HIV AND STI RISK FACTORS AMONG GEORGIAN YOUTH.

Designing effective interventions for youth to address STI/HIV risk factors requires local context knowledge. This study gathers information about STI/HIV knowledge among Georgian youth, identifies STI/HIV risk behaviors and quantifies associations between socio-demographic factors and risk practices with HIV/STIs knowledge. Cross-sectional survey was conducted among 411 students using self-administered questionnaire. Bivariate analysis was conducted and prevalence ratios with 95% confidence intervals were computed. Study participants were more knowledgeable about HIV/AIDS than other STIs, though still lacked information about HIV/AIDS transmission routes. Only 10.1% had ever received HIV testing. Men were less likely to have current permanent sex partner (44.5% vs 79.2%; PR=0.2; 95% CI:0.1-0.5) and more likely to have occasional sex partner past 12 months than women (51% vs 19%; PR=4.3; 95% CI:1.8-10.2). Study describes relatively low awareness of STIs in Georgian youth and revealed possibilities to influence STI transmission through designing gender-tailored public health interventions.

CONFIDENCE IN THE GEORGIA NATIONAL HCV ELIMINATION PROGRAM AMONG WOMEN OF REPRODUCTIVE AGE.

Georgia is among the countries with a very high prevalence of hepatitis C virus (HCV) infection. The recent availability of highly effective, direct-acting antivirals (DAAs) capable of curing >90% of persons treated has made HCV elimination a possibility. All adult citizens infected with HCV are eligible to receive free DAAs through the Georgia National HCV Elimination Program (Program). From April 2015 to December 2018, 54,087 persons were enrolled in the Program throughout the country. However, more than 20,000 individuals are aware of their HCV antibody positive status but did not have HCV RNA testing, a necessary step to determine treatment needs. We hypothesized that a reason for hesitance to enroll in the Program may be a low level of trust of the Program. A cross-sectional study was conducted in Tbilisi, the capital of Georgia. Reproductive aged women were randomly selected from three maternity care centers during prenatal care. The self-administered questionnaire included questions on socio-demographic information, knowledge about HCV infection and trust in the Program. A total of 2185 women of reproductive age were enrolled in the study. The mean age was 28.5 (age range: 17-46) years. The majority of the study participants (76.4%) had a university degree. The vast majority of study participants (>95%) were married and 95.1% were Georgian ethnicity. Almost 90% of the participants were aware of their HCV infection status. Most women (85.3%) had heard of HCV elimination program in Georgia; 74.6% stated that they trust the Program. However, almost 10% of surveyed women stated they would refuse to get enrolled in the Program if their anti-HCV test result is positive. Trust in the Program was higher among women aged >25 years (80.7%) compared to younger women (68.4%) (p<0.0001). Level of education was also associated with trust to the program: more women with higher education level reported that they trust the Program (78.7%) compared to women with lower education level (68.5%) (p<0.0001). Trust in the Georgia National HCV Elimination Program is not sufficiently high among women of reproductive age in Georgia. Effective educational campaigns are needed to improve trust to the Program for this targeted group.

HEPATITIS B VACCINATION: KNOWLEDGE AND ATTITUDE AMONG WOMEN OF REPRODUCTIVE AGE IN GEORGIA.

Georgia is a country with high prevalence of hepatitis B. Based on a 2015 population serosurvey, the prevalence of hepatitis B surface antigen (HBsAg) is 2.9% and prevalence of anti-HBc is 25.5% in general population. Hepatitis B vaccine has been included in the national immunization schedule of Georgia only since 2002. Thus, most reproductive aged women were not vaccinated during young childhood. Cross-sectional study was conducted in the capital of Georgia, Tbilisi. Reproductive aged women were randomly selected and then recruited from three maternity care centers during prenatal care. The self-administered questionnaire included questions on socio-demographic information, hepatitis B vaccination status and awareness of HBV infection status. A total of 2185 reproductive aged women were enrolled in the study. The mean age was 28.5 (age range 17-46) years. Most (76.4%) had a bachelor and/or master's degree. 20.0% of respondents never heard about HBV. Very few (3.3%) knew they were infected with HBV. We could not determine if women were chronically infected or were exposed and developed antibodies. HBV knowledge was limited: 57.5% were not aware of available HBV treatment; 51.6% didn't know HBV infection could be prevented (35.8% named HBV vaccination, 29.3% named condom use). Only 10% of study participants reported being vaccinated for HBV. Awareness of HBV infection was higher among women over age 25 (72.1%) compared to women aged 25 years or less (27.9%) (P<0.0001). Among women who reported having an HBV infection, 40.6% did not name vaccine as a prevention method and 38.2% did not have information about availability of HBV treatment (P<0.05). Based on our study results, knowledge about HBV infection and vaccination is very low among reproductive aged women in Georgia. Women's health centers can be a good place to reach reproductive aged women for counseling on HBV infection and promote vaccination against hepatitis B.

Tularemia transmission to humans: a multifaceted surveillance approach.

Tularemia has sustained seroprevalence in Eurasia, with estimates as high as 15% in endemic regions. The purpose of this report is to characterise the current epidemiology of Francisella tularensis subspecies holarctica in Georgia. Three surveillance activities are summarised: (1) acute infections captured in Georgia's notifiable disease surveillance system, (2) infectious disease seroprevalence study of military volunteers, and (3) a study of seroprevalence and risk factors in endemic regions. Descriptive analyses of demographic, exposure and clinical factors were conducted for the surveillance studies; bivariate analyses were computed to identify risk factors of seropositivity using likelihood ratio χ2 tests or Fisher's exact tests. Of the 19 incident cases reported between 2014 and August 2017, 10 were confirmed and nine met the presumptive definition; the estimated annual incidence was 0.12/100 000. The first cases of tularemia in Western Georgia were reported. Seroprevalences of antibodies for F. tularensis were 2.0% for military volunteers and 5.0% for residents in endemic regions. Exposures correlated with seropositivity included work with hay and contact with multiple types of animals. Seroprevalence studies conducted periodically may enhance our understanding of tularemia in countries with dramatically underestimated incidence rates.

MEASUREMENT OF PERSONAL RISK BEHAVI-OR IN OCCUPATIONAL RISK STUDIES AMONG HEALTH CARE WORKERS.

Risky behaviours, particularly illegal and heavily stigmatized behaviours, are difficult to measure through self-report in both high risk groups and the general population. Underreporting can result in substantially biased estimates of non-injection drug use (IDU) risk of hepatitis C virus (HCV) infection. We hypothesized that asking about the existence of social networks injection drug use may be a useful marker of IDU. A cross-sectional survey of physicians and nurses was conducted in seven hospitals in Georgia. Based on survey responses participants were categorized into three IDU risk groups: ever used injecting drugs (Self IDU), reported a friend, family member or colleague used injecting drugs (Associate IDU), or reported neither (No IDU). Testing on anti-HCV was done using third generation ELISA methods. Both unadjusted and adjusted prevalence ratios between IDU risk groups and HCV prevalence were estimated. Of the 1312 (82.2%) participants, 10 (0.8%), 75 (5.7%), and 1227 (93.5%) were categorized as Self IDU, Associate IDU and No IDU, respectively; with HCV prevalence of 20%, 9.3% and 4.6%, respectively (p=0.016). The association was due primarily to women's reports. Those who reported some IDU risk were more likely to report other personal risk behaviors (e.g., multiple sex partners) and occupational risk behaviors (e.g., frequent exposure to blood and body fluids). This study represents a start of measurement development by assessing the potential usefulness of a marker to measure of IDU. Improved measurement of stigmatized behaviors is needed for confounding adjustment to improve estimates of occupational risks of blood-borne infections.

Universal precautions in Central Asia: the need for multiple strategies in this window of opportunity.

BACKGROUND: Adoption of universal precautions remains a global concern. In low- and middle-income countries, the problem is exacerbated by a shortage of protective supplies, lack of training among clinicians, and an expanding human immunodeficiency virus (HIV) epidemic. AIM: To describe the perceptions of medical students about the risk of HIV and use of universal precautions, and to identify recent exposures to blood or bodily fluids. METHODS: A cross-sectional study was conducted among Kazakh medical students taking a newly-implemented infection control course in 2013. Participants completed a survey to investigate the use of precautions and exposures to blood or bodily fluids. Attitudes towards HIV were explored. Bivariate analyses identified factors related to attitudes about universal precautions, and self-reported behaviours and exposures. FINDINGS: Half (49.6%) of the 785 participants expressed 'a lot of concern' about contracting HIV while caring for patients, and 40.5% of students thought that physicians sometimes refuse to treat HIV-positive patients due to a fear of contracting HIV. Regarding precautions, only half (51.5%) of the students reported that they always use gloves, and even fewer reported that they always use masks or eye protection. Exposure to contaminated blood or bodily fluids was reported by 10.1% of respondents. CONCLUSION: The findings underscore the urgent need for interventions to improve universal precautions and reduce the fear of infectious diseases. Perhaps even more concerning, these data may underestimate the true magnitude of the problem given cultural impediments to transparency.

Quantifying the matrix of relationships between reduced vancomycin susceptibility phenotypes and outcomes among patients with MRSA bloodstream infections treated with vancomycin .

OBJECTIVES: Several phenotypic characteristics of Staphylococcus aureus have been identified as aetiological factors responsible for adverse outcomes among patients receiving vancomycin. However, characterization of the outcomes associated with these reduced vancomycin susceptibility phenotypes (rVSPs) remains largely incomplete and it is unknown if these features contribute to deleterious treatment outcomes alone or in concert. This study described the interrelationship between rVSPs and assessed their individual and combined effects on outcomes among patients who received vancomycin for a methicillin-resistant S. aureus (MRSA) bloodstream infection. METHODS: An observational study of adult, hospitalized patients with MRSA bloodstream infections who were treated with vancomycin between January 2005 and June 2009 was performed. The rVSPs evaluated included the following: (i) Etest MIC; (ii) broth microdilution MIC; (iii) MBC : MIC ratio; and (iv) heteroresistance to vancomycin by the Etest macromethod. Failure was defined as any of the following: (i) 30 day mortality; (ii) bacteraemia ≥ 7 days on therapy; or (iii) recurrence of MRSA bacteraemia within 60 days of therapy discontinuation. RESULTS: During the study period, 184 cases met the study criteria and 41.3% met the failure criteria. There was a clear linear exposure-response relationship between the number of these phenotypic markers and outcomes. As the number of phenotypes escalated, the incidence of overall failure increased incrementally by 10%-18%. CONCLUSIONS: The data suggest that rVSPs contribute to deleterious treatment outcomes in concert.

Comparative evaluation of serotonin toxicity among veterans affairs patients receiving linezolid and vancomycin.

Despite the theoretical risk of serotonin toxicity (ST) with linezolid, "real-world" clinical evaluations of the risk of ST in patients receiving linezolid have been limited to case reports and noncomparator studies. An observational, matched-cohort study was conducted to evaluate the risk of ST among hospitalized patients who received linezolid or vancomycin at the Upstate New York Veterans Affairs Healthcare Network (Veterans Integrated Service Network 2 [VISN-2]). Matching criteria included VISN-2 hospital, hospital ward, prior hospital length of stay, age, and baseline platelet counts. The patients' electronic medical records were evaluated for symptoms consistent with ST and the Hunter serotonin toxicity criteria (HSTC) using an intensive, natural word search algorithm. The study included 251 matched pairs. Demographics and comorbidities were similar between groups. Over half of the study population received at least one concurrent medication with serotonergic activity. Receipt of agents with serotonergic activity was more pronounced in the vancomycin group, and the higher frequency was due to concomitant antihistamine and antiemetic use. Antidepressant use, including selective serotonin reuptake inhibitors (SSRIs), was similar between groups. No patients in either group were found to meet the criteria using the word search algorithm for ST. Fewer linezolid patients than vancomycin patients met the HSTC overall (3.2% versus 8.8%) and when stratified by receipt of a concurrent serotonergic agent (4.3% versus 12.4%). Of the patients meeting the HSTC, most had past or present comorbidities that may have contributed to or overlapped the HSTC. This study of hospitalized patients revealed comparably low frequencies of adverse events potentially related to ST among patients who received linezolid or vancomycin.

Frequency of electrocardiogram testing among HIV-infected patients at risk for medication-induced QTc prolongation.

OBJECTIVES: HIV-infected patients are commonly prescribed several medications and are thus at risk for drug interactions that may result in QTc prolongation. We sought (1) to identify the frequency of electrocardiogram (ECG) monitoring (2), to determine the prevalence of drug interactions involving QTc-prolonging medications, and (3) to quantify the prevalence of QTc prolongation. METHODS: A cross-sectional study was conducted among HIV-infected adults. Demographics, medications, drug interactions and comorbidities were abstracted from patients' medical records. Abnormal QTc interval was defined per the UK Committee for Proprietary Medicinal Products. Clinical characteristics were compared among ECG recipients and nonrecipients. Among ECG recipients, the prevalence and predictors of QTc prolongation were assessed. RESULTS: Among the 454 patients included in the study, 80.8% were prescribed a medication associated with QTc prolongation and 39% had drug interactions expected to increase QTc prolongation risk. There were 138 patients (30.3%) who received ECG testing. Receipt of ECG monitoring was associated with increasing age, diabetes, increasing total number of medications and gastroesophageal reflux disease. Among ECG recipients, the prevalence of abnormal QTc interval was 27.5%. Chronic kidney disease [prevalence ratio (PR) 3.47; 95% confidence interval (CI) 1.37-8.83; P = 0.009], hepatitis C virus coinfection (PR 2.26; 95% CI 0.97-5.27; P = 0.06) and hypertension (PR 2.11; 95% CI 0.93-4.81; P = 0.07) were independently associated with an abnormal QTc interval. CONCLUSIONS: A low frequency of ECG testing was observed, despite a high use of medications associated with QTc prolongation. The risk of abnormal QTc interval was highest among patients with chronic kidney disease, hypertension and hepatitis C virus coinfection.

Occupational exposure to body fluids among health care workers in Georgia.

BACKGROUND: Health care workers (HCWs) are at increased risk of being infected with blood-borne pathogens. AIMS: To evaluate risk of occupational exposure to blood-borne viruses and determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among HCWs in Georgia. METHODS: The sample included HCWs from seven medical institutions in five cities in Georgia. A self-administered questionnaire was used to collect information on demographic, occupational and personal risk factors for blood-borne viruses. After obtaining informed consent, blood was drawn from the study participants for a seroprevalence study of HBV, HCV and HIV infections. RESULTS: There were 1386 participating HCWs from a number of departments, including surgery (29%), internal medicine (19%) and intensive care (19%). Nosocomial risk events were reported by the majority of HCWs, including accidental needlestick injury (45%), cuts with contaminated instruments (38%) and blood splashes (46%). The most frequent risk for receiving a cut was related to a false move during a procedure, reassembling devices and handing devices to a colleague. The highest proportion of needlestick injuries among physicians (22%) and nurses (39%) was related to recapping of used needles. No HIV-infected HCW was identified. Prevalence of HCV infection was 5%, anti-HBc was present among 29% with 2% being HBsAg carriers. CONCLUSIONS: Data from this study can be utilized in educational programs and implementation of universal safety precautions for HCWs in Georgia to help achieve similar reductions in blood-borne infection transmission to those achieved in developed countries.

Barriers to hepatitis B vaccine coverage among healthcare workers in the Republic of Georgia: An international perspective.

BACKGROUND: While the Republic of Georgia has a high prevalence of hepatitis B virus (HBV) infection (3.4% of blood donors tested positive for HBV surface antigen [HBsAg]), relatively few healthcare workers (HCWs) are thought to be immunized. OBJECTIVE: To measure rates of HBV vaccination coverage and identify predictors of vaccine acceptance among HCWs. DESIGN: Cross-sectional survey. METHODS: A study was conducted among full-time physicians and nurses at 2 large hospitals. Self-administered questionnaires included questions about demographic characteristics, HBV vaccine status, willingness to recommend vaccination to other HCWs, and barriers to vaccination. Laboratory tests were conducted for identification of HBsAg and antibody to hepatitis B core antigen. RESULTS: A total of 297 (91%) of 325 randomly selected HCWs provided information for the study (124 physicians and 173 nurses). The rate of HBV vaccination coverage was 12%, and 54% of respondents indicated that they would recommend vaccination to other HCWs. Perception of vaccine safety was identified as the most important predictor for acceptance (prevalence ratio [PR], 3.3 [95% confidence ratio {CI}, 1.2-8.9]) and for willingness to recommend HBV vaccination to other HCWs (PR, 5.5 [95% CI, 3.1-9.4]). Vaccinated HCWs were more likely to recommend vaccination to other healthcare personnel (PR, 1.7 [95% CI, 1.5-2.1]), as were those younger than 40 years of age (PR, 6.0 [95% CI, 2.8-12.6]). Multivariate analyses identified 2 additional factors associated with vaccine acceptance and willingness to recommend vaccination: the hospital at which the HCW was employed and the perception of risk of infection for HCWs. CONCLUSION: Georgia plans a major HBV vaccination campaign for HCWs in 2009. The campaign's success will depend on addressing vaccine safety concerns identified in this study and educating HCWs about risk factors for infection and benefits of immunization.

Agreement in self-reported personal risk factor information collected by different modes in Mongolia.

This study compares two methods (a self-administered paper survey and a face-to-face interview) of collecting information about personal risk behaviours important for studies of HIV and other blood-borne pathogen transmissions in a developing country. In the framework of an epidemiological study conducted among 2504 donors in the Blood Center at the Ministry of Health, Mongolia, 2250 participants completed a short paper survey and 923 participants were interviewed concerning risk factors for hepatitis infections. A total of 669 individuals completed both surveys. McNemar's test and Kappa statistics were used to compare responses from both types of questionnaire. Kappa coefficients for health-care factors ranged from 0.57 (injection outside of hospital) to 0.81 (previous blood donation). Alcohol use and smoking were both reported more often in the interview than in the survey; the kappa coefficient was lowest (0.61) for alcohol use. While the prevalence of these behaviours depended on the mode of data collection, the association between behaviour and an outcome, hepatitis B surface antigen, was not substantially different between the two data collection methods. The results indicate that misclassification of risk behaviours is likely regardless of data collection method. However, in this study we found that biased estimates of prevalence likely did not substantially bias the estimates of association between risk factors and blood-borne infection.

The prevalence of chlamydial infection in Estonia: a population-based survey.

The aim of this study was to estimate the prevalence of Chlamydia trachomatis infection among Estonian men and women by a cross-sectional study based on the screening of a probability sample of the residents of Tartu using participant-collected, mail-delivered testing for C. trachomatis complemented with the self-administered questionnaire. Full participation as defined by returning both the questionnaire and specimen was 34% (n = 479; 95% confidence interval [CI] 32-37%). Study participation was 40% (n = 560; 95% CI 37-43%) for subjects returning either or both the study questionnaire and specimen. After weighing the population distribution, the prevalence estimate for the age group of 18-35 years was 5.4% (95% CI 3.0-7.5%), 6.9% (95% CI 3.6-10.3%) among women and 2.7% (95% CI 0.3-5.0%) among men. The number of sexual partners in the past 12 months was the strongest predictor of infection.

Examining the effect of residential change on intimate partner violence risk.

OBJECTIVES: To examine the relationship between residential change and a woman's subsequent risk of intimate partner violence (IPV), whether by a past or a new offender, a relationship that has not been prospectively examined to date. DESIGN: A dynamic cohort of women who recently changed residence (movers) was compared with those who did not (non-movers) for 12-month risk of IPV by a past offender and of IPV by a new offender. PARTICIPANTS AND METHODS: Secondary analysis of a linked, longitudinal National Crime Victimization Survey dataset including 10 754 recent movers and 10 236 non-movers among women aged 18-44 years. RESULTS: The risk of IPV by either a past or a new offender was almost double for women who had recently moved compared with those who had not moved. This increased risk proved to be robust, as it persisted when the data were weighted and unweighted, and when the main effect was adjusted by measured covariates. CONCLUSIONS: The apparent increase in IPV risk after residential change may be a marker of a pre-existing problem or a precursor of subsequent problems. Unlike past research that has considered residential change after abuse or as a simultaneous exposure, this study focused solely on empirically measuring the risk of IPV after a recent move. This decision has important public health ramifications: determination of IPV exposure is not always possible, whereas soliciting a woman's history of residence may be more feasible. If transience puts a woman at greater risk for victimisation by an intimate partner, increased awareness may have a vital role in protecting women who move.

Barriers to effective STI screening in a post-Soviet society: results from a qualitative study.

OBJECTIVE: This qualitative study assesses knowledge about sexually transmitted infections (STI), identifies perceived barriers to STI testing, and recommends strategies to optimise participation in a home based STI testing programme. METHODS: Five focus groups composed of 29 total participants were recruited using convenience sampling methods based on age (18-40 years), gender (male and female), and residency (Tartu region, Estonia). RESULTS: The focus groups revealed significant knowledge deficits and a widespread attitude of denial. However, participants acknowledged that STIs are a serious problem and recommended strategies for increasing participation in an STI testing and treatment programme. Successful STI prevention programmes must address a number of challenges, including disease stigmatisation and privacy protection. CONCLUSION: The fear of enforced disease control methods coupled with the current stigmatisation of STIs creates a serious challenge for Estonian STI prevention and treatment efforts. This qualitative study provides a good contextual reference for STI control programmes in eastern Europe.

Estimating the mortality rate of hepatitis C using multiple data sources.

The New York State hospital discharge database and the multiple cause-of-death file were used to estimate the mortality rate of hepatitis C in New York State excluding New York City in 1997. The mortality rate with hepatitis C was severely underestimated when each data source was used alone. Applying the capture recapture method using the hospital discharge database and the multiple cause-of-death file appears to be an efficient method to estimate the mortality rate with hepatitis C.

Evaluation of hepatitis C surveillance in Poland in 1998.

The aim was to evaluate hepatitis C surveillance in Poland during 1998. Hepatitis C reports were obtained from epidemiology offices. Public health staff were interviewed to collect information on surveillance operations. To estimate the proportion of acute cases among the total reported, a study was conducted in the Warsaw district to validate case reports. A total of 1661 (97.2%) hepatitis C cases were studied. Hepatitis C surveillance was timely and acceptable to the user, but did not provide a number of information elements required to differentiate acute from chronic cases of infection. Of the 268 case reports available in the Warsaw district, only 15 (5.6%) met the acute hepatitis C case definition. It is concluded that hepatitis C surveillance in Poland cannot provide useful incidence estimates and information regarding risk factors for acute infection. A strict case definition and a modified case form with specific questions for HCV transmission routes should be applied.

Sexual activity and condom use among Eastern European adolescents--the Study of Hungarian Adolescent Risk Behaviours.

While rates of HIV and STD infection in Eastern Europe are increasing rapidly, little is known about sexual behaviour, including condom use, among Eastern European youths. The Study of Hungarian Adolescent Risk Behaviours was designed to assess the knowledge, attitudes, and behaviours of adolescents studying in secondary schools in Budapest, Hungary. Students (n =3486) in a random sample of public secondary schools completed a self-administered questionnaire, including measures of sexual activity and condom use. Thirty-eight percent of students reported ever having had vaginal intercourse. Condom use by those reporting having had sex in the past five weeks was classified as consistent/every time (40%); irregular (25.6%); and none (34.3%). Multivariate analysis revealed positive opinions about condoms, fear of AIDS, and initiation of condom use by both partners to predict more frequent condom use. Implications for targeted AIDS/STD education and prevention among adolescents are discussed.

Prevalence of hepatitis B, hepatitis C, syphilis and HIV in Georgian blood donors.

Prevalence of human immunodeficiency (HIV), hepatitis B (HBV), hepatitis C (HCV) virus and syphilis in the population of blood donors in Georgia has been investigated. Out of 4970 donors 7.3% had anti-HCV (6.9% confirmed), HbsAg was positive in 4.1% (3.4% confirmed), Seroprevalence of Syphilis was 2.3%. Three individuals had HIV. Prevalence of HCV and HBV in Georgia is higher than national prevalence estimates of viral hepatitis in neighboring countries.

Outbreak of severe Pseudomonas aeruginosa infections caused by a contaminated drain in a whirlpool bathtub.

During a 14-month period, 7 patients with hematological malignancies acquired serious infections caused by a single strain of multiply resistant Pseudomonas aeruginosa. A case-control study, culture surveys, and pulsed-field gel electrophoresis implicated a whirlpool bathtub on the unit as the reservoir. All case patients and 32% of control patients used this bathtub (P=.003). The epidemic strain was found only in cultures of samples taken from the bathtub. The drain of the whirlpool bathtub, which was contaminated with the epidemic strain, closed approximately 2.54 cm below the drain's strainer. Water from the faucet, which was not contaminated, became contaminated with P. aeruginosa from the drain when the tub was filled. The design of the drain allowed the epidemic strain to be transmitted to immunocompromised patients who used the whirlpool bathtub. Such tubs are used in many hospitals, and they may be an unrecognized source of nosocomial infections. This potential source of infection could be eliminated by using whirlpool bathtubs with drains that seal at the top.