Effectiveness and cost-benefit of enhancements to a syphilis screening and treatment program at a county jail.

BACKGROUND: High rates of syphilis are found in inmates of county jails. Treatment of this infected transient population necessitated the development of a rapid protocol. GOAL: To evaluate a rapid screening and treatment protocol for syphilis in a county jail. STUDY DESIGN: Over a 2-year period 18,442 inmates were screened for syphilis with a nontreponemal test and record search for treatment history. Confirmatory test results were reviewed following treatment. Cost was defined as deflated marginal outlays. Benefit was calculated as the discounted expected cost of treatment of congenital, late, and neurosyphilis. RESULTS: The sensitivity, specificity, and positive predictive value of the protocol were 99.6%, 80.8%, and 79.3%, respectively. Of 257 confirmed cases, 183 were offered treatment in jail. The percentage of short-term inmates treated increased following implementation. The cost-benefit ratio was 9.14:1. CONCLUSIONS: The protocol was highly effective in patient identification and treatment delivery, and cost-effective as well.

Assessment of a geographically targeted field intervention on gonorrhea incidence in two New York State counties.

BACKGROUND AND OBJECTIVES: Using study findings that demonstrated the importance of core group members in gonorrhea transmission, in 1984, one New York State county changed its approach toward gonorrhea control by targeting its field intervention activities toward infected persons from a geographic core area. In late 1988, New York State experienced an epidemic increase in the number of syphilis cases. In response, the New York State sexually transmitted disease (STD) control program enacted a Syphilis Initiative, which required the diversion of field staff from gonorrhea to syphilis control activities for a 3-year period. Each of these events held the possibility of impacting gonorrhea incidence in this county. GOAL OF THIS STUDY: To evaluate the impact of core interventions on reducing gonorrhea incidence as compared to traditional nontargeted field intervention methods and to determine the influence on gonorrhea incidence of diverting field activities from gonorrhea to syphilis case finding. STUDY DESIGN: A Poisson regression method was used to estimate gonorrhea incidence for a 22-year period in two similar counties: one county that used core intervention and one that applied traditional case-finding methods. The impact of core intervention was estimated in terms of the reduction in the gonorrhea incidence rate from the preintervention incidence rates. RESULTS: After initiation of the core intervention, the relative risk of gonorrhea decreased by 61%. Between 30 % to 40% of the total reported cases were interviewed for contacts annually during the intervention period. In the control county, the relative risk was reduced by 50% despite a significantly higher percentage of annual case interviews (60%-70%). In addition, a small change in the definition of core (from census tracts encompassing 50% of gonorrhea cases to 30%-35%) during the Syphilis Initiative led to a significant increase (16%) in the relative risk of gonorrhea. CONCLUSION: Targeting partner notification activities toward a geographic core area population appears effective in reducing the risk of gonorrhea, and it was more efficient because the overall percentage of cases interviewed was smaller than in a county using a nontargeted approach. Diversion of staff during a syphilis epidemic, combined with a narrowing of the geographic scope of the core intervention, was associated with an increase in gonorrhea incidence.

Impact of a mandatory syphilis delivery test on reported cases of congenital syphilis in Upstate New York.

A regulation mandating a syphilis serology test at delivery was implemented on December 6, 1989. To assess any impact on congenital syphilis reporting, we compared all cases reported in Upstate New York for the year directly preceding the regulation (n = 69) to those born in the three-year period following its implementation (n = 239). After implementation, the percentage of cases not tested at delivery decreased from 10 percent to 1 percent and reports of syphilitic stillbirths tripled. Asymptomatic infection of both mothers and babies increased significantly and at-birth detection of cases in women with negative prenatal serologies increased by 43 percent. Delivery screening failed to identify seven cases due to incubating maternal infection.

Doxycycline and azithromycin for prevention of chlamydial persistence or recurrence one month after treatment in women. A use-effectiveness study in public health settings.

BACKGROUND: To treat chlamydial infection, the Centers for Disease Control and Prevention recommends either a single dose of azithromycin or a 7-day course of doxycycline. Cost is a concern with the single-dose regimen; compliance is a concern with the multidose regimen. GOAL: To compare the use-effectiveness of azithromycin and doxycycline for preventing persistence or recurrence of Chlamydia trachomatis infection in women and to evaluate associated risk behaviors. STUDY DESIGN: One hundred and ninety-six chlamydia-infected women and their sex partners were recruited into a randomized controlled trial of single-dose versus multidose regimens in seven public health clinics, with no incentives for enrollment, compliance, or follow-up. The outcome, measure was a positive test for C. trachomatis by polymerase chain reaction testing at 1 month after treatment. RESULTS: C. trachomatis positivity at 1 month was similar for women receiving single-dose (5.1%, 5/98) and multidose therapy (4.1%, 4/98). Reported compliance among 73 women taking multidose therapy was 94.5%. A twofold to threefold increased risk of chlamydial persistence or recurrence was observed among women who were < or = 24 and white or who reported: a recent new partner, multiple partners, or a partner who may have had multiple partners at the time of enrollment or that not all partners were treated during the 1-month follow-up period after initiation of treatment. CONCLUSIONS: The use-effectiveness of single-dose and multidose therapy was comparably high. Observed rates of persistence or recurrence were consistent with reported rates of pharmacological treatment failure. However, all women with C. trachomatis detected at 1 month had behavioral risk factors that may have contributed to reinfection.

Screening criteria for Chlamydia trachomatis in family planning clinics: accounting for prevalence and clients' characteristics.

The reliability of eight self-reported risk factors as criteria for screening women for Chlamydia trachomatis was evaluated in four family planning clinics in New York State that serve diverse populations. In all, 8,920 women were screened in these clinics; the rates of infection ranged from 2% to 7%. Results of multivariate analyses showed that age was the most important predictor of chlamydial infection in the three clinics where prevalence was 4% or higher; women aged 20-24 were 3-4 times as likely as older women to be infected, and those aged 13-19 were 4-6 times as likely. In these three clinics, screening all women aged 26 or younger (62-80% of the clinic population) would identify about 90% of infected women; in the clinic with the lowest prevalence rate, age was not a reliable criterion. The prevalence of self-reported risk factors varied by clinic, and these factors generally were not reliable indicators of infection. Using the presence of at least one self-reported risk factor as a screening criterion, 80-87% of clinic clients would be screened, and about 90% of infected women would be identified. The presence of clinical signs of chlamydial infection does not increase the reliability of age as a screening criterion.

Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York State nursing homes.

Institutional risk factors associated with the occurrence of nosocomial respiratory or gastrointestinal disease outbreaks in 1992 were examined in a case-cohort study of New York State nursing homes conducted in 1993. Facility size, staffing patterns, and employee sick leave policies were the principal effects found in an unconditional logistic regression model. The risk of having respiratory or gastrointestinal disease outbreaks was greater in larger nursing homes (adjusted risk ratio (RR) = 1.71 for each 100-bed increase in size, 95% confidence interval (CI) 1.20-2.42), for nursing homes with a single nursing unit (adjusted RR = 3.93, 95% CI 0.98-15.71), or those with multiple nursing units with shared staff (adjusted RR = 2.51, 95% CI 1.07-5.89). The risk was less for nursing homes with paid employee sick leave policies (adjusted RR = 0.38, 95% CI 0.15-0.99). Other potential risk factors examined in this study, such as the ratio of beds per unit, type of sponsorship, daily review of laboratory test results, and the proportion of private beds and patient-to-staff ratio, were not significantly associated with the risk of disease outbreaks. The results of this study have direct implications for control of nosocomial disease outbreaks in nursing homes.

Congenital syphilis surveillance in upstate New York, 1989-1992: implications for prevention and clinical management.

Descriptive characteristics and clinical information from 322 cases of congenital syphilis were reviewed. The births (318 mothers) included 31 (10%) stillborn and 59 (18%) with clinical evidence of congenital syphilis. Only 60 (19%) had a complete laboratory workup, including radiographs of long bones and spinal fluid analysis. For a subset of 244 women with available information, 218 (89%) had > or = 1 risk factors for syphilis; however, residence in an area with high morbidity from syphilis was the only identified risk factor for 83 (34%). Eighty women (25%) were treated for syphilis during pregnancy; only 24 were treated appropriately for their stage of syphilis > 30 days before delivery. Five of these pregnancies resulted in infants with clinical signs of syphilis. These findings emphasize the need for expanded prenatal screening of high-risk women, the necessity of screening at delivery, and the need for complete evaluation of infants at risk for congenital syphilis. Further, the data suggest that in some cases therapy in the last trimester of pregnancy may be insufficient to adequately treat the fetus.

Is the high ischemic heart disease mortality rate in New York State just an urban effect?

To determine whether New York State's high ischemic heart disease mortality rate was due primarily to an urban effect, rates for regions in the State were compared with each other and with national data. New York State mortality rates for the period 1980-87 were highest for New York City (344.5 per 100,000 residents), followed by upstate urban and rural areas (267.1-285.1), and New York City suburbs (272.5). However, the overall 1986 age-adjusted rate for the New York State region with the lowest mortality rate (265.7) exceeded that of 42 States. New York State's number one ischemic heart disease mortality ranking reflects the need for statewide intervention programs, because even regions with relatively low mortality rates are high when they are compared with national rates.

Impact of regulation on benzodiazepine prescribing to a low income elderly population, New York State.

On 1 January 1989, in an effort to reduce diversion of benzodiazepines for illicit use and reduce inappropriate prescribing, a regulation was implemented requiring the reporting of all benzodiazepine prescriptions to the New York State Department of Health. To assess the impact of the regulation on prescribing practices to the elderly, we followed the number of benzodiazepines and other central nervous system medications prescribed to a cohort of participants in an elderly pharmaceutical insurance program. Benzodiazepines were prescribed for 4652 (22%) of the 20,944 patients studied. By the last quarter of 1989, benzodiazepines were prescribed for 3120 (15%) patients, a decrease of 33%. The number of prescriptions of benzodiazepines decreased by 5010 (45%), from 11,123 to 6113. Decreases in the number of prescriptions were similar across benzodiazepine brands (range 40-56%). Statistically significant (p < 0.05) decreases were seen in all sex, age, race and marital status groups. Increases in number (and percent increases) of prescriptions for miscellaneous anxiolytics (i.e. hydroxyzine (399, 69%), meprobamate (299, 149%), buspirone (263, 111%), chloral hydrate (138, 265%), antidepressants (658, 19%), barbiturates (150, 29%), and tranquilizers (198, 19%), some of which may be more toxic or less effective, were noted. New York State's reporting regulation was effective in reducing both the number of patients being prescribed benzodiazepines and the number of prescriptions given to those who remain on benzodiazepines in the elderly population studies.

A multistate outbreak of sporotrichosis associated with sphagnum moss.

In the spring of 1988, the largest documented US outbreak of cutaneous sporotrichosis to date occurred, with 84 cases among persons from 15 states who were exposed to Wisconsin-grown sphagnum moss used in packing evergreen tree seedlings. In New York State, 13 cases occurred among 109 forestry workers. All 13 cases occurred among 76 workers who had handled evergreen seedlings and moss (attack rate = 17%). For those exposed to evergreens and moss, the risk of infection increased as worktime exposure to moss increased (attack rates: less than 10 hours, 8%; 10-19 hours, 12%; greater than 19 hours, 33%). While environmental samples of moss from the Wisconsin supplier were negative, Sporothrix schenckii was cultured from multiple samples of the sphagnum moss obtained from one of six Pennsylvania tree nurseries, representing the nursery that was identified as the source for 79 (94%) of the moss-associated cases. Differences in tree-handling procedures at this nursery--including the use of 1- to 3-year-old moss to pack seedlings, use of a pond water source to wet the moss, use of an organic polymer gel on the seedling root system, and underground storage and longer storage of moss-packed seedlings before shipping--suggested possible explanations for the association. Efforts to prevent sporotrichosis among persons handling evergreen seedlings should include the use of alternate types of packing material (e.g., cedar wood chips or shredded paper) and protective clothing such as gloves and long-sleeved shirts.

An outbreak of influenza A (H3N2) in a well immunized nursing home population.

OBJECTIVE: To describe the epidemiologic features of an outbreak of influenza A that occurred in a skilled nursing home although over 90 percent of the resident population had previously received influenza vaccine. DESIGN: Retrospective cohort study. SETTING: Skilled nursing home facility in western New York State. PATIENTS: Nursing home residents and patient-care staff. MAIN OUTCOME MEASURE: Incidence of influenza-like illness among vaccinated versus unvaccinated nursing home residents and staff. RESULTS: Thirty-seven of 124 residents (attack rate = 30%) and 18 of 146 staff (attack rate = 12%) had an influenza-like illness. Staff illness began 16 days prior to onset among residents. Six cases of pneumonia and three influenza-related deaths occurred, all among the vaccinated residents. Ninety percent of the nursing home residents and 10% of the staff received the influenza vaccine prior to the outbreak. The calculated vaccine efficacies were minus 21% and plus 45% for residents and staff, respectively. CONCLUSION: While antigenic drift of the circulating influenza virus was the major factor in the apparent vaccine failure, the observed poor staff immunization rate (10%) and absence of surveillance which precluded the use of amantadine chemoprophylaxis suggest that the use of these strategies may be of importance in controlling influenza outbreaks in nursing homes.

Isolation and characterization of Sporothrix schenckii from clinical and environmental sources associated with the largest U.S. epidemic of sporotrichosis.

The largest recorded epidemic of sporotrichosis in the United States occurred in 1988 and involved a total of 84 cases in 15 states. All cases were associated with Wisconsin-grown sphagnum moss. Twenty-one clinical isolates of Sporothrix schenckii and 69 environmental isolates of Sporothrix spp. from the epidemic were characterized and compared. The environmental isolates were recovered from 102 samples of sphagnum moss and other material by using direct plating techniques. Characteristics examined included macroscopic and microscopic morphology, conversion to a yeast phase, exoantigen reactions, and virulence in mice. On the basis of these studies, eight environmental isolates were identified as S. schenckii, five were identified as Ophiostoma stenoceras, and the remainder were identified as Sporothrix species. The environmental isolates of S. schenckii were recovered from moss samples from one Pennsylvania nursery and from three New York State Soil and Water Conservation districts, but none were recovered from moss directly from the bogs in Wisconsin.

Shigellosis outbreaks at summer camps for the mentally retarded in New York State.

During 1987, four New York State summer camps for the mentally retarded and developmentally disabled experienced outbreaks of Shigella sonnei gastroenteritis. Cases occurred in 150 of 286 (attack rate (AR) = 52%), 167 of 295 (AR = 57%), and 25 of 114 (AR = 22%) persons in three camps, respectively; a fourth camp reported eight cases. Epidemiologic investigation suggested point-source foodborne outbreaks in two camps, while person-to-person spread appeared to predominate in the other two. Numerous secondary cases were identified among contacts outside the facilities in the second and third camps. To quantify the extent of the problem, the authors reviewed data on 77 infectious disease outbreaks (12 in camps for the handicapped and 65 in camps for the nonhandicapped) that occurred in the 12,484 registered camp sessions (316 for the handicapped and 12,168 for the nonhandicapped) held during the six-year period 1982-1987. Camps for the handicapped demonstrated approximately a seven times greater risk for all types of infectious disease outbreaks (AR = 38 outbreaks/1,000 camp sessions vs. five outbreaks/1,000 camp sessions; relative risk (RR) = 7.1, 95% confidence interval (CI) 3.9-13.0), including those of gastrointestinal etiology (RR = 8.6, 95% CI 4.4-16.8) and those due to Shigella (RR = infinity). Large camp size (RR = 2.3, 95% CI 1.3-4.1) and long duration of camp sessions (RR = 3.9, 95% CI 1.3-11.6) also increased the risk for outbreaks; however, this risk was predominantly in the camps for the nonhandicapped--other factors relating to personal hygiene and close camper-staff contact were probably more important in the camps for the handicapped. These outbreaks demonstrate the impact of shigellosis at summer camps for the mentally retarded and the need for early preventive action.

Hodgkin's disease, lymphocyte-predominant type: immunoreactivity with B-cell antibodies.

Utilizing the monoclonal antibodies L26 (a new antibody possessing immunoreactivity with B-lymphocytes in paraffin-embedded tissue), LN1, LN2, and Leu-M1, 44 cases of Hodgkin's disease (HD) were examined for the presence of immunoreactivity in Reed-Sternberg (R-S) cells by the avidin-biotin-peroxidase complex (ABC) technique. In 16 cases of lymphocyte-predominant Hodgkin's disease (LPHD), the L&H variants of R-S cells exhibited a different pattern of staining compared to R-S cells in other histologic types (total, 28 cases: 11, mixed cellularity; 8, nodular sclerosing; 6, lymphocyte depleted; 3, unclassified). L&H variants in LPHD were immunoreactive for L26 and LN1 in 15 and 14 cases, respectively, whereas R-S cells in the remaining types were negative or rarely positive (3, L26; 2, LN1). Leu-M1 was strongly positive in 27 of 28 cases of non-LPHD versus only 4 of 16 in LPHD. LN2 was reactive in virtually all cases (43 of 44). These findings suggest the possibility that the R-S cells of LPHD are derived from a different lineage than R-S cells in other histologic types of HD or that the latter have somehow lost the ability to express the antigens defined by L26 and LN1. Finally, based on immunologic and morphologic findings in this study, the similarities seen between the nodular and diffuse subtypes of LPHD are felt to favor a close relationship between the two subtypes.

Utilization of monoclonal antibody L26 in the identification and confirmation of B-cell lymphomas. A sensitive and specific marker applicable to formalin-and B5-fixed, paraffin-embedded tissues.

Immunophenotypic analysis of paraffin-embedded tissues of lymphoproliferative disorders has been facilitated by recent developments of monoclonal antibodies that react with epitopes that survive histologic processing. Leukocyte common antigen (LCA) antibody has made a significant contribution to the immunocytochemical separation of non-Hodgkin's lymphomas from nonlymphoid neoplasms. However, a small percentage of lymphomas, particularly some large cell or immunoblastic B-cell tumors, will not label with LCA antibody. Other antibodies, directed against B lymphocytes, experience problems of specificity and a lack of sensitivity when applied to formalin-fixed specimens. The authors recently investigated a monoclonal antibody (L26) that demonstrates excellent specificity and sensitivity for B lymphocytes, and tumors derived from them, in formalin- and B5-fixed, paraffin-embedded tissue. The avidin-biotin peroxidase complex (ABC) technique was utilized for immunostaining 95 cases of malignant lymphoproliferative disorders and a variety of normal and neoplastic nonlymphoid tissues. When applied to sections of benign lymphoid tissue, the L26 antibody labeled germinal center cells, mantle zone and scattered interfollicular lymphocytes, but not histiocytes or plasma cells. L26 marked 100% (44/44) of the large cell and immunoblastic B-cell lymphomas, along with 1 case of pre-B cell lymphoblastic lymphoma. This included 8 cases that were LCA-negative. None of the T-cell lymphomas or plasma cell tumors studied demonstrated L26 immunostaining. No normal, benign, or neoplastic nonlymphoid tissues examined stained with this antibody. L26 successfully labels B lymphocytes and B-cell lymphomas in routinely processed tissues, often with greater sensitivity and intensity than LCA. This antibody should prove invaluable in the investigation of atypical lymphoid proliferations and the identification of B-cell derived lymphomas, when fresh or frozen tissue is unavailable for analysis.

Education in laboratory management for pathology residents.

In addition to clinical expertise, pathologists are required to have a background in areas of management, administration, and computer operations. During their training, it is imperative that pathology residents have exposure to the subject of modern laboratory management. The authors feel that a rotation in administration is not adequate to give the necessary training but that a formal program is needed to achieve this goal. They have developed a course in laboratory management that uses the available resources of their own department and hospital to meet these needs.