Preventing transmission of hepatitis B virus from people with chronic infection.

BACKGROUND: People with chronic hepatitis B virus (HBV) infection are the major source of HBV transmission in the United States. The Public Health Service recommends prevention counseling for HBV-infected people and vaccination of their household contacts and sexual partners. OBJECTIVES: To describe the implementation of these recommendations by community physicians. METHODS: Telephone survey of 69 people with chronic HBV infection and their healthcare providers, October 1997 through November 1997, in San Diego, California. MAIN OUTCOME MEASURES: Counseling of people with chronic HBV infection and vaccination of their household contacts and sexual partners. RESULTS: Forty-three percent of providers reported providing prevention counseling to their HBV-infected patients to reduce transmission; 16% of patients reported receiving counseling. For the 32 pairs for which both the patient and provider could be reached and the patients were aware of their HBV infection, 20 (63%) providers reported counseling patients, and 10 (50%) of these providers' patients reported receiving counseling. Fifty-five percent of providers recommended vaccination of contacts; 13% of eligible adult household contacts and sexual partners and 20% of eligible child household contacts had begun hepatitis B vaccination. CONCLUSIONS: Prevention counseling of people with chronic HBV infection and vaccination of their contacts occur infrequently despite guidelines and an effective vaccine. Collaborative efforts between providers and people involved in public health are needed to improve delivery of these preventive health services.

Screening for chronic hepatitis B and C virus infections in an urban sexually transmitted disease clinic: rationale for integrating services.

BACKGROUND AND OBJECTIVES: Clients attending sexually transmitted disease (STD) clinics are at risk for multiple infections (e.g., STDs, HIV, and infectious viral hepatitis). Risk assessment and serosurveys can document the need for hepatitis screening and vaccination services. GOAL: To determine hepatitis C and B virus seroprevalence, identify predictive risk factors, and provide a rationale for integrating hepatitis services in an STD clinic. METHODS: During various periods in 1998, consecutive clients completed a self-administered risk assessment and were offered screening for markers of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection (HBV core antibody and anti-HCV [enzyme-linked immunosorbent assay 3.0, confirmed by recombinant immunoblot assay 2.0]). RESULTS: Sixteen percent of 300 clients tested for an anti-HBV core were positive, with injecting-drug users (IDUs) and men who have sex with men (MSM) having higher prevalences (50% and 37%, respectively). Of 615 clients tested for anti-HCV, 21 (3.4%) were positive. Injecting-drug users (n = 34) had a 38% anti-HCV prevalence compared with 1.1% for non-IDUs. Of 66 non-IDU MSM tested, none was HCV infected. IDUs had a high prevalence of past STDs (> 50%) and unsafe sexual behavior. CONCLUSIONS: Injecting drug users and MSM are at high risk for STDs, HIV, and hepatitis infections and could benefit from a "one-stop" STD clinic that included hepatitis prevention services.

Implementing a syphilis elimination and importation control strategy in a low-incidence urban area: San Diego County, California, 1997-1998.

OBJECTIVES: This study assessed a strategy designed to contain imported cases of syphilis and prevent reestablishment of ongoing transmission. METHODS: Reported syphilis cases during an endemic period (1990-1992) and an elimination period (1997-1998) were compared in San Diego, Calif. The elimination strategy, which focuses on rapid reporting of infectious syphilis cases by clinicians, prompt partner and sexual network management, outreach to marginalized populations, and implementation of an outbreak containment plan, was evaluated. RESULTS: Infectious syphilis incidence rates declined from 18.3 per 100,000 in 1998 to 1.0 per 100,000 in 1998. Of the 46 cases involving probable infection during 1997-1998, 19 (41%) were imported, mostly (79%) from Mexico. Outbreak containment procedures were implemented successfully for 2 small clusters. Outreach workers provided sexually transmitted disease information to a large number of individuals; however, no cases of infectious syphilis were identified, suggesting that syphilis transmission was not occurring among marginalized groups. CONCLUSIONS: This syphilis elimination and importation control strategy will require monitoring and adjustments. Controlling syphilis along the US-Mexico border is a necessary component of syphilis elimination in the United States.

Sexually transmitted disease clinic clients at risk for subsequent gonorrhea and chlamydia infections: possible 'core' transmitters.

BACKGROUND: From an sexually transmitted disease (STD) intervention perspective, developing a practical way to identify persons in core transmitter groups has been difficult. However, persons who have repeated STD infections may be in such groups. GOAL: To evaluate a self-administered risk assessment approach that would identify STD clinic clients who were at an increased risk of being involved in gonorrhea (GC) or chlamydia (CT) transmission in the subsequent year. STUDY DESIGN: Prospective cohort of consecutive STD clinic clients with a 1-year follow-up period. RESULTS: During a 6-month period in 1995, 2576 STD clinic clients in San Diego completed a risk assessment. Of those clients, 204 (7.9%) had a subsequent STD and 79 (3.1%) had a subsequent GC or CT infection during the 1-year follow-up period. The strongest predictor of a subsequent GC/CT was having a recent history or current clinic visit diagnosis of GC or CT (6.1% subsequent GC/CT rate). The more past episodes of GC or CT, the higher the subsequent GC/CT rate. Unsafe sexual behavior had little effect on further increasing subsequent GC/CT risk. CONCLUSION: STD clinic clients with a recent history of GC or CT and a high risk of subsequent GC/CT may be core transmitters who could likely benefit from risk reduction, periodic screening for GC/CT, symptom recognition counseling, and preventive treatment-the essential elements of STD-prevention case management.

Epidemiologic support to state and local sexually transmitted disease control programs. Perceived need and availability. The Field Epidemiology Network for STDs (FENS).

BACKGROUND AND OBJECTIVES: Sexually transmitted diseases (STDs) comprise the majority of national infectious disease morbidity reported, yet the number of epidemiologists working in state and local STD programs is estimated to be small. Even less is known about the training and activities of those epidemiologists. GOALS: To determine the number, training, and affiliation of epidemiologists working with STD programs and the level of satisfaction with epidemiologic support available. STUDY DESIGN: Survey of 65 program managers in state and local health departments. RESULTS: Program managers named 146 people working on epidemiologic activities, and 84 of those people were classified as "epidemiologist" by the criteria we applied. The median number of full-time equivalent (FTE) epidemiologists working in or with STD programs was 0.5; one quarter of all STD program had no epidemiologists. There was a significant association between number of FTE epidemiologist and population, with most programs with more than 0.5 epidemiologists located in areas with at least 1,000,000 population. State Epidemiologists do not provide technical support to most state STD programs. Almost half (45%) of all program managers indicated that they have inadequate epidemiologic support for routine program activities. CONCLUSIONS: The current level of epidemiologic support available to most STD programs is inadequate to perform surveillance and data analyses, interpret data to develop program objectives, and perform program evaluation. An essential next step is the delineation of a set of critical, analytic STD field epidemiology functions to define appropriate standards against which epidemiologic capacity can be more precisely measured.

The changing paradigm of sexually transmitted disease control in the era of managed health care.

Several trends in sexually transmitted diseases (STDs) have laid the foundation for a new paradigm for STD treatment and prevention that encompasses a community-wide, population-oriented approach. Public health STD programs, in partnership with a wide variety of community collaborators, will need to carry out the essential functions of public health-assessment, policy development, and assurance-by developing resources for community organizing and planning, enhanced information systems, and comprehensive training programs for professional staff and community partners. Community providers (particularly practicing clinicians and community and hospital clinics) will need to deliver primary prevention (community health promotion and clinical preventive services) and secondary prevention (screening and treatment) services while categorical STD clinics focus on providing care for high-risk, high-frequency STD transmitters who serve as the reservoir for much of a community's bacterial STDs. Managed care organizations and public health STD programs will need to formalize collaborative arrangements and capitalize on the strengths of each organization in order to have a population-level impact on STD transmission.

Screening high-risk adolescent males for Chlamydia trachomatis infection. Obtaining urine specimens in the field.

BACKGROUND AND OBJECTIVES: Reported case data suggest that few men are being tested for Chlamydia trachomatis (CT) infection (female:male reported case ratio is > 5:1) partially because men seek preventive health services less frequently than women and, until recently, obtaining a CT specimen from men required a urethral swab, which has low patient acceptability. A study was conducted in San Diego, CA, to determine whether urine specimens could be obtained from high-risk teen males in the field using a peer teen outreach approach. GOALS: Identify teen males infected with CT and provide treatment and partner management services. STUDY DESIGN: Prevalence survey of 261 teen males and a program cost evaluation. RESULTS: During the 6.5-month study period (Dec 15, 1995 to June 30, 1996) an estimated 1,860 teen males were approached and 261 submitted a urine specimen; 16 (6.1%) were positive by polymerase chain reaction. All positive males were treated with azithromycin, 1 gm, in the field, and 9 female sex partners were treated, 7 of whom were CT positive. The cost per specimen obtained and per CT infection identified was $103 and $1,677, respectively. The annual cost for adding a peer teen outreach service to an existing STD program using existing staff and adding 1.2 full-time equivalents of outreach time is approximately $25,000. CONCLUSION: Peer teen outreach and in-field collection of urine specimens appear to be an acceptable alternative for screening teen males for CT and should be further evaluated in other communities.

The role of young children in a community-wide outbreak of hepatitis A.

An Hasidic Jewish community has experienced recurrent hepatitis A outbreaks since 1980. To assess risk factors for illness during a 1985-6 outbreak, the authors reviewed case records and randomly selected 93 households for an interview and serologic survey. In the outbreak, 117 cases of hepatitis A were identified, with the highest attack rate (4.2%) among 3-5 year olds. Among the survey households, the presence of 3-5 year olds was the only risk factor that increased a household's risk of hepatitis A (indeterminant relative risk, P = 0.02). Furthermore, case households from the outbreak were more likely to have 3-5 years olds than were control households from the survey (odds ratio = 16.4, P < 0.001). Children 3-5 years old were more likely to have hepatitis A and may have been the most frequent transmitters of hepatitis A in this community. Hepatitis A vaccination of 3-5 year olds can protect this age group and might prevent future outbreaks in the community.

A coccidioidomycosis outbreak following the Northridge, Calif, earthquake.

OBJECTIVE: To describe a coccidioidomycosis outbreak in Ventura County following the January 1994 earthquake, centered in Northridge, Calif, and to identify factors that increased the risk for acquiring acute coccidioidomycosis infection. DESIGN: Epidemic investigation, population-based skin test survey, and case-control study. SETTING: Ventura County, California. RESULTS: In Ventura County, between January 24 and March 15, 1994, 203 outbreak-associated coccidioidomycosis cases, including 3 fatalities, were identified (attack rate [AR], 30 cases per 100,000 population). The majority of cases (56%) and the highest AR (114 per 100,000 population) occurred in the town of Simi Valley, a community located at the base of a mountain range that experienced numerous landslides associated with the earthquake. Disease onset for cases peaked 2 weeks after the earthquake. The AR was 2.8 times greater for persons 40 years of age and older than for younger persons (relative risk, 2.8; 95% confidence interval [CI], 2.1-3.7; P<.001). Environmental data indicated that large dust clouds, generated by landslides following the earthquake and strong aftershocks in the Santa Susana Mountains north of Simi Valley, were dispersed into nearby valleys by northeast winds. Simi Valley case-control study data indicated that physically being in a dust cloud (odds ratio, 3.0; 95% CI, 1.6-5.4; P<.001) and time spent in a dust cloud (P<.001) significantly increased the risk for being diagnosed with acute coccidioidomycosis. CONCLUSIONS: Both the location and timing of cases strongly suggest that the coccidioidomycosis outbreak in Ventura County was caused when arthrospores were spread in dust clouds generated by the earthquake. This is the first report of a coccidioidomycosis outbreak following an earthquake. Public and physician awareness, especially in endemic areas following similar dust cloud-generating events, may result in prevention and early recognition of acute coccidioidomycosis.

Staphylococcal food poisoning caused by imported canned mushrooms.

From February through April 1989, four outbreaks of staphylococcal food poisoning in the United States were associated with eating mushrooms canned in the People's Republic of China (PRC). In the four outbreaks, 99 persons who ate at a suspect facility developed gastrointestinal symptoms within 24 h, including 18 who were hospitalized. Illness was associated with eating mushrooms at a university cafeteria (relative risk [RR] = 53.0), a hospital cafeteria (RR = 13.8), a pizzeria (odds ratio [OR] = infinity), and a restaurant (OR = infinity) (all P < .0001). Staphylococcal enterotoxin A was found by ELISA in mushrooms at the sites of two outbreaks and in unopened cans from the three plants thought to have produced mushrooms implicated in outbreaks. These investigations led to multistate recalls and a US Food and Drug Administration order to restrict entry into the United States of all mushrooms produced in the PRC; until this action, the United States imported approximately 50 million pounds yearly.

Chlamydia trachomatis infection among Hispanic women in the California-Mexico border area, 1993: establishing screening criteria in a primary care setting.

BACKGROUND: Chlamydia prevalence and transmission patterns in California-Mexico border communities are unknown, and selective screening strategies for Hispanic populations have not been evaluated. GOAL OF THIS STUDY: To determine chlamydia prevalence among Hispanic women in the California-Mexico border area and established screening criteria. STUDY DESIGN: This was a cross-sectional prevalence survey of family planning/prenatal Hispanic clients (n = 2378) in San Diego and Imperial Counties, California, and Tijuana, Mexico. RESULTS: Overall, chlamydia prevalence was 3.2% (3.3% in California; 2.1% in Mexico). Women born in Mexico or those who visited Mexico for at least 1 week in the recent past had a prevalence rate similar to women without those characteristics. Multivariate analysis showed that young age (less than 25 years old), unmarried status, or having clinical signs of a chlamydia syndrome (primarily cervicitis) or vaginosis independently predicted chlamydia infection. Applying minimum screening criteria recommended by the Centers for Disease Control would require screening less than half of the clients. However, only 69% of infections would be identified. Using survey-based criteria (less than 25 years old, unmarried, and clinical signs of a chlamydia syndrome) would require screening 64% of clients, but would identify 92% of those infected. CONCLUSION: Chlamydia prevalence among Hispanic women seeking reproductive healthcare was similar (< 5%) on both sides of the California-Mexico border. Among Hispanic women, using easily obtained demographic data (age and marital status) and clinical signs (primarily cervicitis), an effective selective screening strategy can be implemented.

PIP: During January 1-October 15, 1993, three clinics in Imperial County, California, located east of the coastal mountain range which borders Baja California; a large community health center in San Diego County, California; and a public health/family planning clinic in Tijuana in Baja California, Mexico, successfully screened 2378 Hispanic women for Chlamydia trachomatis. The overall chlamydia prevalence was 3.2% (2.1% in Tijuana; 3.3% in California). Chlamydia was more common among the prenatal clients than family planning clients (4.7% vs. 2.6%; p 0.02). Adolescents had the highest chlamydia infection rate (7.5%). Women born in Mexico or those who visited Mexico for at least one week during the last three months had a similar chlamydia prevalence rate as those born in the US or those who had not visited Mexico recently. The multivariate analysis revealed that significant independent predictors of chlamydia infection included young age (25 years) (prevalence ratio [PR] = 4.5 for 20 years and 2.5 for 20-24 years), unmarried status (PR = 2), high risk sex behavior (PR = 1.1), exposure to a sexually transmitted disease (PR = 2.6), discharge/bleeding (PR = 1.4), vaginosis (PR = 3.6), and cervicitis (i.e., chlamydia syndrome) (PR = 6). If the clinics had applied the minimum screening criteria recommended by the US Centers for Disease Control, less than 50% of the clients would have been screened. Yet it would have identified only 69% of chlamydia infections. If clinics would apply the criteria identified in this survey, they would need to screen 64% of their clients, which would identify 92% of clients infected with chlamydia. These findings indicate that, in the California-Mexico border region, chlamydia prevalence among Hispanic women seeking reproductive health care was comparable. They also show that clinics can implement an effective selective screening strategy.

Syphilis in San Diego County 1983-1992: crack cocaine, prostitution, and the limitations of partner notification.

BACKGROUND AND OBJECTIVES: Recent epidemics of syphilis have been associated with crack cocaine use and anonymous sex for drugs, suggesting a potential limitation of sex partner notification as a disease control strategy. To assess these factors in an inner city epidemic of syphilis in San Diego County, California, we performed a descriptive epidemiologic analysis. STUDY DESIGN: Descriptive epidemiologic data were obtained from case investigation reports of primary and secondary syphilis. RESULTS: In the middle and late phases of the epidemic (1990-1992), the incidence of syphilis in the inner city area was more than six times that in remainder of the county. Illegal drug use was reported by 30% of patients. Drug use, especially crack cocaine, was related to prostitution. The estimated total number of sex partners per patient ratio was 4.2, whereas the named sex partners per patient ratio was only 1.5. Twenty-two percent of patients did not report any named partners. Overall, only 26% of the estimated total number of sex partners received treatment. CONCLUSIONS: Expanding partner notification to include more high-risk persons identified through social networks and increasing screening among high-risk populations may improve control of inner city drug/prostitution-related syphilis epidemics.

Epidemiologic aspects of a St. Louis encephalitis outbreak in Fort Walton Beach, Florida in 1980.

From July 10 through August 4, 1980, five cases of St. Louis encephalitis (SLE) occurred in and near Fort Walton Beach on the Gulf Coast of northwest Florida. These were the first cases of SLE ever reported from the Florida panhandle. To determine the extent of SLE infection in the community, sera (n = 968) were collected from patients at the local hospital and county public health unit and tested for SLE virus antibody. The SLE attack rate was highest in a centrally located impoverished census tract. There was a trend toward decreasing seroprevalence with distance from the central area of the city. Overall, seroprevalence was higher in males (prevalence ratio = 2.7) and in all areas, seroprevalence increased with age. The serosurvey results suggest that SLE has been endemic in the Fort Walton Beach area.