The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a US treated public drinking water system.

BACKGROUND: Naegleria fowleri is a climate-sensitive, thermophilic ameba found in warm, freshwater lakes and rivers. Primary amebic meningoencephalitis (PAM), which is almost universally fatal, occurs when N. fowleri-containing water enters the nose, typically during swimming, and migrates to the brain via the olfactory nerve. In August 2013, a 4-year-old boy died of meningoencephalitis of unknown etiology in a Louisiana hospital. METHODS: Clinical and environmental testing and a case investigation were initiated to determine the cause of death and to identify potential exposures. RESULTS: Based on testing of cerebrospinal fluid and brain specimens, the child was diagnosed with PAM. His only reported water exposure was tap water; in particular, tap water that was used to supply water to a lawn water slide on which the child had played extensively prior to becoming ill. Water samples were collected from both the home and the water distribution system that supplied the home and tested; N. fowleri was identified in water samples from both the home and the water distribution system. CONCLUSIONS: This case is the first reported PAM death associated with culturable N. fowleri in tap water from a US treated drinking water system. This case occurred in the context of an expanding geographic range for PAM beyond southern states, with recent case reports from Minnesota, Kansas, and Indiana. This case also highlights the role of adequate disinfection throughout drinking water distribution systems and the importance of maintaining vigilance when operating drinking water systems using source waters with elevated temperatures.

Parkinson Disease Hospitalizations and Mortality in Louisiana, 1999-2012.

This study describes Parkinson Disease hospitalizations and deaths in the Louisiana population during the years 1999-2012. Data from the Louisiana Hospitalization Discharge Database (LAHIDD) were collected and analyzed by age, race, and gender and also compared to length of hospital stay and daily hospitalization cost.

Severe Acute Respiratory Illness (SARI) Surveillance in Louisiana, 2013-2014.

The objectives of this article are to describe the severe acute respiratory illness (SARI) surveillance implemented in Louisiana during the 2013-2014 influenza season, present the epidemiology of reported SARI cases, and identify ways to improve this system by incorporating formal SARI surveillance into the influenza surveillance program. Of the 212 SARI cases, 181 (85%) had at least one underlying medical condition, 54 (25.7%) had two conditions, 43 (20.3%) had three conditions, and 25 (11.8%) reported four or more. The most common four underlying conditions were: obesity (43.4%), chronic cardiac conditions (39.6%), diabetes (29.7%), and chronic pulmonary conditions (26.9%). While obesity was the most reported underlying condition, it was three times more likely to be reported in less than 65 years old rather than those >65. Continuation of SARI data collection in future seasons will allow comparisons regarding severity, populations affected, and identify risk factors most commonly associated with severe illness. Reporting of SARI cases also increased influenza-associated adult mortality reporting to the Office of Public Health's Office of Infectious Diseases Epidemiology (ID Epi). Though all influenza-associated mortality is reportable in Louisiana, adult mortality was reported rarely prior to the 2013-2014 season.

Intensity of Influenza-Like Illness (ILI) and Congestive Heart Failure (CHF) Deaths: A Correlation Study in Louisiana, 2000-2012.

Influenza infection has been linked to significant morbidity and mortality, especially in vulnerable populations including the elderly and those with chronic disease, such as congestive heart failure (CHF). This correlation analysis used influenza surveillance data and vital statistics mortality data to assess the correlation between influenza-like illness (ILI) and CHF deaths in Louisiana from 2000-2012 on a weekly level and at the seasonal level. The correlation between ILI proportion and mean number of deaths for the entire study period was 0.23. The comparisons made at the seasonal level showed some association between season's intensity and CHF mortality. The clinical implication of this study is that ILI surveillance can be used to issue alert to clinicians who treat CHF patient in order to stress measures aimed at preventing deaths from CHF.

Firearm-related mortality, Louisiana 1999-2010.

This report is a purely descriptive study of firearm-related deaths occurring in Louisiana from 1999 to 2010. Mortality data were collected from death certificates from this 12-year period to describe firearm fatalities by year, race, gender, age group, and manner of death (accident, homicide, suicide). Louisiana data were also compared to national data. Race, sex, and age were important factors influencing mortality rates and the death manner. Rates were higher in males than in females and higher in African-Americans than in Whites. The highest rates were observed for homicides among African-American males. The ratio of Louisiana age/race-adjusted firearm mortality rates over the US rates were 1.8. Both Louisiana and the US mortality rates remained fairly constant over the 12-year period. Parish level data showed a wide variation in firearm mortality rates with some urban and some rural parishes having the highest rates. Data obtained from death certificates have limitations due to the limited number of variables available.

Outbreak of Francisella novicida bacteremia among inmates at a louisiana correctional facility.

BACKGROUND: Francisella novicida is a rare cause of human illness despite its close genetic relationship to Francisella tularensis, the agent of tularemia. During April-July 2011, 3 inmates at a Louisiana correctional facility developed F. novicida bacteremia; 1 inmate died acutely. METHODS: We interviewed surviving inmates; reviewed laboratory, medical, and housing records; and conducted an environmental investigation. Clinical and environmental samples were tested by culture, real-time polymerase chain reaction (PCR), and multigene sequencing. Isolates were typed by pulsed-field gel electrophoresis (PFGE). RESULTS: Clinical isolates were identified as F. novicida based on sequence analyses of the 16S ribosomal RNA, pgm, and pdpD genes. PmeI PFGE patterns for the clinical isolates were indistinguishable. Source patients were aged 40-56 years, male, and African American, and all were immunocompromised. Two patients presented with signs of bacterial peritonitis; the third had pyomyositis of the thigh. The 3 inmates had no contact with one another; their only shared exposures were consumption of municipal water and of ice that was mass-produced at the prison in an unenclosed building. Swabs from one set of ice machines and associated ice scoops yielded evidence of F. novicida by PCR and sequencing. All other environmental specimens tested negative. CONCLUSIONS: To our knowledge, this is the first reported common-source outbreak of F. novicida infections in humans. Epidemiological and laboratory evidence implicate contaminated ice as the likely vehicle of transmission; liver disease may be a predisposing factor. Clinicians, laboratorians, and public health officials should be aware of the potential for misidentification of F. novicida as F. tularensis.

Investigating cancer clusters in Louisiana and interpreting results.

Physicians are often asked questions related to cancer frequency in their communities, particularly in Louisiana because of the perception of high cancer rates in this region. When individuals perceive a higher than normal rate of cancer in their geographic area, time frame, or group of people, questions about the potential role of environmental contamination are often raised. The purpose of this article is to educate clinicians about the concept of cancer clusters so they can further disseminate this knowledge to patients concerned about increased cancer frequency in their communities. This article will accomplish this goal through the consideration of potential questions or concerns patients might present related to cancer frequency in their communities.

Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water.

BACKGROUND: Naegleria fowleri is a climate-sensitive, thermophilic ameba found in the environment, including warm, freshwater lakes and rivers. Primary amebic meningoencephalitis (PAM), which is almost universally fatal, occurs when N. fowleri-containing water enters the nose, typically during swimming, and N. fowleri migrates to the brain via the olfactory nerve. In 2011, 2 adults died in Louisiana hospitals of infectious meningoencephalitis after brief illnesses. METHODS: Clinical and environmental testing and case investigations were initiated to determine the cause of death and to identify the exposures. RESULTS: Both patients had diagnoses of PAM. Their only reported water exposures were tap water used for household activities, including regular sinus irrigation with neti pots. Water samples, tap swab samples, and neti pots were collected from both households and tested; N. fowleri were identified in water samples from both homes. CONCLUSIONS: These are the first reported PAM cases in the United States associated with the presence of N. fowleri in household plumbing served by treated municipal water supplies and the first reports of PAM potentially associated with the use of a nasal irrigation device. These cases occurred in the context of an expanding geographic range for PAM beyond southern tier states with recent case reports from Minnesota, Kansas, and Virginia. These infections introduce an additional consideration for physicians recommending nasal irrigation and demonstrate the importance of using appropriate water (distilled, boiled, filtered) for nasal irrigation. Furthermore, the changing epidemiology of PAM highlights the importance of raising awareness about this disease among physicians treating persons showing meningitislike symptoms.

Suicide mortality rates in Louisiana, 1999-2010.

This report is a descriptive study on suicide deaths in Louisiana occurring in the years 1999 to 2010. Mortality data was collected from death certificates from this 12-year period to describe suicide mortality by year, race, sex, age group, and methods of suicide. Data were also compared to national data. Rates and methods used to commit suicide vary greatly according to sex, race, and age. The highest rates were observed in white males, followed by black males, white females, and black females. Older white males had the highest suicide rates. The influence of age was modulated by the sex and race categories. Firearm was the most common method used in all four categories. Other less common methods were hanging/strangulation/suffocation (HSS) and drugs/alcohol. Although no parish-level data were systematically analyzed, a comparison of suicide rates post-Katrina versus pre-Katrina was done for Orleans Parish, the rest of the Greater New Orleans area, and a comparison group. It appears that rates observed among whites, particularly males, were higher after Katrina. Data based on mortality do not give a comprehensive picture of the burden of suicide, and their interpretation should be done with caution.

Respiratory syncytial virus-associated hospitalizations in Louisiana.

Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and pneumonia in children under one year of age worldwide. Records indicative of RSV cases were pulled from The Louisiana Inpatient Hospital Discharge Data based on RSV diagnosis codes to describe the burden of RSV infections in Louisiana from 1999 to 2010. Two thousand to three thousand hospitalized RSV cases occurred each year, with rates ranging from 37.2 to 71.4 hospitalizations per 100,000 population and the majority of cases (79%) being diagnosed with bronchiolitis. The vast majority of cases occurred in children under one year of age, and within that group, 44% of the cases occurred in children ages 0 to 3 months. The RSV season was found to occur from November to March, and immunoprophylaxis for high-risk infants should be given according to that season. Hospital-acquired versus community-acquired infections were also examined and most (96.1%) cases were community-acquired.

Adverse respiratory symptoms and environmental exposures among children and adolescents following Hurricane Katrina.

OBJECTIVES: Children and adolescents are especially vulnerable to environmental exposures and their respiratory effects. Following Hurricane Katrina in 2005, residents experienced multiple adverse environmental exposures. We characterized the association between upper respiratory symptoms (URS) and lower respiratory symptoms (LRS) and environmental exposures among children and adolescents affected by Hurricane Katrina. METHODS: We conducted a cross-sectional study following the return of the population to New Orleans after Hurricane Katrina (October 2005 and February 2006) among a convenience sample of children and adolescents attending New Orleans health facilities. We used uni-, bi-, and multivariable analyses to describe participants, exposures, and associations with URS/LRS. RESULTS: Of 1,243 participants, 47% were Caucasian, 50% were male, and 72% were younger than 11 years of age. Multiple environmental exposures were identified during and after the storm and at current residences: roof/glass/storm damage (50%), outside mold (22%), dust (18%), and flood damage (15%). Self-reported URS and LRS (76% and 36%, respectively) were higher after the hurricane than before the hurricane (22% and 9%, respectively, p<0.0001). Roof/glass/storm damage at home was associated with URS (adjusted odds ratio [AOR] = 1.59, 95% confidence interval [CI] = 1.15, 2.21) and LRS (AOR=1.35, 95% CI 1.01, 1.80), while mold growth at home was associated with LRS (AOR=1.47, 95% CI 1.02, 2.12). CONCLUSIONS: Children and adolescents affected by Hurricane Katrina experienced environmental exposures associated with increased prevalence of reported URS and LRS. Additional research is needed to investigate the long-term health impacts of Hurricane Katrina.

Clostridium difficile hospitalizations in Louisiana: a 10 year review.

Clostridium difficile (CD) is a common cause of diarrhea in hospitalized patients and can cause more serious intestinal conditions such as pseudomembranous colitis, toxic megacolon, perforations of the colon, sepsis, and even death. Clostridium difficile associated disease (CDAD) is mainly a health care associated illness. Known risk factors for CDAD are antibiotics, gastrointestinal surgery/manipulation, long length of stay in health care settings, serious underlying illness, a compromised immune system, and advanced age (>65+). In 2004 a new epidemic strain of CD was identified as causing hospital outbreaks in several states. This new strain is more virulent and is more resistant to fluoroquinolone antibiotics. The Healthcare Cost and Utilization Project (HCUP) analyzed hospitalization discharge rates of CDAD in the United States (US) between 1993 and 2005 and reported that hospital discharges for CDAD doubled between 2001 and 2005. This study was done to see if Louisiana had similar trends in CDAD rates compared to the rest of the nation. Discharge records from the Louisiana Hospital Inpatient Discharge Database (LAHIDD) were analyzed for CDAD rates between 1999 and 2008 and were compared to the HCUPnet national estimates in the US. Trend and variance analyses were performed to compare demographics within Louisiana and overall trends to the US. Our results show that Louisiana had similar trends of CDAD rates compared to the US over the past 10 years. Furthermore, Louisiana also had a doubling of CDAD rates from 2001 to 2005.

Geostatistical model-based estimates of Schistosomiasis prevalence among individuals aged ≤ 20 years in West Africa.

BACKGROUND: Schistosomiasis is a water-based disease that is believed to affect over 200 million people with an estimated 97% of the infections concentrated in Africa. However, these statistics are largely based on population re-adjusted data originally published by Utroska and colleagues more than 20 years ago. Hence, these estimates are outdated due to large-scale preventive chemotherapy programs, improved sanitation, water resources development and management, among other reasons. For planning, coordination, and evaluation of control activities, it is essential to possess reliable schistosomiasis prevalence maps. METHODOLOGY: We analyzed survey data compiled on a newly established open-access global neglected tropical diseases database (i) to create smooth empirical prevalence maps for Schistosoma mansoni and S. haematobium for individuals aged ≤ 20 years in West Africa, including Cameroon, and (ii) to derive country-specific prevalence estimates. We used Bayesian geostatistical models based on environmental predictors to take into account potential clustering due to common spatially structured exposures. Prediction at unobserved locations was facilitated by joint kriging. PRINCIPAL FINDINGS: Our models revealed that 50.8 million individuals aged ≤ 20 years in West Africa are infected with either S. mansoni, or S. haematobium, or both species concurrently. The country prevalence estimates ranged between 0.5% (The Gambia) and 37.1% (Liberia) for S. mansoni, and between 17.6% (The Gambia) and 51.6% (Sierra Leone) for S. haematobium. We observed that the combined prevalence for both schistosome species is two-fold lower in Gambia than previously reported, while we found an almost two-fold higher estimate for Liberia (58.3%) than reported before (30.0%). Our predictions are likely to overestimate overall country prevalence, since modeling was based on children and adolescents up to the age of 20 years who are at highest risk of infection. CONCLUSION/SIGNIFICANCE: We present the first empirical estimates for S. mansoni and S. haematobium prevalence at high spatial resolution throughout West Africa. Our prediction maps allow prioritizing of interventions in a spatially explicit manner, and will be useful for monitoring and evaluation of schistosomiasis control programs.

Characteristics of pesticide-related hospitalizations, Louisiana, 1998-2007.

OBJECTIVE: Pesticides are widely used on agricultural crops and in homes, workplaces, and public spaces. Exposure to pesticides can cause acute and chronic health effects. We analyzed data from the Louisiana Hospital Inpatient Discharge Database from 1998 through 2007 to characterize hospitalizations involving pesticides. METHODS: Data for the study period consisted of 384 pesticide-related hospitalizations. We used demographic information and diagnosis codes for analysis. RESULTS: Males consistently had higher hospitalization rates than females (p=0.0073). Children aged 0-4 years had the highest pesticide-related hospitalization rate of all age groups (2.69 hospitalizations per 100,000); children aged 5-9 years had the lowest rate (0.36 hospitalizations per 100,000). Compared with adults, children had a higher rate of disinfectant exposure (15% vs. 5%; odds ratio [OR] = 3.41, 95% confidence interval [CI] 1.61, 7.21; p=0.0008) and rodenticide exposure (14% vs. 2%; OR=8.55, 95% CI 3.07, 23.78; p<0.0001). Rural parishes (counties) were more likely than urban parishes to have higher pesticide hospitalization rates (OR=4.72, 95% CI 2.34, 9.54; p<0.0001). Intentional poisonings accounted for 27% of cases. Only eight cases were coded as work-related. CONCLUSIONS: Analyzing pesticide-related hospitalization data provides important information about some of the most severe pesticide poisoning cases. Significant findings include the elevated rate of hospitalizations among young children and men, and the large proportion of self-inflicted poisonings. Health departments and health-care providers may use these findings to target outreach and prevention activities.

Epidemiology of animal rabies and its practical application to pre- and postexposure prophylaxis, louisiana, 1988 to 2007.

The incidence of human rabies in the United States has decreased significantly over the past century. This analysis examines the ecological status of rabies in Louisiana with the intent of identifying differences in risk of rabies transmission from exposures to different species of animals. Louisiana presently harbors one terrestrial variant of rabies, a skunk variant, and several bat variants. Surveillance data collected from 1988 through 2007 were examined, comparing areas of the state characterized by circulating terrestrial variants and areas free of terrestrial rabies. Nine state public health regions were also compared. The proportions of rabies-positive laboratory submissions from each species and/or species group were used as indicators of risk. In addition, differences in proportions positive were examined temporally. A significant proportion of positive bats (9.64%) and skunks (44.3%), examined after biting or otherwise exposing a human being, were identified by diagnostic laboratories. Samples from wild terrestrial animals originating in areas known to harbor circulating terrestrial rabies variants were more than 30 times more likely to be positive for rabies than samples originating from areas thought to be free of terrestrial rabies. Bats were also slightly more likely to be positive when submitted from areas known to be endemic for terrestrial rabies. Rabies in pets and agricultural animals were rarely reported. Seasonal variations in prevalence of positive tests were also identified. The results of this examination of rabies epidemiology in Louisiana can be used in determining recommendations for both pre- and postexposure rabies prophylaxis. Similar applications of surveillance data are encouraged in other jurisdictions.

Louisiana death certificate accuracy: a concern for the public's health.

INTRODUCTION: The accuracy of death certificates is essential for public health prevention and research in the State of Louisiana. This article analyzes the accuracy of cause of death stated on Louisiana death certificates. METHODS: Discharge diagnoses from 2007 Louisiana Hospital Inpatient Discharge Diagnosis (LAHIDD) data were compared with the diagnoses in the cause of death section in the corresponding death certificates. RESULTS: Of the immediate causes of death, only 40.5% were considered an exact match and 17.4% did not have any type of match in the LAHIDD discharge diagnoses. For the preceding causes of death 54.0% of death certificates had no exact matches. There were only 55 (8.8%) of death certificates with no missing diagnosis. CONCLUSION: There are significant inconsistencies between the discharge diagnosis upon death and cause of death. This raises concern for public health and education is needed for physicians to improve accuracy of death certificates.

The epidemiology of animal bite, scratch, and other potential rabies exposures, Louisiana.

The authors conducted a review of 318 investigative reports of animal exposures recorded from November 2004 through April 2008. These reports were gathered as components of the rabies surveillance program in Louisiana. The reports were recorded by employees of the Louisiana Office of Public Health. Results were summarized and analyzed using the Centers for Disease Control and Prevention's (CDC) EpiInfo statistical software. The most common victims were children, most often exposed to a pet that was familiar. In children victimized by pets, males were much more likely to be involved. Children most often suffered injuries to the head and upper torso. Exposures to bats and skunks characterized the greatest risks for rabies transmission, but potential for exposure to rabies from pet species remained a reality. Pit bull type dogs were most frequently involved in dog bite exposures. Requests for animal rabies testing peak in the summer months. The increased risk to children demonstrates a need for public education, animal control programs, and evaluation of risk from certain breeds. Promotion of rabies vaccine compliance is of utmost importance to public health.

Louisiana autopsy patterns 1999-2006.

This report presents autopsy trends in Louisiana for 1999-2006 data and provides some comparison with national data for 2003. Mortality data for Louisiana was collected from the field 'autopsy' on the Certificate of Death from 1999-2006 and compared with national data for the year 2003. The overall autopsy rate was 9.3% in Louisiana versus 7.7% in the United States (U.S.) in 2003. Autopsy rates were higher than those of the U.S. in almost all categories of personal factors (gender, race and age group). Louisiana's autopsy levels were generally greater for both natural disease (3.7% versus 3.5% for the U.S.) and the high autopsy rate group (61.1% versus 54.3% for the U.S.).