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Volume 7, Number 5—October 2001

Volume 7, Number 5—October 2001   PDF Version [PDF - 2.28 MB - 152 pages]

Perspective

  • Emerging Infectious Diseases in an Island Ecosystem: The New Zealand Perspective PDF Version [PDF - 54 KB - 6 pages]
    J. A. Crump et al.
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    Several unique features characterize infectious disease epidemiology in New Zealand. Historically, well-organized, government-run control programs have eliminated several zoonoses. More recently, however, communicable disease control has been mixed. Rates of rheumatic fever, tuberculosis, and enteric infectious are high, and rates of meningococcal disease are increasing. These diseases are over-represented in New Zealanders of Polynesian descent, who generally live in more deprived and overcrowded conditions than do those of European descent. Measles and pertussis epidemics are recurring because of inadequate vaccine coverage, despite a well-developed childhood immunization program. A progressive response to the HIV epidemic has resulted in relatively low rates of infection, particularly among injecting drug users; however, the response to other sexually transmitted infections has been poor. A key challenge for the future is to build on successful strategies and apply them to persisting and emerging infectious disease threats in a small, geographically isolated country with limited economic resources.

  • Implementing a Network for Electronic Surveillance Reporting from Public Health Reference Laboratories: An International Perspective PDF Version [PDF - 39 KB - 7 pages]
    N. H. Bean and S. M. Martin
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    Electronic data reporting from public health laboratories to a central site provides a mechanism for public health officials to rapidly identify problems and take action to prevent further spread of disease. However, implementation of reference laboratory systems is much more complex than simply adopting new technology, especially in international settings. We describe three major areas to be considered by international organizations for successful implementation of electronic reporting systems from public health reference laboratories: benefits of electronic reporting, planning for system implementation (e.g., support, resources, data analysis, country sovereignty), and components of system initiation (e.g., authority, disease definition, feedback, site selection, assessing readiness, problem resolution). Our experience with implementation of electronic public health laboratory data management and reporting systems in the United States and working with international organizations to initiate similar efforts demonstrates that successful reference laboratory reporting can be implemented if surveillance issues and components are planned.

Synopses

  • Potential Infectious Etiologies of Atherosclerosis: A Multifactorial Perspective PDF Version [PDF - 94 KB - 9 pages]
    S. O'Connor et al.
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    Coronary heart disease (CHD) contributes substantially to illness and death worldwide. Experimental studies demonstrate that infection can stimulate atherogenic processes. This review presents a spectrum of data regarding the link between CHD and infection. In addition, the need for improved diagnostic tools, the significance of multiple pathogens, and potential intervention strategies are discussed.

  • Changing Epidemiology of Q Fever in Germany, 1947-1999 PDF Version [PDF - 106 KB - 8 pages]
    W. Hellenbrand et al.
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    The epidemiology of Q fever in Germany was examined by reviewing relevant studies since 1947 and by analyzing available surveillance data since 1962. The average annual Q fever incidence nationwide from 1979 to 1989 was 0.8 per million and from 1990 to 1999, 1.4 per million. The mean annual incidence from 1979 to 1999 ranged from a minimum of 0.1 per million in several northern states to 3.1 per million in Baden-Württemberg, in the South. We identified 40 documented outbreaks since 1947; in 24 of these sheep were implicated as the source of transmission. The seasonality of community outbreaks has shifted from predominantly winter-spring to spring-summer, possibly because of changes in sheep husbandry. The location of recent outbreaks suggests that urbanization of rural areas may be contributing to the increase in Q fever. Prevention efforts should focus on reducing sheep-related exposures, particularly near urban areas.

  • Cost-Effectiveness of a Potential Vaccine for Coccidioides immitis PDF Version [PDF - 127 KB - 8 pages]
    A. E. Barnato et al.
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    Coccidioidomycosis, a systemic fungal infection, affects Americans living in the Southwest. We evaluated the cost- effectiveness of a potential vaccine against Coccidioides immitis. Using a decision model we developed, we estimate that among children, vaccination would saved 1.9 quality-adjusted life days (QALD) and $33 per person. Among adults, screening followed by vaccination would save 0.5 QALD per person and cost $62,000 per quality adjusted life year gained over no vaccination. If the birth cohort in highly endemic counties of California and Arizona were immunized in 2001, 11 deaths would be averted and $3 million would be saved (in net present value) over the lifetime of these infants. Vaccination of adults to prevent disseminated coccidioidomycosis would provide a modest health benefit similar in magnitude to other vaccines but would increase net expenditures. Vaccination of children in highly endemic regions would provide a larger health benefit and would reduce total health care expenditures.

Research

  • First Isolation of La Crosse Virus from Naturally Infected Aedes albopictus PDF Version [PDF - 70 KB - 5 pages]
    R. R. Gerhardt et al.
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    La Crosse (LAC) virus, a California serogroup bunyavirus, is the leading cause of pediatric arboviral encephalitis in the United States and an emerging disease in Tennessee, West Virginia, and North Carolina. Human cases of LAC encephalitis in Tennessee and North Carolina have increased above endemic levels during 1997 to 1999 and may represent an expansion of a new southeastern endemic focus. This report describes the isolation of LAC virus from the exotic mosquito Aedes albopictus. The discovery of LAC virus in wild populations of Ae. albopictus, coupled with its expanding distribution in the southeastern United States, suggests that this mosquito may become an important accessory vector, potentially increasing the number of human cases in endemic foci or expanding the range of the disease.

  • Factors Contributing to the Emergence of Escherichia coli O157 in Africa PDF Version [PDF - 145 KB - 8 pages]
    P. Effler et al.
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    In 1992, a large outbreak of bloody diarrhea caused by Escherichia coli O157 infections occurred in southern Africa. In Swaziland, 40,912 physician visits for diarrhea in persons ages >5 years were reported during October through November 1992. This was a sevenfold increase over the same period during 1990-91. The attack rate was 42% among 778 residents we surveyed. Female gender and consuming beef and untreated water were significant risks for illness. E. coli O157:NM was recovered from seven affected foci in Swaziland and South Africa; 27 of 31 patient and environmental isolates had indistinguishable pulsed-field gel electrophoresis patterns. Compared with previous years, a fivefold increase in cattle deaths occurred in October 1992. The first heavy rains fell that same month (36 mm), following 3 months of drought. Drought, carriage of E. coli O157 by cattle, and heavy rains with contamination of surface water appear to be important factors contributing to this outbreak.

  • Clinical Consequences and Cost of Limiting Use of Vancomycin for Perioperative Prophylaxis: Example of Coronary Artery Bypass Surgery PDF Version [PDF - 76 KB - 8 pages]
    G. Zanetti et al.
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    Routine us of vancomycin for perioperative prophylaxis is discouraged, principally to minimize microbial resistance to it. However, outcomes and costs of this recommendation have not been assessed. We used decision-analytic models to compare clinical results and cost-effectiveness of no prophylaxis, cefazolin, and vancomycin, in coronary artery bypass graft surgery. In the base case, vancomycin resulted in 7% fewer surgical site infections and 1% lower all-cause mortality and saved $117 per procedure, compared with cefazolin. Cefazolin, in turn, resulted in substantially fewer infections and deaths and lower costs than no prophylaxis. We conclude that perioperative antibiotic prophylaxis with vancomycin is usually more effective and less expensive than cefazolin. Data on vancomycin's impact on resistance are needed to quantify the trade-off between individual patients' improved clinical outcomes and lower costs and the future long-term consequences to society.

  • Intraoperative Redosing of Cefazolin and Risk for Surgical Site Infection in Cardiac Surgery PDF Version [PDF - 36 KB - 4 pages]
    G. Zanetti et al.
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    Intraoperative redosing of prophylactic antibiotics is recommended for prolonged surgical procedures, although its efficacy has not been assessed. We retrospectively compared the risk of surgical site infections in 1,548 patients who underwent cardiac surgery lasting >240 min after preoperative administration of cefazolin prophylaxis. The overall risk of surgical site infection was similar among patients with (43 [9.4%] of 459) and without (101 [9.3%] of 1,089) intraoperative redosing (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.70-1.47). However, redosing was beneficial in procedures lasting >400 min: infection occurred in 14 (7.7%) of 182 patients with redosing and in 32 (16.0%) of 200 patients without (adjusted OR 0.44, 95% CI 0.23-0.86). Intraoperative redosing of cefazolin was associated with a 16% reduction in the overall risk for surgical site infection after cardiac surgery, including procedures lasting <240 min.

  • Pneumococcal Surface Protein A of Invasive Streptococcus pneumoniae Isolates from Colombian Children PDF Version [PDF - 29 KB - 5 pages]
    M. Coral et al.
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    Pneumococcal surface protein A (PspA) elicits protection in mice against fatal bacteremia and sepsis caused by genetically diverse pneumococci and protects against carriage and lung infection. We determined the PspA families of invasive isolates of Streptococcus pneumoniae recovered from Colombian children <5 years of age. That 97.5% of Colombian isolates belong to PspA families 1 and 2 supports the hypothesis that a human PspA vaccine covering a few PspA families could be broadly effective.

  • Epidemiology of and Surveillance for Postpartum Infections PDF Version [PDF - 54 KB - 5 pages]
    D. S. Yokoe et al.
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    We screened automated ambulatory medical records, hospital and emergency room claims, and pharmacy records of 2,826 health maintenance organization (HMO) members who gave birth over a 30-month period. Full-text ambulatory records were reviewed for the 30-day postpartum period to confirm infection status for a weighted sample of cases. The overall postpartum infection rate was 6.0%, with rates of 7.4% following cesarean section and 5.5% following vaginal delivery. Rehospitalization; cesarean delivery; antistaphylococcal antibiotics; diagnosis codes for mastitis, endometritis, and wound infection; and ambulatory blood or wound cultures were important predictors of infection. Use of automated information routinely collected by HMOs and insurers allows efficient identification of postpartum infections not detected by conventional surveillance.

  • Molecular Identification of Streptomycin Monoresistant Mycobacterium tuberculosis Related to Multidrug-Resistant W Strain PDF Version [PDF - 135 KB - 7 pages]
    P. Bifani et al.
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    A distinct branch of the Mycobacterium tuberculosis W phylogenetic lineage (W14 group) has been identified and characterized by various genotyping techniques. The W14 group comprises three strain variants: W14, W23, and W26, which accounted for 26 clinical isolates from the New York City metropolitan area. The W14 group shares a unique IS6110 hybridizing banding motif as well as distinct polymorphic GC-rich repetitive sequence and variable number tandem repeat patterns. All W14 group members have high levels of streptomycin resistance. When the streptomycin resistance rpsL target gene was sequenced, all members of this strain family had an identical mutation in codon 43. Patients infected with the W14 group were primarily of non-Hispanic black origin (77%); all were US-born. Including HIV positivity, 84% of the patients had at least one known risk factor for tuberculosis.

  • Clonal Expansion of Sequence Type (ST-)5 and Emergence of ST-7 in Serogroup A Meningococci, Africa PDF Version [PDF - 50 KB - 6 pages]
    P. Nicolas et al.
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    One hundred four serogroup A meningococci in our collection, isolated in Africa from 1988 to 1999, were characterized by multilocus sequence typing (MLST). Our results and data from the Internet indicate that sequence type 5 (ST-5) strains were responsible for most of African outbreaks and sporadic cases during this period. In 1995, a new clone, characterized by ST-7 sequence, emerged and was responsible for severe outbreaks in Chad (1998) and Sudan (1999). MLST and epidemiologic data indicate that ST-5 and ST-7 represent two virulent clones. These two STs, which belong to subgroup III, differ only in the pgm locus: allele pgm3 is characteristic for ST-5 and allele pgm19 for ST-7. Subgroup III strains were responsible for two pandemics in the 1960s and 1980s. Our data show that the third subgroup III pandemic has now reached Africa.

  • Multidrug-Resistant Tuberculosis in Prison Inmates, Azerbaijan PDF Version [PDF - 169 KB - 7 pages]
    G. E. Pfyffer et al.
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    In a tuberculosis (TB) program in the Central Penitentiary Hospital of Azerbaijan, we analyzed 65 isolates of Mycobacterium tuberculosis by IS6110-based restriction fragment-length polymorphism (RFLP) and spoligotyping. From 11 clusters associated with 33 patients, 31 isolates had an IS6110-based banding pattern characteristic of the Beijing genotype of M. tuberculosis. In addition, 15 M. tuberculosis isolates with similar RFLP patterns constituted a single group by spoligotyping, matching the Beijing genotype. Multidrug resistance, always involving isoniazid and rifampin, was seen in 34 (52.3%) of 65 isolates, with 28 belonging to the Beijing genotype.

  • Rapid Emergence of Ciprofloxacin-Resistant Enterobacteriaceae Containing Multiple Gentamicin Resistance-Associated Integrons, the Netherlands PDF Version [PDF - 85 KB - 10 pages]
    A. van Belkum et al.
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    In a hematology unit in the Netherlands, the incidence of ciprofloxacin-resistant Enterobacter cloacae and Escherichia coli increased from <0.5% to 20.7% and <0.5% to 64%, respectively, from 1996 to 1999. Clonal spread of single genotypes of both ciprofloxacin-resistant E. coli and Enterobacter cloacae from patient to patient was documented by pulsed-field gel electrophoresis and random amplification of polymorphic DNA. In addition, genetically heterogeneous strains were isolated regularly. Integrons associated with gentamicin resistance were detected in Enterobacter cloacae and E. coli strains. Integron-containing E. coli were detected in all hematology wards. In contrast, in Enterobacter cloacae strains two integron types were encountered only in the isolates from one ward. Although in all patients identical antibiotic regimens were used for selective decontamination, we documented clear differences with respect to the nosocomial emergence of ciprofloxacin-resistant bacterial strains and gentamicin resistance-associated integrons.

  • Topical Insecticide Treatments to Protect Dogs from Sand Fly Vectors of Leishmaniasis PDF Version [PDF - 75 KB - 5 pages]
    R. Reithinger et al.
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    We compared the susceptibility of sand fly vectors to four topical insecticide treatments applied to domestic dogs, a reservoir of human leishmaniasis. Dogs were exposed to sand flies pretreatment and at 1 week, 1 month, and 2 months posttreatment. Sand fly bloodfeeding and survival rate of both fed and unfed flies were significantly reduced by the permethrin, deltamethrin, and fenthion treatments, but diazinon had no effect. The survival rate of bloodfed sand flies was reduced by up to 86% with deltamethrin collars. The antifeeding effect suggests that deltamethrin collars may be recommended to dog owners to protect their pets from sandfly-borne diseases. The combined effects on sand fly feeding and survival indicate that epidemiologic, community-based trials are warranted to test whether deltamethrin collars could reduce the incidence of canine and, hence, human leishmaniasis.

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