Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States.

From October 4 to November 2, 2001, the first 10 confirmed cases of inhalational anthrax caused by intentional release of Bacillus anthracis were identified in the United States. Epidemiologic investigation indicated that the outbreak, in the District of Columbia, Florida, New Jersey, and New York, resulted from intentional delivery of B. anthracis spores through mailed letters or packages. We describe the clinical presentation and course of these cases of bioterrorism-related inhalational anthrax. The median age of patients was 56 years (range 43 to 73 years), 70% were male, and except for one, all were known or believed to have processed, handled, or received letters containing B. anthracis spores. The median incubation period from the time of exposure to onset of symptoms, when known (n=6), was 4 days (range 4 to 6 days). Symptoms at initial presentation included fever or chills (n=10), sweats (n=7), fatigue or malaise (n=10), minimal or nonproductive cough (n=9), dyspnea (n=8), and nausea or vomiting (n=9). The median white blood cell count was 9.8 X 10(3)/mm(3) (range 7.5 to 13.3), often with increased neutrophils and band forms. Nine patients had elevated serum transaminase levels, and six were hypoxic. All 10 patients had abnormal chest X-rays; abnormalities included infiltrates (n=7), pleural effusion (n=8), and mediastinal widening (seven patients). Computed tomography of the chest was performed on eight patients, and mediastinal lymphadenopathy was present in seven. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (<15%) than previously reported.

An outbreak of cyclosporiasis in Florida in 1995: a harbinger of multistate outbreaks in 1996 and 1997.

Before 1995, only one outbreak of cyclosporiasis had been reported in the United States. To identify risk factors for Cyclospora infection acquired in Florida in 1995, we conducted a matched case-control study (24 sporadic cases and 69 controls) and retrospective cohort studies of clusters of cases associated with two May social events (attack rates = 15.4% [8 of 52] and 54.5% [6 of 11]). In univariate analysis of data from the case-control study, consumption of fresh raspberries (odds ratio [OR] = 6.0, 95% confidence interval [CI] = 1.1-31.7) and bare-handed contact with soil (OR = 5.4, 95% CI = 1.4-20.7) were associated with infection; soil contact was also implicated in multivariate analysis. For the events, mixed-fruit items that had only fresh raspberries and strawberries in common had elevated relative risks (3.7 and 4.2), but the confidence intervals overlapped 1.0. The raspberries eaten at the events and by sporadic case-patients were imported. Given the cumulative evidence of the three studies and the occurrence in 1996 and 1997 of outbreaks in North America associated with consumption of Guatemalan raspberries, food-borne transmission of Cyclospora was likely in 1995 in Florida as well.

Risk factors for seabather's eruption: a prospective cohort study.

OBJECTIVE: A prospective cohort study was performed to identify risk factors for seabather's eruption. METHODS: Study participants were recruited at four beaches in Palm Beach County, Florida, during three weekends of May and June 1993. Participants were interviewed by telephone after 48 hours regarding medical history, beach activities, development of rashes, and use of possible preventive measures. RESULTS: Seabather's eruption, defined by the occurrence of a rash within two days of exposure to seawater, was reported by 114 (16%) of 735 respondents. The strongest predictor of seabather's eruption was a past history of the condition. Children less than 16 years of age were also at increased risk, as were surfers. Showering with one's bathing suit off was a useful protective measure. CONCLUSION: The study's findings suggest that when the seasonal risk of seabather's eruption is present, children, people with a history of seabather's eruption, and surfers are at greatest risk. During the sea lice season, seabathers can minimize their risk by showering with their bathing suits off after seabathing. Length of the time spent in water was not significantly associated with seabather's eruption.

Health care reform and the role of public health agencies.

Experience in developing a local public health program, covering a period of approximately 45 years, is described. Included are the assessment and analysis of problems, policy formulation, plan development, and program implementation. A study of problems of seasonal farm workers, particularly those who migrate, is described, as well as a health services delivery program based on this study. Attention is given to incorporation of medical care with core public health services, and the use of a multidisciplinary team. Special features required to overcome cultural, language, educational, and other barriers are outlined. Adaption of knowledge gained from the migrant health project toward meeting needs of the county's medically underserved population is described. Involvement of the community, including representatives of private and public sectors, in the development and implementation of plans is emphasized. Maintaining appropriate emphasis on preventive aspects is discussed, together with mobilization of financial and other support. The importance of qualified public health staff is also emphasized: residency programs for physicians and dentists and training for other personnel are described.

The antibody response in seabather's eruption.

Thirty-six of 44 patients with seabather's eruption had specific IgG antibodies against Linuche unguilata (thimble jelly) medusae antigen. ELISA detected antibodies in serum stored for 10 years. The extent of the cutaneous eruption or sting severity was correlated with antibody titer. Antibodies were detected in patients acquiring the eruption in Florida, the Bahamas and Aruba, reflecting the habitat of these jellyfish. This serological assay can be useful to confirm the clinical diagnosis.

Pediatric tuberculosis and human immunodeficiency virus infection in Palm Beach County, Florida.

OBJECTIVE: To describe the factors underlying an increasing incidence of tuberculosis in children. DESIGN: Descriptive case review. SETTING: Palm Beach County, Fla. PARTICIPANTS: Forty-four children with suspected and confirmed pediatric tuberculosis from 1985 through 1989. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: From 1988 through 1989, tuberculosis was confirmed in 15 children and suspected in another 16 compared with data from 1985 through 1987 in which the disease was confirmed in nine children and suspected in four. Pediatric tuberculosis occurred primarily in blacks younger than 5 years; the increase in the number of cases reported in 1988 and 1989 occurred only in blacks. One child in whom tuberculosis was confirmed during the recent period was infected with the human immunodeficiency virus (HIV); however, among children with suspected tuberculosis, four of the nine children tested were seropositive for HIV. There was no evidence of increased transmission of tuberculosis to children by HIV-seropositive adults compared with transmission by HIV-seronegative adults with TB. New adult tuberculosis cases in the county increased annually, from 92 cases in 1986 to 169 in 1989, of whom at least 36% were infected with HIV. CONCLUSIONS: The largest effect of the HIV epidemic on tuberculosis in children appeared to be indirect, through an increase in the number of adults with active tuberculosis serving as potential sources of tuberculosis infection for children. A direct effect of HIV infection in the progression of tuberculous disease in children is likely, but was not detected in this investigation. Case-finding for tuberculosis among children will need to increase, particularly in areas heavily affected by acquired immunodeficiency syndrome, but may be complicated by the difficulty of diagnosing tuberculosis in HIV-infected children.

A case of neonatal tetanus.

The morbidity and mortality from neonatal tetanus are preventable. It is largely a disease of developing countries. This single case of neonatal tetanus in southern Florida must serve as an indicator for the need for health care professionals to evaluate the degree of utilization of maternal health services and the impact of immunization programs for those women at risk, in this case, women who have migrated from developing countries.

Prevalence of hepatitis B surface antigen among women receiving prenatal care at the Palm Beach County Health Department.

Pregnant women receiving prenatal care at the maternity clinics of the Palm Beach County Health Department were tested for hepatitis B surface antigen. Routine screening of pregnant women for the antigen is discussed. The results of this study indicate the need for routine screening of our medically indigent pregnant population.