The epidemiology and control of communicable diseases (in the outpatient setting).

The primary care practitioner is increasingly required to deal with challenging infectious disease problems. Today, management of many infectious diseases requires evaluating the patient and determining the appropriate treatment, as well as considering disease transmission and prevention issues. As risk factors for communicable disease transmission and prevention strategies are identified, healthcare providers may find themselves providing more complex patient care. The care of the patient diagnosed with an infectious disease may include prophylaxis for family contacts, collection of disease histories and immunity status for "exposed" office workers, and communicating with schools and child care, in addition to the treatment of the patient. This review of some of the most common infectious disease problems and the appropriate interventions should provide helpful information for primary care practitioners.

Management of a measles outbreak among Old World nonhuman primates.

BACKGROUND AND PURPOSE: A measles outbreak in a facility housing Old World nonhuman primates developed over a 2-month period in 1996, providing an opportunity to study the epidemiology of this highly infectious disease in an animal-handling setting. METHODS: Serum and urine specimens were collected from monkeys housed in the room where the initial measles cases were identified, other monkeys with suspicious measles-like signs, and employees working in the affected areas. Serum specimens were tested for measles virus-specific IgG and IgM antibodies, and urine specimens were tested for measles virus by virus isolation or reverse transcriptase-polymerase chain reaction (RT-PCR). RESULTS: A total of 94 monkeys in two separate facilities had evidence of an acute measles infection. The outbreak was caused by a wild-type virus that had been associated with recent human cases of acute measles in the United States; however, an investigation was unable to identify the original source of the outbreak. Quarantine and massive vaccination helped to control further spread of infection. CONCLUSIONS: Results emphasize the value of having a measles control plan in place that includes a preventive measles vaccination program involving human and nonhuman primates to decrease the likelihood of a facility outbreak.

Measles immunity in a population of healthcare workers.

OBJECTIVES: To evaluate measles seroprevalence among cohorts of new employees and to evaluate vaccine responses of susceptible adult healthcare workers. DESIGN: New employees were screened for measles susceptibility as part of employee evaluations. Anti-IgG measles antibody tests were completed on 2,473 workers. Demographic, measles history, and measles vaccination information was collected using a short questionnaire. Susceptible workers were vaccinated and screened for vaccine responses following vaccination. RESULTS: Ninety-three workers (4%) were seronegative, and 56 (2%) were equivocal. Individuals in the youngest cohort (born after 1956) were significantly more likely to be susceptible than those in the middle cohort (born 1951 to 1956) and those in the oldest cohort (born before 1951) (P < 0.01). The middle cohort included eight (5%) of the 149 seronegative or equivocal workers. Among the members of the youngest cohort, those from the United States were more likely to be susceptible (P < 0.01) than those from outside the United States. Of the 106 vaccinated susceptible workers whose follow-up serologies were determined, 90 (85%) developed positive IgG serologies, six had equivocal results, and 10 were seronegative. Eleven of the 16 non- or hyporesponders were revaccinated and re-evaluated; nine developed low positive IgG antimeasles levels, one exhibited an equivocal response, and one failed to respond. CONCLUSIONS: A small but important proportion of healthcare workers are susceptible to measles. Whenever feasible, measles immunity programs for healthcare workers should include workers born before 1957. Of workers born after 1956, those from outside the United States are more likely to be immune than workers from inside the United States. Using the currently available vaccine, revaccination of initial non- or hyporesponders appears to be effective.

Adverse exposures and universal precautions practices among a group of highly exposed health professionals.

An anonymous national survey of a representative population of healthcare workers who were thought likely to have frequent and intensive exposures to blood and other body fluids (certified nurse-midwives [CNMs]), was conducted to assess the type and frequency of self-reported occupational exposures to blood and body fluids experienced, the extent to which barrier precautions and other infection control measures were used, whether or not reported use of barriers was associated with a lower perceived rate of exposures and factors that influenced the use of infection control procedures. Of those responding, 74% had soiled their hands with blood at least one time in the preceding six months, 51% had splashed blood or amniotic fluid in their faces and 24% reported one or more needlestick injuries during that same period. Our study also found evidence of an association between the practice of needle recapping and the occurrence of needlestick injury (p = .003). Despite a high level of training and knowledge, only 55% reported routinely practicing universal precautions (UPs). Several factors that potentially influenced the use of UPs were studied, including healthcare worker perceptions of risk of occupational bloodborne infection, knowledge of routes of transmission of bloodborne pathogens and rationale for not using appropriate barriers. Our data suggest that occupational exposures occur frequently and that healthcare workers' (HCWs') perceptions of risk for occupational infection play an important role in influencing use of UPs. This study emphasizes the importance of developing new strategies for UP training.

Use of precautions by nurse-midwives to prevent occupational infections with HIV and other blood-borne diseases.

A questionnaire was designed with these objectives: (1) to determine the frequency and type of adverse exposures experienced by certified nurse-midwives (CNMs); (2) to determine the extent to which CNMs used recommended precautions to prevent such incidents; and (3) to identify the sources used for obtaining information on AIDS. The questionnaire was mailed to all CNMs with the exception of associate and student members of the American College of Midwives. A response rate of 1,784/2,963 (60.2%) was obtained. These midwives reported frequent exposures to blood and body fluids. Sixty-five percent reported being soaked to the skin with blood or amniotic fluid; 50.7% had face-splashes with blood or amniotic fluid; and 24.0% experienced one or more needlestick(s). Only 55.1% reported using Universal Precautions (UP). Interference with the midwife-client relationship was identified most frequently as the reason for not using UP. Strategies need to be developed for midwives that will increase the use of UP and minimize the frequency of adverse exposures, while maintaining a caring midwife-client relationship.