Infections with Ehrlichia chaffeensis and Ehrlichia ewingii in persons coinfected with human immunodeficiency virus.

The clinical course and laboratory evaluation of 21 patients coinfected with human immunodeficiency virus (HIV) and Ehrlichia chaffeensis or Ehrlichia ewingii are reviewed and summarized, including 13 cases of ehrlichiosis caused by E. chaffeensis, 4 caused by E. ewingii, and 4 caused by either E. chaffeensis or E. ewingii. Twenty patients were male, and the median CD4(+) T lymphocyte count was 137 cells/microL. Exposures to infecting ticks were linked to recreational pursuits, occupations, and peridomestic activities. For 8 patients, a diagnosis of ehrlichiosis was not considered until > or =4 days after presentation. Severe manifestations occurred more frequently among patients infected with E. chaffeensis than they did among patients infected with E. ewingii, and all 6 deaths were caused by E. chaffeensis. Ehrlichiosis may be a life-threatening illness in HIV-infected persons, and the influence of multiple factors, including recent changes in the epidemiology and medical management of HIV infection, may increase the frequency with which ehrlichioses occur in this patient cohort.

Primary isolation of Ehrlichia chaffeensis from patients with febrile illnesses: clinical and molecular characteristics.

Ehrlichia chaffeensis was sought among patients with a history of tick exposure and fever, and the accuracy of other diagnostic tests was compared with that of primary isolation. Among the 38 patients enrolled, E. chaffeensis was isolated from the blood of 7 (18%) and from cerebrospinal fluid specimens of 2 of these 7. All 7 patients also were positive by polymerase chain reaction (PCR) of blood, and 6 patients developed diagnostic titers of antibody to E. chaffeensis. The isolates were characterized by molecular analysis of the 16S rRNA gene, the 120-kDa protein gene, and the variable-length PCR target (VLPT) of E. chaffeensis. On the basis of the 120-kDa and VLPT genotypes, the cerebrospinal fluid and blood isolates from the same patients were identical. This study demonstrates that both PCR and culture of blood for E. chaffeensis have high diagnostic yields. More frequent isolation of E. chaffeensis from patients with infection should further our understanding of the pathogenesis of this infection.

Incidence of Lyme borreliosis in the Würzburg region of Germany.

To assess the incidence of Lyme borreliosis in Central Europe, a 12-month, prospective, population-based surveillance study of Lyme borreliosis was conducted in the Wurzburg region of central Germany, following an aggressive awareness campaign. The diagnosis of Lyme borreliosis required the presence of (i) erythema migrans (diameter > or =5 cm); (ii) lymphocytoma; or (iii) another specific manifestation including Lyme arthritis, neuroborreliosis, carditis or acrodermatitis chronica atrophicans in conjunction with serological confirmation. A total of 313 cases of Lyme borreliosis was diagnosed, giving an incidence of 111 cases/100000 inhabitants, the highest rates occurring in children and elderly adults living in wooded as opposed to agricultural areas. The incidence in city dwellers and inhabitants of rural areas was not significantly different. Erythema migrans was the only manifestation in 279 (89%) patients. Of the 34 patients with manifestations other than erythema migrans alone, 15 had arthritis, nine neuroborreliosis, six lymphocytoma, four acrodermatitis chronica atrophicans and one carditis. Children were more likely than adults to have manifestations other than erythema migrans alone. Lyme borreliosis was very common in central Germany, and one of the most frequent bacterial infections. The observation of more cases of arthritis than neuroborreliosis was similar to that in the USA. These results may be representative for many parts of central Europe and suggest the need for development of a vaccine against borreliosis caused by European strains of Borrelia species.

Outcome of diagnostic tests using samples from patients with culture-proven human monocytic ehrlichiosis: implications for surveillance.

We describe the concordance among results from various laboratory tests using samples derived from nine culture-proven cases of human monocytic ehrlichiosis (HME) caused by Ehrlichia chaffeensis. A class-specific indirect immunofluorescence assay for immunoglobulin M (IgM) and IgG, using E. chaffeensis antigen, identified 44 and 33% of the isolation-confirmed HME patients on the basis of samples obtained at initial clinical presentation, respectively; detection of morulae in blood smears was similarly insensitive (22% positive). PCR amplifications of ehrlichial DNA targeting the 16S rRNA gene, the variable-length PCR target gene, and the groESL operon were positive for whole blood specimens obtained from all patients at initial presentation. As most case definitions of HME require a serologic response with compatible illness for a categorization of even probable disease, PCR would have been required to confirm the diagnosis of HME in all nine of these patients without the submission of a convalescent-phase serum sample. These data suggest that many, if not most, cases of HME in patients who present early in the course of the disease may be missed and underscore the limitations of serologically based surveillance systems.

Childhood bacterial meningitis in Japan.

Haemophilus influenzae type b (Hib) vaccines currently are not used in Japan, but interest in preventing H. influenzae disease by immunization has grown. We performed a retrospective survey for bacterial meningitis in 6 prefectures of Japan. Questionnaires requested the age, sex, clinical outcome and identity of the etiologic organism, if known, of all patients with meningitis younger than 16 years of age who were admitted during calendar year 1994. Of 876 hospitals within the 6 study prefectures, 363 (41.4%) returned a completed questionnaire. There were 1769 cases of meningitis reported, of which 160 (9%) were considered bacterial in origin. H. influenzae was the most common cause of bacterial meningitis, accounting for 68 cases (43%). Sixty-six cases (97%) of H. influenzae meningitis occurred in children 4 years of age or younger, and 27 (40%) occurred in children <1 year of age. Calculated incidence rates based on the population of children 4 years of age or less for each prefecture ranged from 3.4 to 9.9 cases per 100000 (mean, 4.7 cases/100000). H. influenzae is the most common cause of meningitis in Japan, and the estimated incidence rates from this study are very similar to those previously reported from Japan. More comprehensive, prospective surveillance studies will be needed to define better the incidence of Hib meningitis and to aid in making rational decisions regarding the use of Hib vaccination in Japan.

Clinical immunogenicity and tolerance studies of liquid vaccines delivered by jet-injector and a new single-use cartridge (Imule): comparison with standard syringe injection. Imule Investigators Group.

A new needleless jet-injector, Mini-Imojet, was developed that administers liquid vaccines from a single-use, pre-filled cartridge named Imule, which avoids the risk of cross-contamination. We conducted clinical trials in several settings in France and West Africa to compare the immunogenicity and tolerance of five vaccines (influenza vaccine, Vi capsular polysaccharide typhoid vaccine, tetanus toxoid vaccine, diphtheria-tetanus-whole cell pertussis vaccine, and inactivated hepatitis A vaccine) administered with the Imule system vs standard syringe technique. In each vaccine study, all subjects of either group were tested for serum antibody titres to calculate the geometrical mean titres and seroconversion rates after complete vaccination. Immediate local-reactions were noted after each injection, and local and general reactions were evaluated during a predetermined period of follow-up. When delivered by the Imule technique, all the administered vaccines were of equivalent or superior immunogenicity, compared to the syringe technique. The tolerance to vaccines injected by the Imule system was acceptable in all studies. The most frequently observed reactions were mild (e.g. minor bleeding, superficial papules, erythema and induration) and could be considered to be inherent to the injection technique. The technical and safety advantages of the Mini-Imojet/Imule system, compared to sterilizable, standard disposable or autodestruct syringes and to classical multi-dose vial jet-injectors, reinforces the interest of this new injection technique for collective immunizations.

Ehrlichiosis in a golf-oriented retirement community.

BACKGROUND: Ehrlichiosis due to Ehrlichia chaffeensis usually occurs sporadically or in small clusters, with an annual incidence estimated at 3 to 5 cases per 100,000 population in areas of endemic disease. The putative principal vector is the Lone Star tick (Amblyomma americanum). We investigated an outbreak of ehrlichiosis that occurred in June 1993 among members of a golf-oriented retirement community (community A) in Tennessee. The community is densely wooded and borders a wildlife-management area where deer are numerous. METHODS: We conducted a case-control study, using medical-history reviews, serologic testing, and testing with the polymerase chain reaction for E. chaffeensis infection. We also surveyed a sample of 10 percent of the households in community A and in another golf-oriented community (community B) more than 20 miles (32 km) from the wildlife-management area. Survey participants completed a questionnaire and provided specimens for serologic testing. In both communities, searches for ticks were undertaken. RESULTS: Eleven cases of symptomatic ehrlichiosis were identified in the case-control study, 10 of which were in community A (attack rate, 330 per 100,000). Of 311 surveyed residents of community A, 12.5 percent had serologic evidence of past E. chaffeensis infection, as compared with 3.3 percent of 92 in community B (relative risk in community A as compared with community B, 3.9; 95 percent confidence interval, 1.2 to 12.2). The risk of infection was associated with tick bites, exposure to wildlife, golfing, and among golfers, retrieving lost golf balls from the rough. Persons who never used insect repellent were more likely to have had infection than persons who did. In community A, thousands of Lone Star ticks were found; in community B, only three ticks were found. CONCLUSIONS: The high rate of E. chaffeensis infection in community A resulted from its proximity to a wildlife reserve. When outdoor recreational activities are common and concentrations of ticks are high, outbreaks of arthropod-borne zoonoses can be anticipated.

Coccidioidomycosis among visitors to a Coccidioides immitis-endemic area: an outbreak in a military reserve unit.

An outbreak of coccidioidomycosis occurred in a US Marine reserve unit based in Tennessee after a 3-week training exercise in California that involved substantial exposure to soil and dust. Interviews and serologic testing were done on three occasions (6, 11, and 15 weeks) after the men returned from California, and spherulin skin tests were done at 6 months. Of 27 men, 8 (30%) had evidence of recent coccidioidal infection. Of these, 7 (88%) had an illness consistent with coccidioidomycosis that, despite medical evaluation, was diagnosed incorrectly in 5 men (71%). Diagnosis of coccidioidal pneumonia outside an area in which Coccidioides immitis is endemic is unlikely unless the health care provider is aware that the patient traveled recently. Detection of coccidioidomycosis could be facilitated if organizations that regularly send people to C. immitis-endemic regions were to inform these persons about the risks of infection.

Immunization coverage among infants enrolled in the Tennessee Medicaid program.

OBJECTIVES: To determine immunization coverage of infants receiving Medicaid in Tennessee and to identify risk factors for failure to complete recommended vaccinations by 24 months of age. DESIGN: Retrospective cohort study. SUBJECTS: A total of 33,615 children born in one of three urban Tennessee counties from 1980 through 1989 who were enrolled in Medicaid throughout their first 24 months of life. MAIN OUTCOME MEASURES: Receipt of four diphtheria-tetanus-pertussis, three oral polio, and one measles-mumps-rubella vaccines by 24 months of age (up-to-date), as recorded in computerized county immunization records and Medicaid billing files. RESULTS: Overall, 45% of infants enrolled in Medicaid in the three urban counties completed the recommended vaccinations by 24 months. The proportion of infants up-to-date peaked at 50% for those born in 1982 and 1983, and decreased to 44% for those born in 1989. The only strong independent predictors of immunization completion were number of prior births for the mother, timing of the first immunization, and county of birth. The proportion up-to-date was 56% for first-born children compared with 27% for those whose mothers had at least three prior births; 55% for those whose first immunization was on time compared with 22% for those with a delay in the first immunization; and 63%, 52%, and 37% for infants born in the three respective counties. Maternal age, education, race, and marital status predicted immunization completeness only weakly or not at all. CONCLUSIONS: Of infants born in the three counties in the 1980s who were enrolled in the Tennessee Medicaid program, fewer than half completed their recommended childhood vaccinations by 24 months of age. The large differences in immunization levels between infants enrolled in the Medicaid program in the three counties, not accounted for by differences in demographics, suggest that factors related to the health care and vaccine delivery system have important effects on achieving adequate immunization of these infants.

The reporting of communicable diseases: a controlled study of Neisseria meningitidis and Haemophilus influenzae infections.

Surveillance systems for communicable diseases in the United States are primarily passive. We compared the passive reporting system for invasive disease caused by Neisseria meningitidis and Haemophilus influenzae with a concurrent, active laboratory-based system in the four metropolitan counties of Tennessee. The passive reporting system identified approximately 50% of all cases that were identified by the active system and accurately reflected trends in disease occurrence during the study period. Of all reported cases, physicians contributed fewer than 4%. Nearly 40% of all hospitals in the study area did not participate in the passive system. This lack of participation resulted in disproportionately increased reporting of disease among blacks. Inconsistencies in case definition within the state also contributed substantially to underreporting and lack of demographic representativeness of reported cases. The median reporting interval (the time from the onset of disease to transmission of the case report to the Centers for Disease Control and Prevention) was 24 days (range, 5-157 days). Efforts to improve surveillance of those infections for which isolation of a pathogen is tantamount to a diagnosis should concentrate on laboratory-based reporting and the use of currently available computer telecommunication systems.

Nosocomial transmission of Salmonella gastroenteritis to laundry workers in a nursing home.

BACKGROUND: Outbreaks of salmonella gastroenteritis in nursing homes are common. Person-to-person transmission to nursing home personnel occurs occasionally, but infection of laundry staff as a result of handling soiled linen rarely has been reported. OBJECTIVE: To examine the nosocomial transmission of infection to laundry staff during an outbreak of salmonellosis in a nursing home. SETTING: A 250-bed nursing home in a rural Tennessee county. METHODS: Residents and staff of the nursing home were interviewed and cultures of stool samples examined for enteric pathogens. RESULTS: Stool cultures from 32 residents and 8 employees were positive for Salmonella hadar. Infection among the residents was food-borne, but infection among employees likely represented secondary transmission, as none of the employees ate food prepared in the kitchen and their onset of symptoms occurred seven to 10 days after that of ill residents. Three laundry personnel who had no contact with residents were infected. Most of the ill residents (81%) were incontinent, which led to an increase in both the degree of fecal soiling and the amount of soiled linen received by the laundry during the outbreak. Laundry personnel regularly ate in the laundry room, did not wear protective clothing, and did not wear gloves consistently while handling soiled laundry. CONCLUSIONS: This investigation implicates linen soiled with feces as the source of nosocomial S hadar infection in laundry workers and underscores the importance of using appropriate precautions when handling linen.