Diabetes care management: a managed care approach.

A Diabetes Care Management program was developed by PrimeCare, a network model HMO, to improve quality of life health outcomes and reduce the costs of medical care for its members with diabetes. The HMO used a systems-based approach to communicate information about appropriate self-management and standards of care to members and physicians. The focus of the program was to educate and encourage patients to self-manage their illness, and to partner with physicians, other health care providers and community organizations to achieve improved quality of life, clinical and financial results. Clinical process indicators were used to measure results of interventions. Significant increases in the percentage of participants receiving glycosylated hemoglobin (HbA1c) tests, retinal eye exams and lipid panel tests were achieved.

Eradication of wild poliovirus from the Americas: wild poliovirus surveillance--laboratory issues.

The Pan American Regional Poliomyelitis Laboratory Network, developed to support the program to eradicate indigenous wild poliovirus transmission in the Americas, included 10 laboratories, distributed in eight countries in the Americas, organized according to the diagnostic procedures they regularly performed. All laboratories isolated and typed virus in stool specimens, several did intratypic differentiation by nucleic acid probe hybridization, and 2 sequenced wild poliovirus isolates for molecular epidemiologic studies. High performance of the network was maintained through comprehensive training of virologists, continuous monitoring of laboratory performance, and prompt investigation of problems. Recommended field and laboratory procedures were regularly reviewed and revised to optimize sensitivity, specificity, and diagnostic efficiency. Close integration of field and laboratory surveillance was achieved through frequent meetings between virologists and epidemiologists, effective communication of program priorities, and the distribution of weekly surveillance reports.

Hemolytic-uremic syndrome--an outbreak in Sacramento, California.

Between July and November 1982, 14 cases of the hemolytic-uremic syndrome occurred in the Sacramento, California, metropolitan area; 9 of the 14 patients lived within a 7.5-mile radius in northeast Sacramento, 10 were female, 12 were white non-Hispanic and 13 were children with a mean age of 3.6 years. Of the 14 patients, 13 were admitted to hospital; 7 required peritoneal dialysis. The 14th child, a 3-month-old white female infant, was found dead in her crib and had renal histopathologic findings consistent with the hemolytic-uremic syndrome. Of the 13 nonfatal cases, 12 patients had diarrhea before being admitted to hospital. A case-control study involving 11 cases and 22 controls did not show any significant differences in exposure to a variety of possible risk factors including restaurants, specific foods and water supply. Stool specimens were negative for enteric bacterial pathogens by culture and for viruses by tissue culture assay, suckling mouse inoculation and immune electron microscopy; no serologic evidence was found for infection due to enteroviruses, respiratory viruses or arenaviruses. Two of four children tested, however, showed serologic evidence of infection by Vero-cytotoxin-producing Escherichia coli. These 14 cases represent one of the largest reported outbreaks of the hemolytic-uremic syndrome in the United States.

Acute hemorrhagic conjunctivitis caused by enterovirus type 70: an epidemic in American Samoa.

From December 1981 to February 1982, an estimated 22,000 cases of acute hemorrhagic conjunctivitis (AHC) caused by enterovirus type 70 (EV 70) occurred among Samoan and non-Samoan residents of American Samoa. The overall attack rate was estimated to be 68%. Samoans of all ages resident in traditional housing and of large family size were at greatest risk of acquiring AHC, while non-Samoan adults resident in western style housing were at lowest risk. Epidemiologic aspects of AHC acquisition were also different for the Samoan and non-Samoan communities; index cases in Samoan households were frequently young adults, whereas index cases in non-Samoan households were commonly school age children, suggesting a role for school transmission in non-Samoans only. In this outbreak, subclinical AHC was rare; of 50 asymptomatic members of affected households, only 3 had neutralizing antibody to EV 70 (all with titers of 1:10). Investigation documented the highly contagious nature of AHC caused by EV 70, and the ease with which epidemic transmission may develop under conditions of crowding and frequent interpersonal contact.

Poliomyelitis in the USA: virtual elimination of disease caused by wild virus.

The average number of paralytic poliomyelitis cases per year in the United States has fallen from 16 000 just before vaccine was introduced in the 1950s to only 12 in 1978-83. 18 of the 69 cases (26%) reported in this 6-year period were not vaccine associated according to the epidemiological classification of paralytic poliomyelitis cases, established in 1975. The van Wezel antigenic differentiation test and oligonucleotide fingerprinting provide a laboratory basis for definitive characterisation of wild and vaccine-like poliovirus strains. Of the 69 cases, isolates from 42 have been analysed; 31 were vaccine-like poliovirus and 11 wild poliovirus. 7 of the wild poliovirus isolates are from cases in a 1979 outbreak caused by poliovirus imported from the Netherlands through Canada; 1 is from a single importation; and 3 are from isolated cases with no identified source. No indigenous wild strain has been isolated from any reported poliomyelitis case since 1981, when a wild strain was isolated from an immunodeficient individual.

Acute hemorrhagic conjunctivitis, Key West, Florida. An assessment of risk factors for introduction of illness into households and secondary spread during the 1981 epidemic.

From August 22 to November 6, 1981, 989 cases of acute hemorrhagic conjunctivitis were identified in Key West, Florida. The outbreak probably began when an infected 12-year-old Key West resident returned from the Bahamas and transmitted the illness to several neighborhood playmates. The rate of illness was highest for school-aged children, and a high proportion of cases occurred among blacks living in two adjacent low-income housing tracts. A telephone survey of persons living in these two tracts showed that the risk for introduction of illness into a household was 3.8 times greater for families with school-aged children. A study of 100 case households showed that black race, living in the two low-income housing tracts, and having a high ratio of family members per bathroom were variables significantly associated with multiple case households. To limit intracommunity spread of illness, symptomatic children were excluded from school for a period of seven days. The number of reported cases steadily decreased after school exclusion was implemented.

Detection of enterovirus 70 with monoclonal antibodies.

To improve the ability to identify enterovirus-70 (EV-70) from patients with acute hemorrhagic conjunctivitis, we developed four monoclonal antibodies (MAbs) to EV-70. We reacted the four MAbs against nine previously characterized strains of EV-70 and heterologous viruses by virus neutralization, indirect immunofluorescence, and enzyme-linked immunosorbent assay (ELISA). Two of the MAbs neutralized all nine strains of EV-70 and none of the other enterovirus types tested. Two of the MAbs gave a positive reaction with all nine strains by indirect immunofluorescence, and three reacted with all nine strains by ELISA. None of the MAbs gave a positive reaction with heterologous viruses, including those associated with eye disease, by indirect immunofluorescence or ELISA. The two neutralizing MAbs failed to give a positive reaction with some of the strains of EV-70 by indirect immunofluorescence and ELISA, yet they neutralized these viruses. By ELISA with a polyclonal serum as capture antibody and a mixture of MAbs as detector antibody, we were able to detect from 10(2.2) to 10(5.8) 50% tissue culture infective doses of virus and to type lyophilized isolates of EV-70 sent from Taiwan from which we could not recover infectious virus. By choosing the appropriate MAb, or mixture of MAbs, we could construct a test which had the type specificity and strain sensitivity needed to type isolates of EV-70.

Acute hemorrhagic conjunctivitis in Puerto Rico, 1981-1982.

In late 1981, the Western Hemisphere's pandemic of acute hemorrhagic conjunctivitis spread to Puerto Rico. Over 6,000 cases of conjunctivitis were reported to the Puerto Rico Department of Health from November 1981 to March 1982. Enterovirus 70 was isolated from one of 19 eye-swab specimens tested, and 10 of 13 (77%) individuals with acute hemorrhagic conjunctivitis had neutralizing antibody titers to enterovirus 70 of greater than or equal to 1:4. These data suggest that enterovirus 70 was the etiologic agent of the acute hemorrhagic conjunctivitis outbreak in Puerto Rico. In a study of a lower middle socioeconomic sector with relatively intense transmission, 152 of 670 (23%) persons reported illness consistent with acute hemorrhagic conjunctivitis. The highest attack rate was in the 5- to 14-year-old group (30%), and a disproportionate number of household index cases were in the predominantly school age group (5-19 years old). Twelve per cent (3/25) of asymptomatic household contacts of acute hemorrhagic conjunctivitis cases had sera with neutralizing antibody to enterovirus 70. Retrospective surveillance through ophthalmologists and neurologists identified one patient with a neurologic complication, a seventh nerve palsy temporally associated with recent enterovirus 70 infection. Household transmission was significantly associated with crowding and sharing of beds (p less than 0.05). This and other recent studies in Florida suggest that school age children play an important role in the transmission of acute hemorrhagic conjunctivitis. This study also suggests that asymptomatic enterovirus 70 infection is uncommon, and that in Puerto Rico, neurologic complications associated with acute hemorrhagic conjunctivitis were quite rare.

Quantitation of enterovirus 70 antibody by microneutralization test and comparison with standard neutralization, hemagglutination inhibition, and complement fixation tests with different virus strains.

We describe here a microneutralization procedure for conveniently testing large numbers of specimens for antibodies to enterovirus 70. The test utilized human rhabdomyosarcoma cells and was read by staining with crystal violet after 4 days of incubation. The test compares well with other serological assays, being more sensitive than the standard tube neutralization test and the complement fixation test, but less sensitive than the hemagglutination inhibition test. However, the hemagglutination inhibition test required concentrated, partially purified virus as antigen, as did the complement fixation test, and was difficult to read, so that its greater sensitivity may not be of practical significance. By all four test procedures, a recent isolate of enterovirus 70 was a more sensitive antigen than the prototype strain, as shown by greater geometric mean titers in sera of patients from various epidemics.

The effect of immune globulin on the response to trivalent oral poliovirus and yellow fever vaccinations.

To assess whether immune globulin may be administered concurrently with trivalent oral poliovirus vaccine (OPV) or yellow fever vaccine, antibody responses were studied in Peace Corps volunteers embarking for overseas duty in 1978. Of 200 volunteers who received OPV, 192 (96%) had pre-existing neutralizing antibody to at least 2 poliovirus types; of 160 yellow fever vaccinees, 24 (15%) had pre-existing 17D yellow fever antibody. Each volunteer received 5 ml of immune globulin, 0-7 days before, 3-5 days after, or 28-32 days after vaccination. This last group was designated the control group. Of the volunteers who received immune globulin 0-7 days before vaccination, 71% 72%, 49%, and 82% responded to poliovirus types 1, 2, and 3, and yellow fever, respectively (response was defined as a 4-fold or greater rise in serum neutralizing antibody titre between baseline (0-7 days before vaccination) and follow-up (15-40 days after vaccination)). These rates did not differ significantly from those in persons who received immune globulin 28-32 days after vaccination (61%, 60%, 51%, and 83%, respectively). Thus, among individuals who, for the most part, were immune to poliomyelitis but not to yellow fever, immune globulin did not decrease the antibody response to OPV or to yellow fever vaccine when given 0-7 days before vaccination.

The paralytic poliomyelitis epidemic of 1978 in Jordan: epidemiological implications.

Poliomyelitis is endemic in Jordan, but until 1978 there were no epidemics. In that year, 66 children were admitted to the Jordan University Hospital with a paralytic illness, compared with 13 in 1979 and 11 in 1980. The epidemic reached a peak in the summer and fall of 1978. While 54% of the patients had not received any vaccine, 19% had received 3 doses of oral poliovaccine; 82% of the cases were in children less than 2 years of age, and all belonged to the lower socioeconomic group. There were 28 deaths with complications of the disease.Poliovirus was isolated from 10 out of 14 rectal swab samples examined (9 with poliovirus 1, 1 with poliovirus 2), and from 4 out of 13 throat specimens from the same patients. It is concluded that as a result of improving living standards in Jordan and neighbouring countries, more epidemics may occur unless immunization efforts against poliomyelitis are intensified.

An outbreak of acute hemorrhagic conjunctivitis in central Minnesota.

The only confirmed outbreak of acute hemorrhagic conjunctivitis in the continental United States during 1982 occurred in Brainerd, Minnesota. The disease first appeared in a 27-year-old woman during a trip to Tahiti. The patient's two daughters (8 months old and 3 years old) developed mild conjunctivitis two days later. Although the symptoms of all three had completely resolved before they arrived in Brainerd, illness compatible with acute hemorrhagic conjunctivitis developed in five other individuals who shared a house with them there. Symptoms appeared within two days in four of the five and within three days in the fifth. All five had high neutralizing antibody titers to enterovirus 70 (1:128, 1:32, 1:32, 1:128, and 1:256) and one had high antibody titers to coxsackievirus A24 which may cause similar symptoms (less than 1:4 in all cases). The symptoms resolved without sequelae in all five patients within five days. These cases demonstrated that a person who is no longer symptomatic can still infect others and that an infected person can transmit enterovirus 70 for at least eight days after the onset of symptoms.

Oligonucleotide fingerprint analysis of enterovirus 70 isolates from the 1980 to 1981 pandemic of acute hemorrhagic conjunctivitis: evidence for a close genetic relationship among Asian and American strains.

Enterovirus 70 isolates obtained in Asia and the Americas between 1980 and 1981 from cases of acute hemorrhagic conjunctivitis were found to be very closely related by RNase T1 oligonucleotide fingerprinting. Two closely related isolates from the first acute hemorrhagic conjunctivitis epidemic (1969 to 1972) differed by many oligonucleotides from the 1980 to 1981 pandemic strains. The strong similarities of oligonucleotide patterns of isolates from the same epidemic but from distant regions of the world suggest that the genome of enterovirus 70 tends to be conserved during natural infection, a possible consequence of the transient nature of the disease.

Aseptic meningitis and high school football players. 1978 and 1980.

During 1978 and 1980, epidemiologists at the Centers for Disease Control investigated seven outbreaks of aseptic meningitis-like illness (AMLI) occurring in high school football players in four different states. One or more enterovirus types were isolated from affected students at all seven schools. Attack rates were highest among the varsity football teams (range, 21% to 68%), although junior varsity teams were also affected at most schools (range, 5% to 63%). Non-football athletes were relatively spared. The illness was also reported by nonathletes at all three schools where more extensive investigations were undertaken. At one school, the AMLI attack rate was higher among students who were close friends of football players than among students who were not close friends; at the other two schools, these rates were similar. Hospitalization was more likely for football players with AMLI than for affected nonfootball players. Transmission of enteroviruses among football players was probably from person to person, although there was additional evidence to implicate common vehicle transmission at two schools. We conclude that football players may or may not have been more likely to be exposed to the enteroviruses circulating in their communities, but once introduction of a virus into a team occurred, transmission potential may have been enhanced, resulting in a large number of AMLI cases in players.

Acute hemorrhagic conjunctivitis Investigation of a large-scale community outbreak in Dade County, Florida.

An outbreak of acute hemorrhagic conjunctivitis (AHC) due to enterovirus type 70 occurred in Dade County, Florida, from September to December 1981. Younger age groups, members of larger households, and the poor were at significantly greater risk of acquiring AHC than others in the community. Schoolchildren were most likely to introduce AHC into the household. After exclusion of all affected children from school, there was a dramatic reduction in reported cases, with attack ratesups, members of larger households, and the poor were at significantly greater risk of acquiring AHC than others in the community. Schoolchildren were most likely to introduce AHC into the household. After exclusion of all affected children from school, there was a dramatic reduction in reported cases, with attack ratesups, members of larger households, and the poor were at significantly greater risk of acquiring AHC than others in the community. Schoolchildren were most likely to introduce AHC into the household. After exclusion of all affected children from school, there was a dramatic reduction in reported cases, with attack rates declining more rapidly for school-aged children than for other age groups. Although AHC spread readily among family members, a retrospective study of 124 affected households showed an association between lower attack rates and simple hygienic measures. Should outbreaks of AHC recur, measures to reduce transmission should include exclusion of affected schoolchildren and educating the public about hygienic precautions.