were implemented. The early experience with this program indicates that in this setting the contractual model possesses a number of distinct advantages over the direct delivery of prison health services. Disadvantages include a significantly higher cost.

A study of 128 deaths in New York City correctional facilities (1971-1976): implications for prisoner health care.

During a 5 1/2 year period, January, 1971 through July, 1976, 128 deaths occurred in New York City. The epidemiology of prisoner deaths including suicide was examined in a large incarcerated population. Each death was categorized according to the International Classification of Diseases. The mean age of the prisoner death was 34 years. Only 3 deaths occurred among females. Ethnic distribution of these deaths was similar to the prison population. Deaths of prisoners fell into 2 categories: external causes (suicide, accidents, homicide, legal intervention) and nonviolent causes. External causes accounted for 71 deaths. The leading cause of death was suicide, accounting for 52 deaths. Suicides occurred in all time periods of incarceration. The highest rate was in the 35 to 44 year age group. History of drug or alcohol abuse was reported by 69 per cent of the suicides. One-third of the prisoners committing suicides had histories of previous attempts or previous mental hospitalizations. Except for 2 individuals, the method was hanging. For the most part, prisoners at risk for suicide exhibited a common pattern and were identifiable. During the last 2 1/2 years of the study period, deaths were reviewed by a prisoner death committee. Deficiencies of care in deaths of nonviolent causation were categorized as "provider," "corrections," or "system." The most common deficiency in care was delay in hospitalization of prisoners requiring care.

The Vermont health risk survey and the design of community wide preventive health programs.

A Vermont health risk survey was performed to gain information on health knowledge and behaviors of the population. Telephone interviews with 1,594 individuals ascertained respondents' demographic characteristics, preventive health behaviors, and health knowledge. Risk prevalence was obtained on five health risks: alcohol (12%), smoking (33%), lack of exercise (70%), overweight (39%), and non-use of seatbelts (86%). Low income, less education, and blue collar occupation status were associated with increased risks of smoking, lack of exercise, and non-use of seatbelts. Increased prevalence of certain risks are associated with the 18-24 year old age group; 32% of those males reported an alcohol risk and 94% reported non-use of seatbelts. Combined risk scores were increased in groups with low income, less education, and blue collar occupations. These variations in health behaviors by social group were not explained by differences in health knowledge. Design of primary prevention activities needs to be community wide, utilize information on the epidemiology of health behaviors, influence diverse community groups and intervene before risk behaviors are established.

HIV seroprevalence in clients of sentinel family planning clinics.

In February 1988 the New York State Department of Health initiated a study to determine the prevalence of HIV antibody in women attending selected, publicly subsidized family planning clinics. During a 26-month study period, 27,549 blood specimens were obtained from women having an initial medical examination in 41 clinic sites throughout the state. Of these clients 144 (0.52 percent) were seropositive. The HIV seroprevalence rate increased with age to a high of 1.56 percent for 831 women ages 35 to 39. The seroprevalence rate for non-Hispanic Black or Hispanic clients (0.76 percent) was about six times the rate for non-Hispanic Whites (0.13 percent). No overall increasing or decreasing trend in prevalence of HIV infection was detected during the study period.

Hospitalization of HIV-seropositive newborns with AIDS-related disease within the first year of life.

The purpose of this study was to estimate the proportion of HIV-seropositive newborns hospitalized for an AIDS-related diagnosis within 12 months of birth and to characterize these hospitalizations. The number of HIV-seropositive infants born December 1987 through June 1988 was derived from the blinded New York State Newborn HIV Seroprevalence Study. The number of infants who were born in these same months and hospitalized with an ARD within 12 months of birth was obtained from a data base containing information on all hospital discharges in New York State. Comparisons were made on the basis of month of birth. Of infants born during the study period, 995 tested positive for HIV antibody, and 151 infants (15 percent) were hospitalized with an ARD within 12 months of birth. The 151 ARD cases had a total of 240 hospitalizations, accounting for 5,772 patient days. Fifty-six percent of the ARD cases were diagnosed within six months of birth.

Tracking sexual contacts of HIV patients: a study of physician practices.

Notification of sexual partners of HIV-infected individuals has become a focus of debate at local, state, and national levels. Issues of confidentiality and ethical concerns continue to pose challenges to state and local health departments addressing this issue. We conducted a telephone survey with physicians in Syracuse, New York to ascertain opinions about HIV partner notification and the role of public health agencies in that notification process. In general, physicians mostly relied upon the HIV-infected individuals to notify their own partners but were supportive of enhanced efforts regarding partner notification.