Estimated paediatric mortality associated with influenza virus infections, United States, 2003-2010.

Death certificate reports and laboratory-confirmed influenza deaths probably underestimate paediatric deaths attributable to influenza. Using US mortality data for persons aged <18 years who died during 28 September 2003 to 2 October 2010, we estimated influenza-attributable deaths using a generalized linear regression model based on seasonal covariates, influenza-certified deaths (deaths for which influenza was a reported cause of death), and occurrence during the 2009 pandemic period. Of 32 783 paediatric deaths in the death categories examined, 853 (3%) were influenza-certified. The estimated number of influenza-attributable deaths over the study period was 1·8 [95% confidence interval (CI) 1·3-2·8] times higher than the number of influenza-certified deaths. Influenza-attributable deaths were 2·1 (95% CI 1·5-3·4) times higher than influenza-certified deaths during the non-pandemic period and 1·1 (95% CI 1·0-1·8) times higher during the pandemic. Overall, US paediatric deaths attributable to influenza were almost twice the number reported by death certificate codes in the seasons prior to the 2009 pandemic.

Heavy alcohol use as a risk factor for severe outcomes among adults hospitalized with laboratory-confirmed influenza, 2005-2012.

We examined heavy alcohol use as a risk factor for severe influenza (intensive care admission or death) among hospitalized adults. In <65- and ≥65-year-olds, heavy alcohol use increased disease severity [relative risk (RR) 1.34; 95 % confidence interval (CI): 1.04-1.74, and RR 2.47; 95 % CI: 1.69-3.60, respectively]. Influenza vaccination and early, empiric antiviral treatment should be emphasized in this population.

Impact of medical and behavioural factors on influenza-like illness, healthcare-seeking, and antiviral treatment during the 2009 H1N1 pandemic: USA, 2009-2010.

We analysed a cross-sectional telephone survey of U.S. adults to assess the impact of selected characteristics on healthcare-seeking behaviours and treatment practices of people with influenza-like illness (ILI) from September 2009 to March 2010. Of 216,431 respondents, 8.1% reported ILI. After adjusting for selected characteristics, respondents aged 18-64 years with the following factors were more likely to report ILI: a diagnosis of asthma [adjusted odds ratio (aOR) 1.88, 95% CI 1.67-2.13] or heart disease (aOR 1.41, 95% CI 1.17-1.70), being disabled (aOR 1.75, 95% CI 1.57-1.96), and reporting financial barriers to healthcare access (aOR 1.63, 95% CI 1.45-1.82). Similar associations were seen in respondents aged ≥ 65 years. Forty percent of respondents with ILI sought healthcare, and 14% who sought healthcare reported receiving influenza antiviral treatment. Treatment was not more frequent in patients with high-risk conditions, except those aged 18-64 years with heart disease (aOR 1.90, 95% CI 1.03-3.51). Of patients at high risk for influenza complications, self-reported ILI was greater but receipt of antiviral treatment was not, despite guidelines recommending their use in this population.

Pneumonia in US hospitalized patients with influenza-like illness: BioSense, 2007-2010.

We used data from BioSense, a national electronic surveillance system, to describe pneumonia in hospitalized patients with influenza-like illness (ILI). Ninety-five hospitals from 20 states reported ICD-9-CM-coded inpatient final diagnosis data during the study period of September 2007 to February 2010. We compared the characteristics of persons with and without pneumonia among those with ILI-related hospitalizations. BioSense captured 26 987 ILI-related inpatient hospitalizations; 8979 (33%) had a diagnosis of pneumonia. Analysis of trends showed highest counts of pneumonia during the 2007-2008 season and the second 2009 pandemic wave. Pneumonia was more common with increasing age. Microbiology and pharmacy data were available for a subset of patients; 107 (5%) with pneumonia had a bloodstream infection and 17% of patients were prescribed antiviral treatment. Our findings demonstrate the potential utility of electronic healthcare data to track trends in ILI and pneumonia, identify risk factors for disease, identify bacteraemia in patients with pneumonia, and monitor antiviral use.

Investigating the effect of high spring incidence of pandemic influenza A(H1N1) on early autumn incidence.

A pandemic H1N1 infection wave in the USA occurred during spring 2009. Some hypothesized that for regions affected by the spring wave, an autumn outbreak would be less likely or delayed compared to unaffected regions because of herd immunity. We investigated this hypothesis using the Outpatient Influenza-like Illness (ILI) Network, a collaboration among the Centers for Disease Control and Prevention, health departments, and care providers. We evaluated the likelihood of high early autumn incidence given high spring incidence in core-based statistical areas (CBSAs). Using a surrogate incidence measure based on influenza-related illness ratios, we calculated the odds of high early autumn incidence given high spring incidence. CBSAs with high spring ILI ratios proved more likely than unaffected CBSAs to have high early autumn ratios, suggesting that elevated spring illness did not protect against early autumn increases. These novel methods are applicable to planning and studies involving other infectious diseases.

Staphylococcus aureus community-onset pneumonia in patients admitted to children's hospitals during autumn and winter of 2006-2007.

Staphylococcus aureus is a relatively uncommon cause of community-onset pneumonia (COP) that may complicate influenza infection. We reviewed admissions to children's hospitals to describe more systematically this entity. Records of patients hospitalized at three children's hospitals between 1 October 2006 and 30 April 2007 who had a positive S. aureus culture from a sterile site or respiratory specimen were reviewed and data were abstracted for episodes of primary S. aureus COP. Overall, 30 episodes met criteria for primary S. aureus COP; 12 (41%) involved methicillin-resistant S. aureus. Patients in 11 (37%) episodes were seen by a healthcare provider for their symptoms prior to hospital admission; three received an antimicrobial, none of which had activity against the S. aureus isolated. Mechanical ventilation was required in 21 (70%) episodes; five (17%) patients died. When evaluating patients with severe COP, providers should be aware of the potential for S. aureus, including methicillin-resistant strains.

Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights.

INTRODUCTION: Historically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care. METHODS: This qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology. RESULTS: Medical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care. CONCLUSIONS: In the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services.

Risk factors for sporadic infection with Escherichia coli O157:H7.

BACKGROUND: Little is known about risk factors for sporadic infection with Escherichia coli O157:H7. In response to a sharp increase in reported cases in New Jersey during July 1994, we conducted a case-control study to identify principal sources of infection and contributing practices. METHODS: Standardized questionnaires were used to evaluate (1) potential exposures of case patients and matched controls and (2) knowledge, attitudes, and practices of food preparers in case and control households. Patient isolates were subtyped by pulsed-field gel electrophoresis. RESULTS: Patients with E coli O157:H7 infection (N = 23; median age, 9 years; 55% female) were more likely than healthy controls to have eaten a hamburger in the week preceding illness (matched odds ratio, undefined; P < .001); 80% of the hamburgers eaten by ill persons were prepared at home. Food preparers in case households were less likely than those in control households to report washing their hands (odds ratio, 8.5; P < .005) and work surfaces (odds ratio, 10.5; P < .05) after handling raw ground beef. Pulsed-field gel electrophoresis yielded 17 unique subtypes among the 23 patient isolates, indicating multiple sources of infection. CONCLUSIONS: Hamburgers prepared at home are an important source of sporadic E coli O157:H7 infections. We estimate that adequate hand washing by food preparers could have prevented 34% of E coli O157:H7 infections in the study population.

Individual 'fingerprints' in human sleep EEG topography.

The sleep EEG of eight healthy young men was recorded from 27 derivations during a baseline night and a recovery night after 40 h of waking. Individual power maps of the nonREM sleep EEG were calculated for the delta, theta, alpha, sigma and beta range. The comparison of the normalized individual maps for baseline and recovery sleep revealed very similar individual patterns within each frequency band. This high correspondence was quantified and statistically confirmed by calculating the Manhattan distance between all pairs of maps within and between individuals. Although prolonged waking enhanced power in the low-frequency range (0.75-10.5 Hz) and reduced power in the high-frequency range (13.25-25 Hz), only minor effects on the individual topography were observed. Nevertheless, statistical analysis revealed frequency-specific regional effects of sleep deprivation. The results demonstrate that the pattern of the EEG power distribution in nonREM sleep is characteristic for an individual and may reflect individual traits of functional anatomy.

Serotonin-2 receptors and human sleep: effect of a selective antagonist on EEG power spectra.

To investigate the effect on the sleep EEG, a 1-mg oral dose of SR 46349B, a novel 5-HT2 antagonist, was administered three hours before bedtime. The drug enhanced slow wave sleep (SWS) and reduced stage 2 without affecting subjective sleep quality. In nonREM sleep (NREMS) EEG slow-wave activity (SWA; power within 0.75-4.5 Hz) was increased and spindle frequency activity (SFA; power within 12.25-15 Hz) was decreased. The relative NREMS power spectrum showed a bimodal pattern with the main peak at 1.5 Hz and a secondary peak at 6 Hz. A regional analysis based on bipolar derivations along the antero-posterior axis revealed significant 'treatment' x 'derivation' interactions within the 9-16 Hz range. In enhancing SWA and attenuating SFA, the 5-HT2 receptor antagonist mimicked the effect of sleep deprivation, whereas the pattern of the NREMS spectrum differed.

Dual electroencephalogram markers of human sleep homeostasis: correlation between theta activity in waking and slow-wave activity in sleep.

To investigate the relationship between markers of sleep homeostasis during waking and sleep, the electroencephalogram of eight young males was recorded intermittently during a 40-h waking episode, as well as during baseline and recovery sleep. In the course of extended waking, spectral power of the electroencephalogram in the 5-8Hz band (theta activity) increased. In non-rapid eye movement sleep, power in the 0.75-4.5Hz band (slow-wave activity) was enhanced in the recovery night relative to baseline. Comparison of individual records revealed a positive correlation between the rise rate of theta activity during waking and the increase in slow-wave activity in the first non-rapid eye movement sleep episode. A topographic analysis based on 27 derivations showed that both effects were largest in frontal areas. From these results, we suggest that theta activity in waking and slow-wave activity in sleep are markers of a common homeostatic sleep process.

Beliefs and practices regarding childhood vaccination among urban pediatric providers in New Jersey.

BACKGROUND: In 1991, the fourth largest measles outbreak in the nation (824 cases) occurred in the Jersey City, New Jersey area. Data from a subsequent intervention trial in Jersey City demonstrated that vaccinations were more likely to be delayed for children who had received care from private rather than public clinic providers. In addition, failure to administer multiple indicated vaccines at a single visit was associated with vaccination delay, and reluctance to administer multiple vaccines was more common among private providers. These findings prompted an investigation of vaccination beliefs and practices among urban pediatric providers. METHODS: A telephone survey of vaccination beliefs and practices was administered to all pediatric providers in both private and public clinics in the Paterson and Jersey City areas. RESULTS: Private providers were less likely than public clinic providers to consider vaccinating children during emergency room visits (relative risk [RR] = 2.2; 95% confidence interval [CI] = 1.2-4.2) or hospital admissions (RR = 13.2; 95% CI = 1.9-92.7) and less likely to believe that all recommended vaccine doses should be administered simultaneously (RR = infinite; lower 95% confidence limit = 3.0). Private providers were less likely to consider administering live-virus vaccines to children with minor acute illnesses and low-grade fever (RR = 2.2; 95% CI = 1.2-3.8) or killed-virus vaccines to children with minor acute illnesses without fever (RR = 3.4; 95% CI = 1.4-8.5) or with low-grade fever (RR = 2.2; 95% CI = 1.2-3.9). Private providers were more likely to believe that multiple injections should be avoided because of potential psychological and physical trauma to the child (RR = 4.0; 95% CI = 1.3-12.3). CONCLUSIONS: Adherence to Standards for Pediatric Immunization Practices by pediatric providers could improve vaccine coverage rates among urban children.

Boilerbaisse: an outbreak of methemoglobinemia in New Jersey in 1992.

BACKGROUND: On October 20, 1992, > 40 children from one elementary school visited the school nurse due to the acute onset of blue lips and hands, vomiting, and headache during and after the school lunch periods. Forty-nine children were seen by physicians that day and 14 were hospitalized. Laboratory analysis revealed methemoglobinemia in many of the children. All recovered in 36 hours. OBJECTIVE: A case-control study was supplemented by environmental and laboratory investigations to determine the outbreak source. METHODS: Cases were selected based on the laboratory diagnosis of methemoglobinemia (methemoglobin level > 2%). Children whose methemoglobin levels were missing or < 2% were excluded from analysis. Controls were obtained by selecting every third name from a school roster. The parents of 29 students who met the case definition and 52 controls were interviewed. RESULTS: All 29 cases and 33% (17/52) of the controls ate soup during the school lunch (odds ratio undefined, lower 95% confidence limit 16.1). Two pots of soup were prepared from ready-to-serve cans, which were diluted with water and enriched with a commercially prepared flavor enhancer. The school's boiler, dormant during the previous 5 months, was restarted on the morning of the outbreak. The boiler also served as a tankless hot water heater. Laboratory analysis of the soup identified abnormally high quantities of nitrite (459 ppm) and sodium metaborate, major components of the boiler water treatment solution. Undiluted soup from the same lot had 2.0 ppm nitrites; the flavor enhancer had 2.2 ppm nitrites. Nitrites were present in the hot potable water system (4 to 10 ppm) and absent in the cold potable water system. CONCLUSIONS: This outbreak of methemoglobinemia due to nitrite poisoning was traced to soup contaminated by nitrites in a boiler additive. Nitrites are ubiquitous and potentially hazardous inorganic ions. Extreme caution should be used when the possibility for toxic human exposure to nitrites exists.

Initial drug regimens for the treatment of tuberculosis: evaluation of physician prescribing practices in New Jersey, 1994 to 1995.

STUDY OBJECTIVE: To evaluate physician prescribing practices for the initial therapy for tuberculosis (TB) according to the recommendations of the Centers for Disease Control and Prevention (CDC) and American Thoracic Society (ATS). DESIGN: Cross-sectional study. SETTING: Statewide TB surveillance system in New Jersey, 1994 to 1995. PATIENTS: We studied 1,230 culture-positive TB patients who were alive at diagnosis and whose isolates were tested for isoniazid susceptibility. RESULTS: Almost all TB patients (98%) were reported from counties with an isoniazid-resistant proportion of 4% or more, which is the minimum level for implementation of an initial four-drug regimen recommended by CDC/ATS. Overall, 36% of the 1,230 patients were not initially treated with four or more drugs. Multivariate analyses found that non-Hispanic white patients were more likely to be treated with fewer than four drugs than were non-Hispanic black patients. Private practitioners and physicians at chest clinics were about five times more likely to prescribe fewer than four drugs initially than were physicians at the hospital where a national TB center is located. CONCLUSION: A substantial proportion of physicians did not initially treat their TB patients according to the CDC/ATS recommendations. The results suggest that New Jersey physicians should be better informed about the recommendation and the high level of drug resistance in the communities they serve to assure that TB patients receive appropriate initial therapy.

Surveillance of pharyngeal colonization: detection and control of serious bacterial illness in low birth weight infants.

Routine surveillance for bacterial colonization has been used for the past three decades as a tool for the prediction of nosocomial infection in low birth weight infants; however, its usefulness has never been proven. A prospective cohort study was conducted to examine the utility of surveillance for pharyngeal colonization in detection and control of serious bacterial illness in low birth weight infants. One hundred fifty-four infants who weighed less than 1750 g and who were admitted to the Neonatal Intensive Care Unit were enrolled and followed for a total of 5620 infant-days. Pharyngeal cultures were collected at the time of enrollment and then weekly. All infants had bacterial pharyngeal colonization by the third day of life. Coagulase-negative staphylococci were the most common organisms cultured from the pharynx, followed by viridans streptococci and Staphylococcus aureus. More than 90% of the pharyngeal cultures grew multiple isolates. Gram-positive organisms, particularly coagulase-negative staphylococci, were the most prevalent organism recovered from blood and cerebrospinal fluid cultures. Fifty-two episodes of bacteremia and 6 episodes of cerebrospinal fluid infection occurred in 42 infants. Among infants with viridans streptococci in pharyngeal cultures, the subsequent risk of serious bacterial illness was significantly reduced (odds ratio = 0.16). However, pharyngeal cultures were poor predictors of the causative organism in an episode of serious bacterial illness. Pharyngeal and blood/cerebrospinal fluid cultures were concordant in only 11% of invasive infections. We conclude that pharyngeal surveillance cultures provide little clinically meaningful information and have no apparent utility in the Neonatal Intensive Care Unit setting.

Epidemiology of drug-resistant tuberculosis in New Jersey from 1991 to 1995.

BACKGROUND: In a nationwide survey in 1991, the proportion of Mycobacterium tuberculosis isolates resistant to both isoniazid and rifampin (MDR-TB) in New Jersey (6.6%) was ranked second highest in the United States. The objectives of this study were to describe drug-resistant TB trend and to investigate risk factors for TB patients with isolates resistant to isoniazid or rifampin or both. METHODS: TB surveillance data in New Jersey from 1991-1995 were analysed. Data on Mycobacterium tuberculosis culture and drug susceptibility testing of all TB isolates were obtained from public health and clinical laboratories. Logistic regression was performed to calculate odds ratios (OR) and 95% confidence intervals (CI) and to adjust for potential confounders. RESULTS: From 1991 to 1995, the proportion of MDR-TB was 5.7%, 4.1%, 2.7%, 3.3% and 2.6%, respectively. There was 10.6% isoniazid resistance and 4.3% rifampin resistance among TB patients in 1993-1995. As expected, recurrent TB was the most important risk factor for resistance to isoniazid (OR = 4.5, 95% CI: 2.6-7.6), rifampin (OR = 5.5, 95% CI: 2.8-11) or both (OR = 6.1, 95% CI: 2.9-13). HIV infection was significantly associated with MDR-TB (OR = 3.6, 95% CI: 1.5-8.8). Drug resistance was not found to be significantly associated with homelessness, injecting drug use and excess alcohol use. CONCLUSIONS: The proportion of MDR-TB in New Jersey declined significantly from 1991 to 1993, but remained at a plateau from 1993-1995. The results suggest that continuous efforts should be directed at the prevention of MDR-TB among people infected with HIV and at improving the proportion who complete chemotherapy among those with TB.

A statewide surveillance system for antimicrobial-resistant bacteria: New Jersey.

OBJECTIVES: To determine the validity of an active, hospital laboratory isolate-based surveillance system in estimating rates of infection and to evaluate the use of surveillance data in describing institutional risk factors for increased rates of infection. Methicillin-resistant Staphylococcus aureus (MRSA) was chosen as the prototype organism for these evaluations. DESIGN: Correlation Study: linear regression analysis and Student's t test were used to evaluate the correlation between number of MRSA isolates and number of MRSA infections in acute-care hospitals. Cross-Sectional Study: Student's t test, analysis of variance, and multiple linear regression analysis were used to evaluate the association between mean annual rate of MRSA blood isolates and institutional risk factors for increased rates of infection. SETTING: Acute-care hospitals, New Jersey. RESULTS: The number of MRSA blood isolates was significantly correlated with MRSA blood infections (R, 0.78; P < .01) and provided a good proxy measure for number of infections. Multivariate analysis demonstrated hospital location in the inner city (P = .02) and number of occupied beds (P < .01) to be independently associated with increased mean annual rates of MRSA blood isolates in acute-care hospitals. CONCLUSIONS: This surveillance system is a valid tool for the estimation of institutional rates of infection and for the determination of institutional risk factors for increased rates of infection. It is ideal for further population-based investigations of antimicrobial-resistant bacteria.

Secular trends in bloodstream infection caused by antimicrobial-resistant bacteria in New Jersey hospitals, 1991 to 1995.

INTRODUCTION: Antimicrobial resistance among bacteria is an increasing public health problem. In 1991, New Jersey was the first state to establish statewide, hospital-based surveillance for antimicrobial-resistant bacteria. METHODS: Each month, all 96 nonfederal New Jersey hospital laboratories complete a form listing the species identity and drug susceptibility results for selected antimicrobial-resistant bacteria isolated from blood cultures from hospital inpatients. Penicillin-resistant Streptococcus pneumoniae and aminoglycoside-resistant gram-negative rods were studied from 1991 to 1995. Vancomycin-resistant enterococci and imipenem-resistant gram-negative rods were studied from 1992 through 1995. RESULTS: From 1992 to 1995, the vancomycin-resistant enterococci bloodstream infection prevalence rate increased from 11 to 29 per 100,000 hospital admissions (p < 0.001); the rate was higher at larger hospitals, urban and inner-city hospitals, and teaching hospitals. From 1991 to 1995, the penicillin-resistant S. pneumoniae bloodstream infection rate increased from 1.1 to 9.9 per 100,000 admissions (p < 0.001). In contrast, bloodstream infection rates did not change significantly for imipenem-resistant (12.5 during 1992 and 14.1 during 1995, p = 0.4) or aminoglycoside-resistant (8.0 during 1991 and 6.8 during 1995, p = 0.4) gram-negative rods. CONCLUSIONS: We found that vancomycin-resistant enterococci and penicillin-resistant S. pneumoniae, but neither of two groups of antimicrobial-resistant gram-negative rods, are increasing rapidly in prevalence in New Jersey. Continued monitoring and interventions to slow these increases are needed.

Unihemispheric enhancement of delta power in human frontal sleep EEG by prolonged wakefulness.

EEG power spectra exhibit site-specific and state-related differences in specific frequency bands. In the present study we investigated the effect of total sleep deprivation on sleep EEG topography. Eight healthy, young, right-handed subjects were recorded during baseline sleep and recovery sleep after sleep deprivation. Forty hours of sleep deprivation affected power spectra in all derivations. However, hemispheric asymmetries were observed in the delta range. Sleep deprivation enhanced the anterior predominance of delta activity in the left hemisphere but not in the right one. This effect may reflect a functional asymmetry between the dominant and non-dominant hemisphere. The results provide further evidence for the presence of both global and local aspects of sleep regulation.

Ultrasonically-guided percutaneous transcholecystic cholangiography--an alternative approach in cases of biliary obstruction and failure of percutaneous transhepatic cholangiography.

Fourteen ultrasonically-guided percutaneous transcholecystic cholangiographies (PTCC) were performed in subjects with biliary obstruction with different underlying diseases. No complication was observed, and the procedure permitted diagnosis in all cases, although the previously reported difficulty of visualizing proximal bile ducts was confirmed in two cases. PTCC can constitute a valid and safe diagnostic alternative in obstructive jaundice in which no dilation of intrahepatic bile ducts is revealed on US, in cases in which percutaneous trans-hepatic cholangiography fails.