Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data From 20 States and a Large Metropolitan Area-United States, 2015.

BACKGROUND: Legionnaires' disease, a severe pneumonia, is typically acquired through inhalation of aerosolized water containing Legionella bacteria. Legionella can grow in the complex water systems of buildings, including health care facilities. Effective water management programs could prevent the growth of Legionella in building water systems. METHODS: Using national surveillance data, Legionnaires' disease cases were characterized from the 21 jurisdictions (20 U.S. states and one large metropolitan area) that reported exposure information for ≥90% of 2015 Legionella infections. An assessment of whether cases were health care-associated was completed; definite health care association was defined as hospitalization or long-term care facility residence for the entire 10 days preceding symptom onset, and possible association was defined as any exposure to a health care facility for a portion of the 10 days preceding symptom onset. All other Legionnaires' disease cases were considered unrelated to health care. RESULTS: A total of 2,809 confirmed Legionnaires' disease cases were reported from the 21 jurisdictions, including 85 (3%) definite and 468 (17%) possible health care-associated cases. Among the 21 jurisdictions, 16 (76%) reported 1-21 definite health care-associated cases per jurisdiction. Among definite health care-associated cases, the majority (75, 88%) occurred in persons aged ≥60 years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term care facilities). The case fatality rate was 25% for definite and 10% for possible health care-associated Legionnaires' disease. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Exposure to Legionella from health care facility water systems can result in Legionnaires' disease. The high case fatality rate of health care-associated Legionnaires' disease highlights the importance of case prevention and response activities, including implementation of effective water management programs and timely case identification.

Chemical and optical phototransformation of dissolved organic matter.

Dissolved organic matter represents the main reservoir of organic carbon in most aquatic ecosystems. In the present study, we determined the optical changes and the quantum yields of transient species formation for chromophoric dissolved organic matter (CDOM) samples undergoing photodegradation. The results show that the triplet states (3)CDOM* are potentially key players in CDOM photodegradation and that such transformations are strongly influenced by small differences in CDOM sources and sinks. In contrast, ·OH radicals are very unlikely to play a key role in phototransformation. These results represent an important first step in combining optical and transient species analyses to understand photodegradation processes of dissolved organic matter.

Basin-scale control on the phytoplankton biomass in Lake Victoria, Africa.

The relative bio-optical variability within Lake Victoria was analyzed through the spatio-temporal decomposition of a 1997-2004 dataset of remotely-sensed reflectance ratios in the visible spectral range. Results show a regular seasonal pattern with a phase shift (around 2 months) between the south and north parts of the lake. Interannual trends suggested a teleconnection between the lake dynamics and El-Niño phenomena. Both seasonal and interannual patterns were associated to conditions of light limitation for phytoplankton growth and basin-scale hydrodynamics on phytoplankton access to light. Phytoplankton blooms developed during the periods of lake surface warming and water column stability. The temporal shift apparent in the bio-optical seasonal cycles was related to the differential cooling of the lake surface by southeastern monsoon winds. North-south differences in the exposure to trade winds are supported by the orography of the Eastern Great Rift Valley. The result is that surface layer warming begins in the northern part of the lake while the formation of cool and dense water continues in the southern part. The resulting buoyancy field is sufficient to induce a lake-wide convective circulation and the tilting of the isotherms along the north-south axis. Once surface warming spreads over the whole lake, the phytoplankton bloom dynamics are subjected to the internal seiche derived from the relaxation of thermocline tilting. In 1997-98, El-Niño phenomenon weakened the monsoon wind flow which led to an increase in water column stability and a higher phytoplankton optical signal throughout the lake. This suggests that phytoplankton response to expected climate scenarios will be opposite to that proposed for nutrient-limited great lakes. The present analysis of remotely-sensed bio-optical properties in combination with environmental data provides a novel basin-scale framework for research and management strategies in Lake Victoria.

Chlorine dioxide inactivation of bacterial threat agents.

AIMS: To evaluate the efficacy of chlorine dioxide (ClO(2)) against seven species of bacterial threat (BT) agents in water. METHODS AND RESULTS: Two strains of Bacillus anthracis spores, Yersinia pestis, Francisella tularensis, Burkholderia pseudomallei, Burkholderia mallei and Brucella species were each inoculated into a ClO(2) solution with an initial concentration of 2.0 (spores only) and 0.25 mg l(-1) (all other bacteria) at pH 7 or 8, 5 or 25°C. At 0.25 mg l(-1) in potable water, six species were inactivated by at least three orders of magnitude within 10 min. Bacillus anthracis spores required up to 7 h at 5°C for the same inactivation with 2.0 mg l(-1) ClO(2). CONCLUSIONS: Typical ClO(2) doses used in water treatment facilities would be effective against all bacteria tested except B. anthracis spores that would require up to 7 h with the largest allowable dose of 2 mg l(-1) ClO(2). Other water treatment processes may be required in addition to ClO(2) disinfection for effective spore removal or inactivation. SIGNIFICANCE AND IMPACT OF STUDY: The data obtained from this study provide valuable information for water treatment facilities and public health officials in the event that a potable water supply is contaminated with these BT agents.

Chlorine disinfection of Francisella tularensis.

AIMS: To determine the range of free available chlorine (FAC) required for disinfection of the live vaccine strain (LVS) and wild-type strains of Francisella tularensis. METHODS AND RESULTS: Seven strains of planktonic F. tularensis were exposed to 0·5 mg·l(-1) FAC for two pH values, 7 and 8, at 5 and 25°C. LVS was inactivated 2 to 4 times more quickly than any of the wild-type F. tularensis strains at pH 8 and 5°C. CONCLUSIONS: Free available chlorine residual concentrations routinely maintained in drinking water distribution systems would require up to two hours to reduce all F. tularensis strains by 4 log10. LVS was inactivated most quickly of the tested strains. SIGNIFICANCE AND IMPACT OF THE STUDY: This work provides contact time (CT) values that are useful for drinking water risk assessment and also suggests that LVS may not be a good surrogate in disinfection studies.

Assessing the optical changes in dissolved organic matter in humic lakes by spectral slope distributions.

The impact of photodegradation and mixing processes on the optical properties of dissolved organic matter (DOM) was examined using a distribution of absorption spectral slopes and fluorescence measurements in two Argentine lakes. By examining the variability of the absorption spectral slopes throughout the ultraviolet and visible wavelengths, it was possible to determine which wavelength intervals were most sensitive to dominant loss processes. For DOM photodegradation, results show that increases in the absorption spectral slope between 265 and 305 nm were highly sensitive to increased exposure to solar ultraviolet radiation. A slightly larger wavelength range (265-340 nm) was found to be influenced when both mixing and photodegradation processes were considered, in terms DOM residence time, DOM absorption and UV diffuse attenuation coefficients. This same interval of spectral slopes (265-340 nm) was found to highly correlate with changes in fluorescence emission/excitation in wavelengths that are typically associated with terrestrial humic-like DOM. The identification of specific wavelength intervals, rather than the use of standard wavelength intervals or ratios, improved our ability to identify the dominant dissolved organic matter (humic-like) and major loss mechanisms (photodegradation) in these lakes.

Variability in photobleaching yields and their related impacts on optical conditions in subtropical lakes.

Changes in the concentration and spectral absorption of chromophoric dissolved organic matter (CDOM) may strongly condition the optical properties of tropical and subtropical water bodies. We examined the spatial distribution of CDOM-related absorption, spectral slope and vertical attenuation of solar radiation in two shallow lakes in the Esteros del Iberá wetland system. In situ measurements were made to examine spatial variations in photobleaching yields in natural lake conditions. The results showed that "fresh" allochthonous CDOM is more susceptible to phototransformations than either "aged" allochthonous organic matter or autochthonous sources, if the distances from sources are considered as proxies for residence time. Based on measured changes in absorption spectral slope in relation to solar ultraviolet irradiance, a model was developed which used CDOM as a non-conservative tracer of water masses. Spatial changes in CDOM absorption within the lake were then used to compare photo related transformations to those associated with conservative mixing.

Pseudo-outbreak of Mycobacterium abscessus Infection Caused by laboratory contamination .

OBJECTIVE: To investigate the cause(s) of an increased incidence of clinical cultures growing Mycobacterium abscessus at a hospital in Florida. DESIGN: Outbreak investigation. SETTING: University-affiliated, tertiary-care hospital. METHODS: A site visit was done during the first week of September 2006. We reviewed the medical records of patients from whom M. abscessus was recovered during the period from January 1, 2003, through June 30, 2006. We collected environmental samples from various sites and evaluated specimen processing procedures in the microbiology laboratory. Isolates of M. abscessus recovered from the environment and from 12 randomly selected patients who sought medical care in 2006 were compared by pulsed-field gel electrophoresis (PFGE). Follow-up case surveillance was continued through March 31, 2007. RESULTS: Specimens from 143 patients obtained from various anatomical sites grew M. abscessus on culture in 2005-2006, compared with specimens from 21 patients in 2003-2004. The 12 isolates from patients that were selected for molecular typing had indistinguishable PFGE patterns. Observations revealed no major breaches in the processing of mycobacterial specimens in the laboratory. Isolates grew only after prolonged incubation (mean +/- SD, 45 +/- 15 days) in test tubes containing diagonally oriented Middlebrook and Cohn 7H10 agar or Lowenstein-Jensen medium. Environmental samples obtained from the inside of the specimen incubator grew M. abscessus on culture. A test tube containing diagonally oriented, uninoculated Middlebrook and Cohn 7H10 agar that was incubated in the same incubator as clinical specimens grew M. abscessus with a PFGE pattern that matched the pattern of the patient isolates. Cases of M. abscessus infection decreased to baseline after the hospital changed suppliers of mycobacterial media and cleaned the incubator. CONCLUSIONS: Although the source was never confirmed, our investigation suggests that this was a pseudo-outbreak of M. abscessus infection that resulted from contamination of mycobacterial cultures during incubation. Our findings emphasize the need for guidance on the disinfection of specimen incubators.

Satellite-based indices in the analysis of land cover for municipalities in the province of Siena, Italy.

Territorial indicators based on the satellite measured reflected or emitted energy can provide valuable information on the spatial evolution of a territory. Information regarding land use, biomass coverage and radiant temperature were obtained from remotely obtained measurements for each municipality in the Province of Siena. Remotely sensed data were combined into different indices to compare characteristics of land cover between territories and create an information base for continued study. A classification was performed on a municipal level and land use classes were grouped together and a general index of use pressure was created. A vegetation index was used to compare biomass densities. A radiant temperature index was calculated using measure thermal infrared emissions. The results of these analyses allowed researchers to examine the intra and inter-municipal spatial heterogeneity within the Province. A comparison between the results of each index was made and the problems related to the use of such indices were examined.

Evaluation of a macrofoam swab protocol for the recovery of Bacillus anthracis spores from a steel surface.

A protocol to recover Bacillus anthracis spores from a steel surface using macrofoam swabs was evaluated for its accuracy, precision, reproducibility, and limit of detection. Macrofoam swabs recovered 31.7 to 49.1% of spores from 10-cm2 steel surfaces with a < or =32.7% coefficient of variation in sampling precision and reproducibility for inocula of > or =38 spores.

Estimate of the effects of ultraviolet radiation on the mortality of Artemia franciscana in naupliar and adult stages.

The impact of different doses of artificial ultraviolet (UV) radiation on the growth stages of a marine zooplankton was investigated using laboratory microcosms. Mortality percentages of naupliar and adult samples of Artemia franciscana were recorded in relation to different UV doses (single exposure: 75, 150, 300, 600, 1,200, 2,400, 3,900, 7,800 J m(-2)) at specific observation times after exposure (24, 48, 72, 96 and 120 h). The relationship between mortality percentage and UV dose showed significant differences in relation to the zooplankton growth stage. The elevated susceptibility of the naupliar samples to UV radiation is described through a mortality model based on a logistic equation. The data analysis shows that the slope of mortality versus dose remains the same for the two growth stages while the lethal dose in the naupliar stage was 3.3 smaller than that determined for the adult stage. The slope of the UV mortality rate versus post-incubation time was found to be significantly different (P<0.05) at low UV doses for the two life stages examined, i.e. naupliar and adult. The lower value of LD(50) in naupliar stages compared to that for adults confirms that in the early growth stage this marine zooplankton is more susceptible to UV radiation.

Morphological anomalies in pollen tubes of Actinidia deliciosa (kiwi) exposed to 50 Hz magnetic field.

The role of the pollen grain, with respect to the reproductive process of higher plants, is to deliver the spermatic cells to the embryo sac for egg fertilisation. Delivery occurs through the pollen tube, a self produced organ that is generated when the pollen grain reaches the stigma surface. The effect of magnetic fields on pollen tube growth was reported in a recent publication by Germanà et al. Pollen tube growth is an interesting candidate for the detailed study of the effects of electromagnetic fields on cytoplasmic structures and organelles. In this research Actinidia deliciosa (kiwifruit) pollen grains were germinated in the presence of an alternating magnetic field (50 Hz). Our results, although of preliminary nature, show that pollen tube growth is affected by magnetic fields. The analysis of the observed anomalies in the pollen tube appear to be the result of changes in the ionic charges within the pollen tube cytoplasm.

Analysis of extinction in ultraviolet and visible spectra of water bodies of the Paraguay and Brazil wetlands.

The extinction spectra in ultraviolet and visible radiation were analyzed using filtered and unfiltered water samples obtained in 11 open water bodies in the Neembucù (Paraguay) and Pantanal (Brazil) wetlands. The role of dissolved and suspended matter in the total extinction was analyzed between 260 nm and 700 nm. The chromophoric dissolved organic matter (CDOM) was the major component in extinction of considered ultraviolet radiation (260-400 nm). The differences in CDOM concentrations explained the main pattern of extinction of the ultraviolet radiation in the samples. Nevertheless, differences between the studied water bodies were found also to depend on the rate of photodegradation and photobleaching. The methodology developed in the present study was to distinguish "humic optic waters" according to quantity and quality of dissolved and suspended matter present. In the "humic optic water", the penetration of 10% of incident UV radiation and the photoactive layer are estimated. The influence of particulate matter increases in the total extinction of the wavelengths higher than 400 nm. The integral of the extinction curve of suspended matter in the visible wavelengths (400-700 nm) was found to relate with the total suspended solids and chlorophyll concentrations.

Methicillin-resistant Staphylococcus aureus sepsis associated with the transfusion of contaminated platelets: a case report.

BACKGROUND: Platelet transfusion-associated sepsis is usually due to donor skin flora introduced into the unit during phlebotomy. An unusual case of a platelet component contaminated with methicillin-resistant Staphylococcus aureus (MRSA) is reported. CASE REPORT: A 54-year-old man, terminally ill with progressive non-Hodgkin's lymphoma, developed fever and hypotension during a platelet transfusion. He was receiving multiple antibiotics, including vancomycin. Blood cultures taken soon after transfusion were negative. An aliquot taken from the platelet pool grew MRSA at a count of 1.6 x 10(8) CFUs per mL. One of the individual bags constituting the pool showed MRSA at a count of 5.1 x 10(8) CFUs per mL. The patient died soon after the platelet transfusion. This case was reported to the FDA and submitted to the BaCon Study. The identity of the isolate and its methicillin resistance were confirmed by the CDC as part of the BaCon Study protocol. The source of contamination of the implicated unit could not be established with certainty. CONCLUSION: The emergence of antimicrobial-resistant organisms poses additional challenges for the diagnosis and treatment of transfusion-associated sepsis. Measures to prevent or intercept the transfusion of contaminated platelets should be developed.

Pontiac fever due to Legionella micdadei from a whirlpool spa: possible role of bacterial endotoxin.

During January 1998, a cluster of illnesses occurred among hotel guests in Wisconsin. Ill persons had been exposed to the hotel's whirlpool spa and swimming pool. Symptoms included headache, fever, chills, myalgia, shortness of breath, and fatigue. A diagnosis of Pontiac fever was made, based on serologic evidence of acute infection with Legionella micdadei. High concentrations of heterotrophic bacteria were recovered from the spa, despite apparently high disinfectant levels. L. micdadei was isolated from the swimming pool filter and water from the spa after heat enrichment but not from pools and spas at nearby hotels. Water from hotel pools and spas was tested to determine endotoxin levels; water from the spa of the implicated hotel contained the highest concentration of endotoxin (14,400 endotoxin units/mL). Additional studies are needed to determine the role of endotoxin from legionellae or other bacteria in the pathogenesis of Pontiac fever.

Vancomycin-resistant enterococci colonization in patients at seven hemodialysis centers.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are increasing in prevalence at many institutions, and are often reported in dialysis patients. We studied the prevalence of and risk factors for VRE at seven outpatient hemodialysis centers (three in Baltimore, MD, USA, and four in Richmond, VA, USA). METHODS: Rectal or stool cultures were performed on consenting hemodialysis patients during December 1997 to April 1998. Consenting patients were recultured during May to July 1998 (median 120 days later). Clinical and laboratory data and functional status (1 to 10 scale: 1, normal function; 9, home attendant, not totally disabled; 10, disabled, living at home) were recorded. RESULTS: Of 478 cultures performed, 20 (4.2%) were positive for VRE. Among the seven centers, the prevalence of VRE-positive cultures varied from 1.0 to 7.9%. Independently significant risk factors for a VRE-positive culture were a functional score of 9 to 10 (odds ratio 6.9, P < 0.001), antimicrobial receipt within 90 days before culture (odds ratio 6.1, P < 0.001), and a history of injection drug use (odds ratio 5.4, P = 0.004). CONCLUSIONS: VRE-colonized patients were present at all seven participating centers, suggesting that careful infection-control precautions should be used at all centers to limit transmission. In agreement with previous studies, VRE colonization was more frequent in patients who had received antimicrobial agents recently, underscoring the importance of judicious antimicrobial use in limiting selection for this potential pathogen.

Infection control in hemodialysis units.

Infectious complications of hemodialysis include bacterial infections caused by contaminated water or equipment, other bacterial infections (including vascular access infections), and bloodborne viruses (primarily the hepatitis B and C viruses). Infections caused by contaminated water and equipment can be prevented by a well-designed water-treatment system, routine cleaning and disinfection of system components, and routine bacteriologic monitoring of dialysis water and dialysis fluid. Standard precautions with additional measures recommended specifically for dialysis centers will prevent transmission of bacteria and viruses from patient to patient. These precautions include routine use of gloves, handwashing, and cleaning and disinfection of the external surface of the dialysis machine and other environmental surfaces. In addition, preventing transmission of hepatitis B virus infection requires vaccination of susceptible patients and staff, avoiding dialyzer reuse, and use of a dedicated room, dialysis machine, and staff members when treating patients chronically infected with this virus.

Nosocomial outbreak of Microbacterium species bacteremia among cancer patients.

To date, only 6 sporadic Microbacterium species (formerly coryneform Centers for Disease Control and Prevention [CDC] groups A-4 and A-5) infections have been reported. The source, mode of transmission, morbidity, mortality, and potential for nosocomial transmission of Microbacterium species remain unknown. From 26 July through 14 August 1997, 8 episodes of coryneform CDC group A-5 symptomatic bacteremia occurred in 6 patients on the oncology ward at the Maine Medical Center. One patient died. All isolates were identified at CDC as Microbacterium species and had identical DNA banding patterns by pulsed-field gel electrophoresis. To assess risk factors for Microbacterium species infection, a retrospective cohort study was conducted. The presence of a central venous catheter was the strongest risk factor (6/6 vs. 22/48; relative risk, 3.2; P<.0001). This outbreak demonstrates significant Microbacterium species-associated morbidity and mortality in immunocompromised populations and confirms the potential for epidemic nosocomial transmission.

Control of vancomycin-resistant enterococcus in health care facilities in a region.

BACKGROUND: In late 1996, vancomycin-resistant enterococci were first detected in the Siouxland region of Iowa, Nebraska, and South Dakota. A task force was created, and in 1997 the assistance of the Centers for Disease Control and Prevention was sought in assessing the prevalence of vancomycin-resistant enterococci in the region's facilities and implementing recommendations for screening, infection control, and education at all 32 health care facilities in the region. METHODS: The infection-control intervention was evaluated in October 1998 and October 1999. We performed point-prevalence surveys, conducted a case-control study of gastrointestinal colonization with vancomycin-resistant enterococci, and compared infection-control practices and screening policies for vancomycin-resistant enterococci at the acute care and long-term care facilities in the Siouxland region. RESULTS: Perianal-swab samples were obtained from 1954 of 2196 eligible patients (89 percent) in 1998 and 1820 of 2049 eligible patients (89 percent) in 1999. The overall prevalence of vancomycin-resistant enterococci at 30 facilities that participated in all three years of the study decreased from 2.2 percent in 1997 to 1.4 percent in 1998 and to 0.5 percent in 1999 (P<0.001 by chi-square test for trend). The number of facilities that had had at least one patient with vancomycin-resistant enterococci declined from 15 in 1997 to 10 in 1998 to only 5 in 1999. At both acute care and long-term care facilities, the risk factors for colonization with vancomycin-resistant enterococci were prior hospitalization and treatment with antimicrobial agents. Most of the long-term care facilities screened for vancomycin-resistant enterococci (26 of 28 in 1998 [93 percent] and 23 of 25 in 1999 [92 percent]) and had infection-control policies to prevent the transmission of vancomycin-resistant enterococci (22 of 25 [88 percent] in 1999). All four acute care facilities had screening and infection-control policies for vancomycin-resistant enterococci in 1998 and 1999. CONCLUSIONS: An active infection-control intervention, which includes the obtaining of surveillance cultures and the isolation of infected patients, can reduce or eliminate the transmission of vancomycin-resistant enterococci in the health care facilities of a region.

Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center.

BACKGROUND: In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions occurred in outpatients at a hemodialysis center. METHODS: We performed a cohort study of all hemodialysis sessions on days that staff members reported S. liquefaciens bloodstream infections or pyrogenic reactions. We reviewed procedures and cultured samples of water, medications, soaps, and hand lotions and swabs from the hands of personnel. RESULTS: We analyzed 208 sessions involving 48 patients. In 12 sessions, patients had S. liquefaciens bloodstream infections, and in 8, patients had pyrogenic reactions without bloodstream infection. Sessions with infections or reactions were associated with higher median doses of epoetin alfa than the 188 other sessions (6500 vs. 4000 U, P=0.03) and were more common during afternoon or evening shifts than morning shifts (P=0.03). Sessions with infections or reactions were associated with doses of epoetin alfa of more than 4000 U (multivariate odds ratio, 4.0; 95 percent confidence interval, 1.3 to 12.3). A review of procedures revealed that preservative-free, single-use vials of epoetin alfa were punctured multiple times, and residual epoetin alfa from multiple vials was pooled and administered to patients. S. liquefaciens was isolated from pooled epoetin alfa, empty vials of epoetin alfa that had been pooled, antibacterial soap, and hand lotion. All the isolates were identical by pulsed-field gel electrophoresis. After the practice of pooling epoetin alfa was discontinued and the contaminated soap and lotion were replaced, no further S. liquefaciens bloodstream infections or pyrogenic reactions occurred at this hemodialysis facility. CONCLUSIONS: Puncturing single-use vials multiple times and pooling preservative-free epoetin alfa caused this outbreak of bloodstream infections in a hemodialysis unit. To prevent similar outbreaks, medical personnel should follow the manufacturer's guidelines for the use of preservative-free medications.