Risk factors for meningococcal disease in students in grades 9-12.

BACKGROUND: Meningococcal disease is a serious problem in adolescents, including high school students. Universal immunization of adolescents with meningococcal conjugate vaccine was recently recommended. We studied risk factors for meningococcal disease in students in grades 9-12. METHODS: This was a matched case-control study using surveillance for meningococcal disease in students in grades 9-12 in sites throughout the United States. For each case-patient, up to 4 controls were selected from the home room classroom. All subjects answered an extensive questionnaire. Logistic regression was performed to identify risk factors associated with meningococcal disease. Meningococcal isolates were characterized. RESULTS: Of 69 eligible patients, 49 (71%) were enrolled and had at least 1 control. Isolates were available for 59 (86%) cases. Attending at least 1 barbeque or picnic [matched odds ratio (MOR): 0.26, P value = 0.003] or school dance (MOR: 0.30, P = 0.04) were independently associated with decreased risk of meningococcal disease. Male gender (MOR: 2.94, P = 0.009), upper respiratory infection symptoms (MOR: 2.43, P = 0.04), marijuana use (MOR: 4.21, P = 0.009), and nightclub/disco attendance (MOR: 3.30, P = 0.04) were associated with increased risk. Among 54 students not from Oregon (where serogroup B strains predominate) with available serogroup, 38 (73.1%) cases were potentially vaccine preventable: 18 (34.6%) serogroup C, 19 (36.5%) serogroup Y, and 1 (1.9%) serogroup W-135. CONCLUSIONS: Certain behaviors increase the risk of meningococcal infection, whereas others are associated with decreased risk. Most meningococcal disease in high school students can be prevented if recommendations on use of meningococcal conjugate vaccine are implemented.

The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004.

BACKGROUND: Invasive group A Streptococcus (GAS) infection causes significant morbidity and mortality in the United States. We report the current epidemiologic characteristics of invasive GAS infections and estimate the potential impact of a multivalent GAS vaccine. METHODS: From January 2000 through December 2004, we collected data from Centers for Disease Control and Prevention's Active Bacterial Core surveillance (ABCs), a population-based system operating at 10 US sites (2004 population, 29.7 million). We defined a case of invasive GAS disease as isolation of GAS from a normally sterile site or from a wound specimen obtained from a patient with necrotizing fasciitis or streptococcal toxic shock syndrome in a surveillance area resident. All available isolates were emm typed. We used US census data to calculate rates and to make age- and race-adjusted national projections. RESULTS: We identified 5400 cases of invasive GAS infection (3.5 cases per 100,000 persons), with 735 deaths (case-fatality rate, 13.7%). Case-fatality rates for streptococcal toxic shock syndrome and necrotizing fasciitis were 36% and 24%, respectively. Incidences were highest among elderly persons (9.4 cases per 100,000 persons), infants (5.3 cases per 100,000 persons), and black persons (4.7 cases per 100,000 persons) and were stable over time. We estimate that 8950-11,500 cases of invasive GAS infection occur in the United States annually, resulting in 1050-1850 deaths. The emm types in a proposed 26-valent vaccine accounted for 79% of all cases and deaths. Independent factors associated with death include increasing age; having streptococcal toxic shock syndrome, meningitis, necrotizing fasciitis, pneumonia, or bacteremia; and having emm types 1, 3, or 12. CONCLUSIONS: GAS remains an important cause of severe disease in the United States. The introduction of a vaccine could significantly reduce morbidity and mortality due to these infections.

Invasive group A streptococcal infection in older adults in long-term care facilities and the community, United States, 1998-2003.

Limited information exists on the incidence and characteristics of invasive group A streptococcal (GAS) infections among residents of long-term care facilities (LTCFs). We reviewed cases of invasive GAS infections occurring among persons > or =65 years of age identified through active, population-based surveillance from 1998 through 2003. We identified 1,762 invasive GAS cases among persons > or =65 years, including 1,662 with known residence type (LTCF or community). Incidence of invasive GAS infection among LTCF residents compared to community-based elderly was 41.0 versus 6.9 cases per 100,000 population. LTCF case-patients were 1.5 times as likely to die from the infection as community-based case-patients (33% vs. 21%, p<0.01) but were less often hospitalized (90% vs. 95%, p<0.01). In multivariate logistic regression modeling, LTCF residence remained an independent predictor of death. Additional prevention strategies against GAS infection in this high-risk population are urgently needed.

Adults with invasive pneumococcal disease: missed opportunities for vaccination.

BACKGROUND: The pneumococcal polysaccharide vaccine (PPV) can prevent invasive pneumococcal disease (IPD) in the elderly and those with certain underlying illnesses. However, vaccine uptake remains suboptimal. Identification of missed opportunities for vaccination could guide new strategies for improving uptake. Missed opportunities for vaccination were defined as one or more visits to a hospital, emergency room (ER), or main provider in the 2 years before infection among unvaccinated, adult IPD case-patients with a vaccine indication. METHODS: Adults aged 18 years or older with IPD were identified in six Active Bacterial Core surveillance/Emerging Infections Program Network sites during a 1-year period in 2001 to 2003. Using chart review, patient/proxy interview, a main provider questionnaire, and vaccine questionnaires from additional providers, data were collected on demographics, vaccine indications, vaccine status, and recent healthcare encounters. RESULTS: A total of 1878 cases were enrolled, and 83% had a vaccine indication. Of the 1177 cases with a vaccine indication and sufficient information on recent healthcare encounters, 617 (52%) were unvaccinated. Of these, 566 (92%) had one or more opportunities for vaccination, 54% were hospitalized, 58% had ER visits, and 76% visited their main provider in the 2 years before illness. The number of visits to main providers (median = 6) was higher than hospitalizations (median = 1), and ER visits (median = 1). CONCLUSIONS: One or more missed opportunities for vaccination were documented in nearly all unvaccinated IPD case-patients with a vaccine indication. Most visited their main provider multiple times. Implementation of systematic PPV programs in outpatient settings will likely increase pneumococcal vaccine uptake among high-risk adults.

Preventability of invasive pneumococcal disease and assessment of current polysaccharide vaccine recommendations for adults: United States, 2001-2003.

UNLABELLED: BACKGROUND. To prevent Streptococcus pneumoniae infection among persons at highest risk for invasive pneumococcal disease (IPD), the pneumococcal polysaccharide vaccine (PPV) is currently recommended for persons >or=65 years old and persons 2-64 years old with certain underlying conditions. Policymakers have considered expanding recommendations for PPV to include persons who are 50-64 years old and additional populations at risk for IPD. Our objectives were to determine the proportion of IPD cases that might have been prevented if all persons with vaccine indications had been vaccinated and to evaluate new indications. METHODS: From 2001 to 2003, we performed a case series study of IPD in adults at 6 sites of the Active Bacterial Core surveillance-Emerging Infections Program Network. A case of IPD was defined as isolation of pneumococcus from a normally sterile site from a resident of 1 of the surveillance areas. RESULTS: Among 1878 case patients, 1558 (83%) had at least 1 current vaccine indication; of these, 968 case patients (62%) were unvaccinated. Adherence to existing vaccine recommendations would have prevented 21% of all cases. The proportions of all cases potentially prevented by each new indication were as follows: lowering the universal age of recommended vaccination to 50 years, 5.0%-7.0%; adding new risk-based indications to include current smoking, 1.5%-2.5%; former smoking, 0.4%-0.7%; black race, 1.0%-1.4%; and asthma, 0.3%-0.4%. CONCLUSIONS: Increasing vaccine coverage rates among persons with a current indication may prevent more cases than expanding existing indications. Of the potential new indications studied, the strategy that may prevent most cases is lowering the recommended age for universal vaccination to 50 years.

Gram-positive rod surveillance for early anthrax detection.

Connecticut established telephone-based gram-positive rod (GPR) reporting primarily to detect inhalational anthrax cases more quickly. From March to December 2003, annualized incidence of blood isolates was 21.3/100,000 persons; reports included 293 Corynebacterium spp., 193 Bacillus spp., 73 Clostridium spp., 26 Lactobacillus spp., and 49 other genera. Around-the-clock GPR reporting has described GPR epidemiology and enhanced rapid communication with clinical laboratories.

Declining incidence of invasive Streptococcus pneumoniae infections among persons with AIDS in an era of highly active antiretroviral therapy, 1995-2000.

BACKGROUND: Our goal was to describe trends in invasive pneumococcal disease incidence among persons with acquired immunodeficiency syndrome (AIDS) since the introduction of highly active antiretroviral therapy (HAART). METHODS: We used time-trend analysis of annual invasive pneumococcal disease incidence rates from a population-based, active surveillance system. Annual incidence rates were calculated for 5 July-June periods by use of data from San Francisco county, the 6-county Baltimore metropolitan area, and Connecticut. The numerators were the numbers of invasive Streptococcus pneumoniae infections among persons 18-64 years of age with AIDS; the denominators were the numbers of persons living with AIDS, estimated on the basis of AIDS surveillance data. RESULTS: The annual incidence of invasive pneumococcal disease declined from 1094 cases/100,000 persons with AIDS (July 1995-June 1996) to 467 cases/100,000 persons living with AIDS (July 1999-June 2000). The annual percentage changes in incidence were -34%, -29%, -8%, and -1%. Declines were similar by surveillance area, sex, and race/ethnicity. During the final year of the study, the invasive pneumococcal disease incidence in persons with AIDS was half that of the pre-HAART era but was still 35 times higher than that in similarly aged non-HIV-infected adults. CONCLUSIONS: In the United States, invasive pneumococcal disease incidence declined sharply across a range of subgroups living with AIDS during the period after widespread introduction of HAART. Despite these gains, persons with AIDS remain at high risk for invasive pneumococcal disease.

A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns.

BACKGROUND: Athletics-associated methicillin-resistant Staphylococcus aureus (MRSA) infections have become a high-profile national problem with substantial morbidity. METHODS: To investigate an MRSA outbreak involving a college football team, we conducted a retrospective cohort study of all 100 players. A case was defined as MRSA cellulitis or skin abscess diagnosed during the period of 6 August (the start of football camp) through 1 October 2003. RESULTS: We identified 10 case patients (2 of whom were hospitalized). The 6 available wound isolates had indistinguishable pulsed-field gel electrophoresis patterns (MRSA strain USA300) and carried the Panton-Valentine leukocidin toxin gene, as determined by polymerase chain reaction. On univariate analysis, infection was associated (P<.05) with player position (relative risk [RR], 17.5 and 11.7 for cornerbacks and wide receivers, respectively), abrasions from artificial grass (i.e., "turf burns"; RR, 7.2), and body shaving (RR, 6.1). Cornerbacks and wide receivers were a subpopulation with frequent direct person-to-person contact with each other during scrimmage play and drills. Three of 4 players with infection at a covered site (hip or thigh) had shaved the affected area, and these infections were also associated with sharing the whirlpool > or =2 times per week (RR, 12.2; 95% confidence interval, 1.4-109.2). Whirlpool water was disinfected with dilute povidone-iodine only and remained unchanged between uses. CONCLUSIONS: MRSA was likely spread predominantly during practice play, with skin breaks facilitating infection. Measures to minimize skin breaks among athletes should be considered, including prevention of turf burns and education regarding the risks of cosmetic body shaving. MRSA-contaminated pool water may have contributed to infections at covered sites, but small numbers limit the strength of this conclusion. Nevertheless, appropriate whirlpool disinfection methods should be promoted among athletic trainers.

Aggregated antibiograms and monitoring of drug-resistant Streptococcus pneumoniae.

Community-specific antimicrobial susceptibility data may help monitor trends among drug-resistant Streptococcus pneumoniae and guide empiric therapy. Because active, population-based surveillance for invasive pneumococcal disease is accurate but resource intensive, we compared the proportion of penicillin-nonsusceptible isolates obtained from existing antibiograms, a less expensive system, to that obtained from 1 year of active surveillance for Georgia, Tennessee, California, Minnesota, Oregon, Maryland, Connecticut, and New York. For all sites, proportions of penicillin-nonsusceptible isolates from antibiograms were within 10 percentage points (median 3.65) of those from invasive-only isolates obtained through active surveillance. Only 23% of antibiograms distinguished between isolates intermediate and resistant to penicillin; 63% and 57% included susceptibility results for erythromycin and extended-spectrum cephalosporins, respectively. Aggregating existing hospital antibiograms is a simple and relatively accurate way to estimate local prevalence of penicillin-nonsusceptible pneumococcus; however, antibiograms offer limited data on isolates with intermediate and high-level penicillin resistance and isolates resistant to other agents.

Utilization of extended-spectrum beta-lactamase (ESBL) detection systems in microbiology laboratories: survey of Connecticut hospitals from 1998-2002.

There has been recent concern raised over the detection, prevalence, and clinical implications of infection with Escherichia coli and Klebsiella spp. which produce extended-spectrum beta-lactamases (ESBLs). These enzymes hydrolyze beta-lactams including the cephalosporins (i.e., ceftazidime, ceftriaxone, cefotaxime), thus frequently leading to treatment failures. Standard in vitro testing may report these isolates as susceptible when in fact they are resistant in vivo. As a result of this phenomenon, additional testing for suspected isolates is recommended nationally. We surveyed 28 Connecticut hospitals from 1998-2002 to determine if these institutions utilized screening and confirmation methods for suspected isolates. The number of hospitals which have implemented ESBL detection systems doubled from 11 to 22 over the study period. Currently, 15 of the 22 laboratories conduct both screening and confirmatory testing. This expanded testing will be of great assistance to clinicians in optimizing the clinical care of patients with Gramnegative infections.

Epidemiology of invasive group a streptococcus disease in the United States, 1995-1999.

Severe invasive group A streptococcal (GAS) disease is believed to have reemerged during the past 10-20 years. We conducted active, laboratory, population-based surveillance in 5 US states (total population, 13,214,992). From 1 July 1995 through 31 December 1999, we identified 2002 episodes of invasive GAS (3.5 cases per 100,000 persons). Rates varied by age (higher among those <2 or >/=65 years old), surveillance area, and race (higher among black individuals) but did not increase during the study period. The 5 most common emm types (1, 28, 12, 3, and 11) accounted for 49.2% of isolates; newly characterized emm types accounted for 8.9% of isolates. Older age; presence of streptococcal toxic shock syndrome, meningitis, or pneumonia; and infection with emm1 or emm3 were all independent predictors of death. We estimate that 9600-9700 cases of invasive GAS disease occur in the United States each year, resulting in 1100-1300 deaths.