Outbreaks of Salmonellosis From Small Turtles.

OBJECTIVE: Turtle-associated salmonellosis (TAS), especially in children, is a reemerging public health issue. In 1975, small pet turtles (shell length <4 inches) sales were banned by federal law; reductions in pediatric TAS followed. Since 2006, the number of multistate TAS outbreaks has increased. We describe 8 multistate outbreaks with illness-onset dates occurring in 2011-2013. METHODS: We conducted epidemiologic, environmental, and traceback investigations. Cases were defined as infection with ≥ 1 of 10 molecular subtypes of Salmonella Sandiego, Pomona, Poona, Typhimurium, and I 4,[5],12:i:-. Water samples from turtle habitats linked to human illnesses were cultured for Salmonella. RESULTS: We identified 8 outbreaks totaling 473 cases from 41 states, Washington DC, and Puerto Rico with illness onsets during May 2011-September 2013. The median patient age was 4 years (range: 1 month-94 years); 45% percent were Hispanic; and 28% were hospitalized. In the week preceding illness, 68% (187 of 273) of case-patients reported turtle exposure; among these, 88% (124 of 141) described small turtles. Outbreak strains were isolated from turtle habitats linked to human illnesses in seven outbreaks. Traceback investigations identified 2 Louisiana turtle farms as the source of small turtles linked to 1 outbreak; 1 outbreak strain was isolated from turtle pond water from 1 turtle farm. CONCLUSIONS: Eight multistate outbreaks associated with small turtles were investigated during 2011-2013. Children <5 years and Hispanics were disproportionately affected. Prevention efforts should focus on patient education targeting families with young children and Hispanics and enactment of state and local regulations to complement federal sales restrictions.

Outbreak of hepatitis A in the USA associated with frozen pomegranate arils imported from Turkey: an epidemiological case study.

BACKGROUND: In May, 2013, an outbreak of symptomatic hepatitis A virus infections occurred in the USA. Federal, state, and local public health officials investigated the cause of the outbreak and instituted actions to control its spread. We investigated the source of the outbreak and assessed the public health measures used. METHODS: We interviewed patients, obtained their shopping information, and did genetic analysis of hepatitis A virus recovered from patients' serum and stool samples. We tested products for the virus and traced supply chains. FINDINGS: Of 165 patients identified from ten states, 69 (42%) were admitted to hospital, two developed fulminant hepatitis, and one needed a liver transplant; none died. Illness onset occurred from March 31 to Aug 12, 2013. The median age of patients was 47 years (IQR 35-58) and 91 (55%) were women. 153 patients (93%) reported consuming product B from retailer A. 40 patients (24%) had product B in their freezers, and 113 (68%) bought it according to data from retailer A. Hepatitis A virus genotype IB, uncommon in the Americas, was recovered from specimens from 117 people with hepatitis A virus illness. Pomegranate arils that were imported from Turkey--where genotype IB is common--were identified in product B. No hepatitis A virus was detected in product B. INTERPRETATION: Imported frozen pomegranate arils were identified as the vehicle early in the investigation by combining epidemiology--with data from several sources--genetic analysis of patient samples, and product tracing. Product B was removed from store shelves, the public were warned not to eat product B, product recalls took place, and postexposure prophylaxis with both hepatitis A virus vaccine and immunoglobulin was provided. Our findings show that modern public health actions can help rapidly detect and control hepatitis A virus illness caused by imported food. Our findings show that postexposure prophylaxis can successfully prevent hepatitis A illness when a specific product is identified. Imported food products combined with waning immunity in some adult populations might make this type of intervention necessary in the future. FUNDING: US Centers for Disease Control and Prevention, US Food and Drug Administration, and US state and local public health departments.

Disparities in breast cancer treatment among American Indian, Hispanic and non-Hispanic White Women Enrolled in Medicare.

Because racial/ethnic disparities in breast cancer survival have persisted, we investigated differences in breast cancer treatment among American Indian, Hispanic, and non-Hispanic White (NHW) women. Surveillance, Epidemiology and End Results data linked to Medicare claims in New Mexico and Arizona (1987-1997) among enrollees aged 65 and older were used to identify treatment, treatment interval, and mortality risk associated with delays in care. We identified 2,031 women (67 American Indian, 333 Hispanic and 1,631 NHW women with time to treatment information. Treatment intervals from diagnosis to surgery (all stages, 18 versus 4 days, p.

Misclassifying the indications for prostate-specific antigen testing may bias case-control studies of the efficacy of prostate cancer screening.

BACKGROUND AND OBJECTIVE: In the absence of data from randomized controlled trials, prostate cancer (CaP) screening recommendations may be based on observational studies that contrast exposure to screening between cases and controls. We evaluated the potential bias from mis-classifying indications for PSA testing in observational studies of CaP screening. METHODS: We randomly selected men undergoing PSA testing and obtained data on PSA results and prostate biopsies. Data were linked with a tumor registry to identify incident and prevalent cases of CaP. We abstracted medical records for 45 incident cases with CaP and 118 controls without, recording information on lower urinary tract symptoms (LUTS), constitutional symptoms, and digital rectal examination findings. PSA testing was classified as definitely, likely, or possibly screening, or not screening based on clinical history. RESULTS: Changing the definitions for PSA screening to variably exclude men with LUTS and enlarged prostates differentially lowered the frequency of screening. With more restrictive screening definitions, the odds ratio for screening decreased from 0.47 to 0.07. CONCLUSION: Accurately classifying PSA testing status is difficult because LUTS are common among men targeted for CaP screening. Failing to correctly classify PSA tests may bias study results.

Prostate-specific antigen testing accuracy in community practice.

BACKGROUND: Most data on prostate-specific antigen (PSA) testing come from urologic cohorts comprised of volunteers for screening programs. We evaluated the diagnostic accuracy of PSA testing for detecting prostate cancer in community practice. METHODS: PSA testing results were compared with a reference standard of prostate biopsy. Subjects were 2,620 men 40 years and older undergoing (PSA) testing and biopsy from 1/1/95 through 12/31/98 in the Albuquerque, New Mexico metropolitan area. Diagnostic measures included the area under the receiver-operating characteristic curve, sensitivity, specificity, and likelihood ratios. RESULTS: Cancer was detected in 930 subjects (35%). The area under the ROC curve was 0.67 and the PSA cutpoint of 4 ng/ml had a sensitivity of 86% and a specificity of 33%. The likelihood ratio for a positive test (LR+) was 1.28 and 0.42 for a negative test (LR-). PSA testing was most sensitive (90%) but least specific (27%) in older men. Age-specific reference ranges improved specificity in older men (49%) but decreased sensitivity (70%), with an LR+ of 1.38. Lowering the PSA cutpoint to 2 ng/ml resulted in a sensitivity of 95%, a specificity of 20%, and an LR+ of 1.19. CONCLUSIONS: PSA testing had fair discriminating power for detecting prostate cancer in community practice. The PSA cutpoint of 4 ng/ml was sensitive but relatively non-specific and associated likelihood ratios only moderately revised probabilities for cancer. Using age-specific reference ranges and a PSA cutpoint below 4 ng/ml improved test specificity and sensitivity, respectively, but did not improve the overall accuracy of PSA testing.