Survey of obstetrician-gynecologists in the United States about toxoplasmosis.

BACKGROUND: Although the incidence of toxoplasmosis is low in the United States, up to 6000 congenital cases occur annually. In September 1998, the Centers for Disease Control and Prevention held a conference about toxoplasmosis; participants recommended a survey of the toxoplasmosis-related knowledge and practices of obstetrician-gynecologists and the development of professional educational materials for them. METHODS: In the fall of 1999, surveys were mailed to a 2% random sample of American College of Obstetricians and Gynecologists (ACOG) members and to a demographically representative group of ACOG members known as the Collaborative Ambulatory Research Network (CARN). Responses were not significantly different for the random and CARN groups for most questions (p value shown when different). RESULTS: Among 768 US practicing ACOG members surveyed, 364 (47%) responded. Seven per cent (CARN 10%, random 5%) had diagnosed one or more case(s) of acute toxoplasmosis in the past year. Respondents were well-informed about how to prevent toxoplasmosis. However, only 12% (CARN 11%, random 12%) indicated that a positive Toxoplasma IgM test might be a false-positive result, and only 11% (CARN 14%, random 9%) were aware that the Food and Drug Administration sent an advisory to all ACOG members in 1997 stating that some Toxoplasma IgM test kits have high false-positive rates. Most of those surveyed (CARN 70%, random 59%; chi2 p < 0.05) were opposed to universal screening of pregnant women. CONCLUSIONS: Many US obstetrician-gynecologists will encounter acute toxoplasmosis during their careers, but they are frequently uncertain about interpretation of the laboratory tests for the disease. Most would not recommend universal screening of pregnant women.

National surveillance for infection with Cryptosporidium parvum, 1995-1998: what have we learned?

OBJECTIVE: Infection with Cryptosporidium parvum generally causes a self-limiting diarrheal illness. Symptoms can, however, last for weeks and can be severe, especially in immunocompromised individuals. In 1994, the Council of State and Territorial Epidemiologists (CSTE) recommended that cryptosporidiosis be a nationally notifiable disease. Forty-seven states have made infection with C. parvum notifiable to the Centers for Disease Control and Prevention (CDC), and laboratories in the three remaining states report cases to state health departments, which may report them to the CDC. To see what the data show about patterns of infection, the authors reviewed the first four years of reports to the CDC. METHODS: The authors analyzed reports of laboratory-confirmed cases of cryptosporidiosis for 1995-1998. RESULTS: During 1995-1998, 11,612 laboratory-confirmed cases of cryptosporidiosis were reported to the CDC. All ages and both sexes were affected. An increase in case reporting was observed in late summer during each year of surveillance for people <20 years of age. CONCLUSION: The first national data on laboratory-confirmed cryptosporidiosis cases, although incomplete, provide useful information on the burden of disease in the nation as well as provide baseline data for monitoring of future trends.

Genetic variation in Pneumocystis carinii isolates from different geographic regions: implications for transmission.

To study transmission patterns of Pneumocystis carinii pneumonia (PCP) in persons with AIDS, we evaluated P. carinii isolates from patients in five U.S. cities for variation at two independent genetic loci, the mitochondrial large subunit rRNA and dihydropteroate synthase. Fourteen unique multilocus genotypes were observed in 191 isolates that were examined at both loci. Mixed infections, accounting for 17.8% of cases, were associated with primary PCP. Genotype frequency distribution patterns varied by patients' place of diagnosis but not by place of birth. Genetic variation at the two loci suggests three probable characteristics of transmission: that most cases of PCP do not result from infections acquired early in life, that infections are actively acquired from a relatively common source (humans or the environment), and that humans, while not necessarily involved in direct infection of other humans, are nevertheless important in the transmission cycle of P. carinii f. sp. hominis.

Vaccination practices, policies, and management factors associated with high vaccination coverage levels in Georgia public clinics. Georgia Immunization Program Evaluation Team.

BACKGROUND: Controlling vaccine-preventable diseases by achieving high childhood vaccination coverage levels is a national priority. However, there are few, if any, comprehensive evaluations of state immunization programs in the United States, and little attention has been given to the importance of vaccination clinic management style and staff motivation. OBJECTIVE: To evaluate the factors associated with the increase in childhood vaccination coverage levels from 53% in 1988 to 89% in 1994 in Georgia's public health clinics. DESIGN: A 1994 mail survey obtaining information on clinic vaccination policies and practices and management practices. SETTING: All 227 public health clinics in Georgia. PARTICIPANTS: Clinic nurses responsible for vaccination services. OUTCOME MEASURE: The 1994 clinic-specific coverage level for 21- to 23-month-old children for 4 doses of diphtheria and tetanus toxoids and pertussis vaccine, 3 doses of polio vaccine, and 1 dose of a measles-containing vaccine as determined by an independent state assessment of clinic coverage levels. RESULTS: Univariate analysis showed that higher coverage levels were significantly (P<.05) associated with smaller clinic size, higher proportions of clientele enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), being a nonurban clinic, and numerous vaccination practices and policies. Multivariable analysis showed that only 8 of greater than 150 factors remained associated with higher coverage levels, including having no waiting time to be seen, having telephone reminder systems, conducting home visits for defaulters, and restricting WIC vouchers when a child was undervaccinated. Motivational factors related to higher coverage included clinic lead nurses receiving an incentive to raise coverage and lead nurses participating in assessments of clinic coverage levels by state immunization staff. CONCLUSIONS: No single factor is responsible for raising vaccination coverage levels. Efforts to improve coverage should include local assessment to provide feedback on performance and identify appropriate local solutions. Coordinating with WIC, conducting recall and reminder activities, motivating clinic staff, and having staff participate in decisions are important in raising vaccination levels.

Preventing congenital toxoplasmosis.

SCOPE OF THE PROBLEM: Toxoplasmosis is caused by infection with the protozoan parasite Toxoplasma gondii. Acute infections in pregnant women can be transmitted to the fetus and cause severe illness (e.g., mental retardation, blindness, and epilepsy). An estimated 400-4,000 cases of congenital toxoplasmosis occur each year in the United States. Of the 750 deaths attributed to toxoplasmosis each year, 375 (50%) are believed to be caused by eating contaminated meat, making toxoplasmosis the third leading cause of foodborne deaths in this country. ETIOLOGIC FACTORS: Toxoplasma can be transmitted to humans by three principal routes: a) ingestion of raw or inadequately cooked infected meat; b) ingestion of oocysts, an environmentally resistant form of the organism that cats pass in their feces, with exposure of humans occurring through exposure to cat litter or soil (e.g., from gardening or unwashed fruits or vegetables); and c) a newly infected pregnant woman passing the infection to her unborn fetus. RECOMMENDATIONSFOR PREVENTION: Toxoplasma infection can be prevented in large part by a) cooking meat to a safe temperature (i.e., one sufficient to kill Toxoplasma); b) peeling or thoroughly washing fruits and vegetables before eating; c) cleaning cooking surfaces and utensils afterthey have contacted raw meat, poultry, seafood, or unwashed fruits or vegetables; d) pregnant women avoiding changing cat litter or, if no one else is available to change the cat litter, using gloves, then washing hands thoroughly; and e) not feeding raw or undercooked meat to cats and keeping cats inside to prevent acquisition of Toxoplasma by eating infected prey. RESEARCH AGENDA: Priorities for research were discussed at a national workshop sponsored by CDC in September 1998 and include a) improving estimates of the burden of toxoplasmosis, b) improving diagnostic tests to determine when a person becomes infected with Toxoplasma, and c) determining the applicability of national screening programs. CONCLUSION: Many cases of congenital toxoplasmosis can be prevented. Specific measures can be taken by women and their health-care providers to decrease the risk for infection during pregnancy and prevent severe illness in newborn infants.

Trichinellosis in the United States, 1991-1996: declining but not gone.

Since the U.S. Public Health Service began recording statistics on trichinellosis in 1947, the number of cases reported by state health departments has decreased steadily. In the late 1940s, health departments reported an average of 400 cases and 10-15 deaths each year. From 1991 to 1996, the period covered in this report, three deaths in 230 cases were reported to the Centers for Disease Control and Prevention (an average of 38 cases per year), including 14 multiple case outbreaks from 31 states and Washington, DC. Information on the suspected food item was available for 134 (58%) of the 230 reported cases. Pork was implicated in 80 (60%) cases, bear meat in 31 (23%), walrus meat in 13 (10%), and cougar meat in 10 (7%). Sausage was the most frequently implicated pork product (i.e., 57 of the 64 cases for which the form of the pork product was identified). The proportion of trichinellosis cases attributable to consumption of commercial pork continued to decrease; this decrease was probably due to a combination of factors, including the continued reduction in the prevalence of Trichinella spiralis in domestic swine, the increased use of home freezers, and the practice of thoroughly cooking pork. As a proportion of all cases reported, those associated with wild game meat products has increased; however, the absolute numbers of such cases have remained similar at approximately 9-12 per year. The continued multiple case outbreaks and the identification of nonpork sources of infection indicate the need for further education and control measures.

Evaluation of failure to follow vaccination recommendations as a marker for failure to follow other health recommendations.

OBJECTIVE: To determine whether families who fail to vaccinate their children also fail to follow other health recommendations. SETTING: US civilian noninstitutionalized population. DESIGN: National survey with a stratified cluster design. PARTICIPANTS: Adult respondents for children 19 to 35 months of age surveyed in the 1991 National Health Interview Survey with documented vaccination history. MEASUREMENTS: Comparison of responses to 23 questions related to health behaviors between respondents of up-to-date (UTD), i.e. having received 4 doses of diphtheria and tetanus toxoids and pertussis vaccine, 3 doses of polio vaccine and one measles vaccine, and non-UTD children. RESULTS: Of the 781 studied children, non-UTD (n = 357) and UTD (n = 424) children, or their respondents, did not differ in 18 of the 23 studied health behaviors. However, although non-UTD and UTD children were equally likely to have car seats, non-UTD children were less likely to use them always (84.3% vs. 92.9%, P = 0.002). National Health Interview Survey respondents of non-UTD children were more likely than their counterparts never to read food labels for ingredients (28.9% vs. 20.5%, P = 0.04) or for fat/cholesterol content (33.6% vs. 22.3%, P = 0.02) and never to buy low salt foods (37.5% vs. 21.5%, P = 0.001). Multivariate analyses showed that parental education level, not a child's vaccination status, was associated with compliance with the studied health behaviors. CONCLUSION: Failure to vaccinate children on time is not consistently related to the likelihood of family member's following of other health recommendations. However, these data suggest that although mediated via parental educational levels, a child's immunization status helps to define families at risk for poor nutrition-related behaviors and those who are in need of counseling on seat belt use.

Potential impact on vaccination coverage levels by administering vaccines simultaneously and reducing dropout rates.

BACKGROUND: Retrospective immunization coverage surveys conducted during 1991 and 1992 demonstrated that coverage levels for the routine childhood vaccines by 24 months of age in selected urban areas of the United States ranged from 10% to 52%, far below the US Public Health Service goal of 90%. Therefore, appropriate programmatic changes must be identified and incorporated. METHODS: We analyzed coverage survey data collected from 21 sites to measure the potential impact on coverage levels of implementing selected changes in vaccination practices. In a multistaged cluster survey design, school health records of kindergarten or first-grade students were randomly selected and dates of vaccination assessed. We evaluated changes in the vaccination practices, such as eliminating missed opportunities for simultaneous administration of vaccines and ensuring that children initiated the vaccination series on time (ie, by 3 months of age). We then calculated potential increases in coverage levels for a best-case scenario. RESULTS: From 77% to 96% of all children in the 21 sites had received at least one vaccination by their first birthday. Children were 2.3 to 17 times more likely to be up to date on their vaccinations by 24 months of age if they were up to date at 3 months of age. Each child had many opportunities for the simultaneous administration of diphtheria and tetanus toxoids and pertussis (DTP) vaccine, oral polio vaccine (OPV), and measles-mumps-rubella (MMR) vaccine that, if used appropriately, could have potentially raised coverage levels by 12% to 22% (median, 17%). The highest coverage levels could have been attained if all children had started the series on time and if advantage had been taken of all opportunities for simultaneous vaccination. Coverage levels for four doses of DTP vaccine, three doses of OPV, and one dose of MMR vaccine would have increased from a baseline of 10% to 52% to levels of 54% to 83%. CONCLUSIONS: Although the majority of children received a vaccination by their first birthday, the coverage level at 24 months of age was low. Tracking systems are needed to ensure that children do not drop out of the system once they have begun the vaccination series. In addition, all children who are late in beginning their vaccination series are at increased risk of not completing the recommended vaccination series on time, and these children need intensive follow-up and recall efforts. Also, providers need to administer all needed vaccines simultaneously.

Diagnosis of measles by clinical case definition in dengue-endemic areas: implications for measles surveillance and control.

In many countries, measles surveillance relies heavily on the use of a standard clinical case definition; however, the clinical signs and symptoms of measles are similar to those of dengue. For example, during 1985, in Puerto Rico, 22 (23%) of 94 cases of illnesses with rashes that met the measles clinical case definition were serologically confirmed as measles, but 32 (34%) others were serologically confirmed as dengue. Retrospective analysis at the San Juan Laboratories of the Centers for Disease Control showed also that at least 28% of all laboratory-confirmed cases of dengue in Puerto Rico in 1985 met the measles clinical case definition. If the true measles vaccine efficacy (VE) is assumed to be 90%, the occurrence of laboratory-confirmed dengue cases that meet the measles clinical case definition results in a reduction of the apparent measles VE to only 64% (a 29% relative reduction from the true VE). The results of the study demonstrate the importance of a laboratory-based surveillance system in measles control or elimination efforts in dengue-endemic areas.

PIP: In many countries, measles surveillance relies heavily on the use of a standard clinical case definition; however, the clinical signs and symptoms of measles are similar to those of dengue. For example, during 1985, in Puerto Rico. 22 (23%) of 94 cases of illnesses with rashes that met the measles clinical case definition were serologically confirmed as measles, but 32 (34%) others were serologically confirmed as dengue. Retrospective analysis at the San Juan Laboratories of the Centers for Disease Control showed also that at least 28% of all laboratory-confirmed cases of dengue in Puerto Rico in 1985 met the measles clinical case definition. If the true measles vaccine efficacy (VE) is assumed to be 90%, the occurrence of laboratory-confirmed dengue cases that meet the measles clinical case definition results in a reduction of the apparent measles VE to only 64% (a 29% relative reduction from the true VE). The results of the study demonstrate the importance of a laboratory-based surveillance system in measles control or elimination efforts in dengue-endemic areas. (author's)

Smoking-attributable mortality, years of potential life lost, and direct health care costs for Puerto Rico, 1983.

The authors report the impact of smoking upon health in Puerto Rico for the year 1983. Using a microcomputer spread-sheet program that calculates smoking-attributable disease impact, they estimated that 2,468 deaths were attributable to smoking. This represented 11.5% of all deaths on the island in 1983 and resulted in approximately 19,445 years of potential life lost (YPLL). It appears that cigarette smoking caused US+55.9 million in direct health care expenditures for Puerto Rico in 1983, an amount equal to 10% of the island's yearly expenditures on health. Calculations such as these demonstrate the enormous disease impact of smoking and may assist policy-makers in planning prevention and intervention activities, both in Puerto Rico and elsewhere in Latin America.

Epidemic dengue 1 in Brazil, 1986: evaluation of a clinically based dengue surveillance system.

In the last 15 years, dengue fever has emerged as a major health problem in tropical America. Prevention and control of epidemic disease are enhanced by the rapid identification of new or increased dengue activity. Most surveillance systems, however, identify cases by clinical case reports and, therefore, lack the sensitivity needed for early detection. During the 1986 dengue 1 epidemic in Rio de Janeiro, Brazil, the authors evaluated the usefulness of a clinical case definition by comparing it with laboratory-confirmed infection status of residents in two cities. The case definition had a sensitivity of 64% and a false-positive rate of 57%. Thus, for every 100 laboratory-confirmed dengue infections, 230 cases were reported. Both infected and noninfected residents who used medical services and who lived in the city with the highest transmission were more likely to meet the case definition. Thus, factors unrelated to actual infection influenced the sensitivity. With the use of stepwise logistic regression, the authors analyzed combinations of patient symptoms and produced nine new hypothetical case definitions. However, none of the new definitions had a false-positive rate lower than 38%. This study emphasizes the need for laboratory-based dengue surveillance systems.