Seasonal incidence and molecular characterization of Salmonella from dairy cows, calves, and farm environment.

The occurrence patterns and molecular characteristics of Salmonella are important for surveillance and control of the pathogens. Objectives of this study were to determine month-to-month variation and seasonal effects on the occurrence of Salmonella in dairy animals and environments and to characterize selected Salmonella isolates. A total of 7680 animal and environmental samples, collected monthly from a dairy farm, were analyzed for the presence of Salmonella during a 12-month study. Major sources of Salmonella on the dairy farm (% positive) were milking parlor air (62%) and bird droppings (63%) during winter; feeds (50-58%), water (53-67%), calf bedding (63%), soils (60-63%), milking parlor air (60%), and bird droppings (50%) in spring; all animal and environmental samples (40-92%) except milking parlor air (25%) and bulk tank milk (29%) in summer; and feeds (60-71%), cow beddings (59%), cow soils (50%), air (46-71%), and insects (63%) during fall. Salmonella ribotyping indicated that most serovars came from different sources but some might have originated from a common source and transmitted from site to site on the farm. These data provide some important information on key animal and environmental sampling sites needed to initiate on-farm management programs for control of this important foodborne pathogen.

Occurrence of Escherichia coli O157:H7 in diverse farm environments.

In the United States, foodborne outbreaks of Escherichia coli O157:H7 illness have often been linked to the consumption of contaminated, undercooked ground beef. However, the occurrence of E. coli O157:H7 has also been reported in other farm animals. The objective of this study was to evaluate the occurrence of E. coli O157:H7 on diverse farm types and from a variety of farm samples. Rectal swabs (n=1686) and environmental samples (n=576) were collected from 16 farms in five states over 24 months and analyzed for the presence of E. coli O157:H7. Overall, E. coli O157:H7 was found in 3.6% of beef cattle, 3.4% of dairy cattle, 0.9% of chicken, 7.5% of turkey, and 8.9% of swine samples. The pathogen was isolated sporadically from each of the environmental sample types. Of particular concern was the isolation of E. coli O157:H7 from fresh feed samples, indicating a potential vector for transmission. The data from this study indicate a high occurrence of E. coli O157:H7 on swine and turkey farms. This unexpected result suggests that more research on the occurrence of E. coli O157:H7 on these types of farms is required in order to better understand potential reservoirs of pathogenic E. coli.

Improving influenza vaccination rates in children with asthma: a test of a computerized reminder system and an analysis of factors predicting vaccination compliance.

Fewer than 10% of children with moderate or severe asthma receive an annual influenza vaccination despite their heightened susceptibility to severe infections and recommendations by the American Academy of Pediatrics and the Immunization Practices Advisory Committee that all such children be vaccinated annually. Patient, provider, and system factors leading to this poor vaccination rate are not well understood. This study tested the effectiveness of a computerized reminder system in improving influenza vaccination rates in children with asthma and examined patient barriers to vaccination at one pediatric clinic in an urban teaching hospital. A computer database identified 124 children with moderate or severe asthma. Patients were randomly assigned either to study group (n = 63), who were sent a personalized letter reminder about the need for an influenza vaccination, or to a control group (n = 61), who received no reminder. Study group mothers were interviewed 2 months after the letter was sent to assess factors associated with receipt of vaccination, including demographic features, parental worry about asthma and vaccine side effects, the four dimensions of the Health Belief Model, and health locus of control beliefs. Nineteen study group patients (30%) received an influenza vaccination, compared with only 4 control patients (7%) (P < .01). Forty-three mothers of children in the study group were interviewed; 14 (33%) of these children had received the vaccination. Of the characteristics investigated, two significantly correlated with vaccination compliance: high levels of parental worry about asthma (positively correlated: odds ratio = 23.3, P < .01) and high levels of parental worry about vaccine side effects (negatively correlated: odds ratio = 0.087, P = .025).(ABSTRACT TRUNCATED AT 250 WORDS)

Immunization practices of pediatricians and family physicians in the United States.

OBJECTIVE: To assess current practices and attitudes among pediatricians and family physicians across the United States regarding immunizations. DESIGN: Survey of a random sample of pediatricians and family physicians. SUBJECTS: Fellows of the American Academy of Pediatrics (N = 746) and American Academy of Family Medicine (N = 429). SURVEY TOPICS: General immunization practices (eg, types of visits during which vaccinations are provided, mechanisms to identify undervaccinated children); and opinions about perceived barriers to immunizations, acceptance of alternative sites for immunizations, and possible immunization requirements for Medicaid and The Special Supplemental Food Program for Women, Infants, and Children (WIC). RESULTS: Pediatricians and family physicians (combined) reported the following: immunizing children during acute illness visits (28%), follow-up visits (90%), and chronic illness visits (77%); using computer or reminder files to identify undervaccinated children (13%); and simultaneously administering four vaccines (diphtheria-tetanus-pertussis, oral poliovaccine, measles, mumps, and rubella and Haemophilus influenzae type b) to an eligible 18-month-old child (66%). Physicians perceived the following as barriers to immunizations: missed preventive visits (40%), vaccine costs (24%), lack of insurance coverage (24%), inability to track undervaccinated patients (22%), incomplete immunization records (12%), and missed vaccination opportunities (12%). Physicians agreed with offering vaccinations during hospitalizations (51%) or emergency department visits (30%), and with immunization requirements for continued eligibility for Medicaid (66%) or WIC (64%). Pediatricians were more likely to vaccinate during chronic illness and follow-up visits, and were more likely to use systems to track undervaccinated children (P < .05); however, most immunization practices and attitudes of pediatricians and family physicians were similar. Physicians who graduated from medical school more recently and those in high-risk urban practices were more likely to vaccinate during acute illness visits, provide simultaneous vaccinations, and favor vaccinations in hospital settings. CONCLUSIONS: Vaccination rates might be improved by closer adherence to current immunization guidelines regarding vaccinations during all encounters and simultaneous vaccinations, by developing systems to identify undervaccinated children, and by reducing patient costs for vaccinations. Current immunization practices fall short of the immunization guidelines; changes in individual practice styles will be required to conform with these standards.

Is an emergency department visit a marker for undervaccination and missed vaccination opportunities among children who have access to primary care?

The purpose of this study was to determine: (1) whether preschool-age patients who utilize the emergency department (ED) are undervaccinated compared with patients having the same primary care provider and (2) whether reducing missed vaccination opportunities in the primary care office can potentially reduce the differences in undervaccination between the groups. This retrospective cohort study involved two groups: 583 ED patients, aged 4 to 48 months, who had primary care providers; and 583 control subjects randomly selected from primary care sites and matched according to date of birth and primary care site. The major outcome variable was the point prevalence of undervaccination, defined as more than 60 days past due for a vaccine at the time of the ED visit, and for control subjects, at the time of their matched patient's ED visit. Demographic variables, vaccination history, presence of chronic illness, and office utilization history were abstracted from office charts. The mean age of all patients was 20.0 months. Emergency department patients were more likely to be boys (61% vs 50%) and had more chronic illness, but did not differ racially from those in the control group. Primary care sites included a hospital-based clinic (n = 137), neighborhood health centers (n = 172), and private practices (n = 274). The undervaccination rates by primary provider type were for (1) hospital clinic ED patients 21.1%, control subjects 19.7%; (2) neighborhood health center ED patients 29.1%, control subjects 22.7%; and (3) private practice ED patients 26.6%, control subjects 14.9%. Overall, the odds ratio of ED patients' being undervaccinated compared with control subjects was 1.8 (95% confidence interval 1.3 to 2.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status.

To determine the rate of childhood under-vaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a group-model health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever > 60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Patient-specific reminder letters and pediatric well-child-care show rates.

The objective of this study was to determine whether patient-specific letters, which describe the content of an upcoming well-child appointment, improve the show rate of well-child appointments better than postcard reminders. In this prospective clinical trial conducted at a pediatric continuity clinic in a teaching hospital, 288 newborns were randomized to a letter, postcard, or control group. For every well-child appointment, families were sent either a letter pertaining to the particular well-child appointment or a postcard; the control group received no reminders. There were no differences in demographics among the groups. The show rates between the letter and postcard groups were not different, but were significantly higher than the show rate for the control group (75.0%, 73.7%, and 67.5%, respectively; P < .05). A cost comparison between the use of postcards versus not using postcards revealed a benefit in the former. We concluded postcard reminders are effective in improving show rates for well-child-care visits, and that patient-specific letters have no additional benefit above that of postcard reminders.

Genetic characterization of a diverse Escherichia coli O157:H7 population from a variety of farm environments.

Many of the current studies on the genetic diversity of Escherichia coli O157:H7 have focused on pathogenic clinical, veterinary, or food isolates. These studies did not explore the diversity of the larger population in the farm environment. Research on selected farm isolates address this wider diversity but have typically been limited to a specific geographic locale or farm type, thus giving limited insight into the greater diversity across geographic regions and varied environments. The objective of this study was to evaluate a diverse population of E. coli O157:H7 collected from a variety of locations and farm environments. Eighty-eight isolates were collected from four farm types (swine, dairy, beef, and poultry) across the southeastern and western United States. Eighteen farms were sampled every 3 months over a period of 24 months. Isolates were analyzed by ribotyping and pulsed field gel electrophoresis (PFGE). Real-time PCR was used to determine the presence or absence of key pathogenic genes (stx1, stx2, and eae). The data indicate a significant amount of genetic diversity, however, ribotype analysis revealed meaningful clusters within the larger population. These groupings were consistent with PFGE analysis. Most of these isolates were clustered by location (i.e. from the same state or region) or farm type. Of the isolates in these clusters, most did not contain pathogenic genes. Of notable interest is a single group in which the majority of isolates, collected from four of the five states sampled, contained at least one stx gene and the eae gene suggesting the existence of a specific pathogenic cluster. These data suggest that, while there is notable diversity within the broader E. coli O157:H7 population, pathogenic isolates may be limited to a subset of strains within the population.

Ischemic gastritis and duodenitis.

Erosive gastritis and duodenitis resulting from chronic ischemia were seen at endoscopy in a 69-year-old woman with classical abdominal angina and severe atheromatous disease of all three splanchnic arteries.

Decision rules for predicting vaccination status of preschool-age emergency department patients.

We produced and tested rules to predict undervaccination among preschool-age emergency department (ED) patients. Data were gathered on demographics, vaccination status, health status, and health care utilization from parents, ED physicians, and ED charts at an urban teaching hospital in Rochester, N.Y. Primary care charts were reviewed to verify vaccination status. Using recursive partitioning, we developed decision rules to predict undervaccination. Decision rules were developed on a sample of 602 ED patients 4 to 48 months of age and then prospectively tested on 1832 ED patients aged 6 to 36 months. Factors associated with undervaccination for any vaccine included parental report of vaccination delay (odds ratio = 8.1; p < 0.001), inability to report the receipt of the appropriate number of vaccines (odds ratio = 4.5; p < 0.001), lack of health insurance (odds ratio = 3.6, p < 0.001), elapsed time since the last visit to primary care provider (p < 0.001), household size (p < 0.001), and maternal age (p < 0.01). Eight decision rules were produced that varied in their number of questions (one to six), sensitivity (0.27 to 0.87), and specificity (0.54 to 0.98). No single rule was both highly sensitive and highly specific. The rules' sensitivities and specificities were similar for the validation sample of 1832 patients. Thus a decision rule could not be produced that was both sensitive and specific. Identification of undervaccinated children by means of information available at an ED visit is inherently difficult. Interventions in the ED may be inefficient unless better methods of assessing vaccination status can be developed.