The potential role of an adult mentor in influencing high-risk behaviors in adolescents.

BACKGROUND: While mentorship programs, which connect adolescents with adults to whom they can turn to for help and advice, are proliferating in an attempt to prevent high-risk behaviors in teenagers, there are few data to show that mentorship actually makes a difference. OBJECTIVE: To determine if there is an association between having an adult mentor and high-risk behaviors in adolescents. HYPOTHESIS: Adolescents who have an adult mentor would be less likely to engage in high-risk behaviors than those without an adult mentor. DESIGN: Cross-sectional study. A self-administered, anonymous questionnaire was developed to assess demographics, involvement in risk behaviors, and the prevalence of a mentor in the life of a young person. PARTICIPANTS: A convenience sample of 294 adolescents, seen consecutively (93% of those approached), receiving outpatient medical care. Participants were predominantly female (68%), of mixed race/ethnicity, aged between 12 and 23 years (mean +/- SD age, 16.9 +/- 2.4), and from diverse socioeconomic backgrounds. SETTING: An adolescent health service in a suburban community-based teaching hospital. MAIN OUTCOME MEASURES: Adolescent smoking, alcohol and drug use, sexual practices, and weapon carrying. RESULTS: Adolescents with mentors were significantly less likely to participate in 4 of the 5 measured risk behaviors: ever carrying a weapon (odds ratio, 0.41; P< or =.01), illicit drug use in the past 30 days (odds ratio, 0.44; P< or =.01), smoking more than 5 cigarettes per day (odds ratio, 0.54; P< or =.05), and sex with more than 1 partner in the past 6 months (odds ratio, 0.56; P< or =.05). No significant difference was found with alcohol use (> or =3 drinks in the past 30 days). CONCLUSION: A strong positive relationship was found between adolescents having an adult mentor and decreased participation in 4 of the 5 risk behaviors evaluated.

Increased susceptibility to measles in infants in the United States.

BACKGROUND: Women born in the United States after measles vaccine licensure in 1963 transfer less measles antibody to their infants than do older women. This may result in increased susceptibility to measles among infants. OBJECTIVE: To determine the effect of maternal year of birth on the risk for measles in infants. METHODS: We enrolled 128 unvaccinated infants

Treatment of infants with reactive syphilis serology, New Jersey: 1992 to 1996.

BACKGROUND AND RATIONALE: Diagnosis of congenital syphilis is problematic: infants with congenital syphilis are often asymptomatic, and signs in symptomatic infants are frequently subtle and nonspecific. Furthermore, there are no readily available diagnostic tests that provide a definitive diagnosis. Previously, the diagnosis of congenital syphilis was based on a complex set of clinical and laboratory criteria, and only infants with clinically apparent illness or laboratory findings indicating congenital syphilis were classified as cases and reported to health departments and the Centers for Disease Control and Prevention (CDC). To systematize diagnosis and case-reporting, the CDC developed a standardized surveillance case definition in 1988. This case definition includes symptomatic infants as well as asymptomatic infants of mothers with untreated or inadequately treated syphilis during pregnancy. It is intended to be highly sensitive to better estimate the burden of disease in the community. Treatment guidelines for congenital syphilis are intentionally conservative and err on the side of overtreatment so that all potentially infected infants are treated. The congenital syphilis surveillance case definition is compatible with the American Academy of Pediatrics (AAP) and CDC treatment guidelines; thus, the number of infants identified and reported to state health departments and the CDC should reflect the number of infants treated. Hundreds of infants with reactive serologic tests for syphilis (STS) are reported each year to the New Jersey Department of Health and Senior Services (NJDHSS). The majority of these infants do not meet the case definition for congenital syphilis, and most are treated although treatment guidelines indicate that treatment is not necessary. OBJECTIVE: To determine whether infants with reactive STS in New Jersey are being treated according to the AAP treatment guidelines. METHODS: Medical records of newborns with reactive STS reported to NJDHSS between July 1, 1992, and June 30, 1996, were reviewed to determine status of infection and compliance with the AAP treatment guidelines. The 1995 NJDHSS Uniform Billing and Hospital Discharge Data was used to estimate the mean cost of hospitalization per day for infants with the diagnosis of congenital syphilis. Results. During the study period, 1669 newborns with reactive STS were reported to the NJDHSS Sexually Transmitted Disease Program. Medical record review was completed for 1480 infants (88%). Infants were classified by CDC surveillance criteria as follows: 0 confirmed cases; 515 (35%) presumptive cases; 16 (1%) syphilitic stillbirths; and 949 (64%) cases that did not meet the definition for congenital syphilis. Of the 512 presumptive cases that survived the immediate perinatal period, 478 (93%) were treated with antibiotics and 459 (90%) were treated according to the AAP treatment guidelines. Only 27 infants (6%) were treated with a single intramuscular dose of benzathine penicillin. Thirty-four infants (7%) were not treated; instead, their physicians chose to follow them clinically and serologically. All of those treated were asymptomatic, and most were born to mothers with a history of adequate treatment before or during pregnancy, but who were without serologic follow-up. Of the 949 infants that did not meet the case definition, 329 infants (35%) were not treated and 620 (65%) were treated with antibiotics. The 508 (82%) infants treated with antibiotics were treated with intravenous or intramuscular antibiotics for 10 days; only 62 (10%) were treated with a singular intramuscular dose of benzathine penicillin. According to NJDHSS Uniform Billing Hospital Discharge Data, 267 infants weighing >/= 2500 g were discharged with a diagnosis of congenital syphilis in 1995. The median number of hospital days for these infants was 10, and the mean cost of hospitalization per day was $1010. Sources of payment of hospital charges for most infants were public in

Emergence of Lyme disease in Hunterdon County, New Jersey, 1993: a case-control study of risk factors and evaluation of reporting patterns.

Reported cases of Lyme disease in Hunterdon County, New Jersey, increased almost 200% from 75 (67/100,000 population) in 1992 to 216 (193/100,000 population) in 1993. For evaluation of risk factors for Lyme disease and for determination of the cause of this increase, a case-control study was conducted, and the reporting practices of physicians' offices were evaluated. For cases reported in 1993, age and sex distribution, month of disease onset, and proportion of cases with erythema migrans rash were within expected limits. Analysis of age-matched case-control data showed that rural residence; clearing periresidential brush during spring and summer months; and the presence of rock walls, woods, deer, or a bird feeder on residential property were associated with incident Lyme disease. A review of physician reporting patterns suggested that the increase in reported cases in 1993 was due to improved reporting as well as to an increase in the numbers of patients diagnosed with Lyme disease. In addition, substantial underreporting of Lyme disease by physicians' offices was found.

Mycobacterium tuberculosis transmission from a pediatrician to patients.

UNLABELLED: The following report describes the contact investigation of a pediatrician with tuberculosis (TB). The pediatrician's disease was discovered in late February 1993 after tuberculin skin testing (TST) of his 15-month-old son was positive (13-mm induration). Further investigation to identify the source of the child's infection revealed a positive (15-mm induration) TST in the pediatrician. The pediatrician had been symptomatic with a cough since September 1992. The pediatrician had a chest radiograph that revealed numerous cavitary lesions and a sputum smear that was positive for acid-fast bacilli. An investigation was initiated to assess whether the transmission of Mycobacterium tuberculosis had occurred in the pediatrician's office to patients, families, or other visitors. The investigation was later extended to include the hospitals and the day care center where the pediatrician worked. METHODS: A letter was mailed to parents of children served by the practice, explaining the potential exposure to TB and requesting that all persons who visited the office after September 1, 1992 complete an interview and Mantoux TST. Mass interviewing, testing, and test interpretation within the practice took place seven times during March and April 1993. RESULTS: At the completion of screening, 181 (87%) of 208 children who had close contact with the index case were reliably skin-tested and returned for interpretation. Three (1.7%) of the 181 children were TST-positive (>/=5 mm). Thirty-seven (13%) of the 286 adults tested and returning for interpretations were TST-positive (>/=10 mm). Thirty-two (86%) of the 37 adults who tested positive were foreign-born. CONCLUSION: This investigation highlighted the need for identifying childhood TB infection as a sentinel event for adult disease. It also demonstrated the difficulty associated with deciding the extent of contact investigation of a health care worker with TB. Finally, the investigation emphasized the importance of maintaining regularly scheduled and appropriate testing for TB infection in health care workers and the need for health care workers to be cognizant of their own risk and be able to identify, especially in themselves, signs and symptoms of potential TB disease.

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.

Selective screening versus presumptive treatment criteria for identification of women with chlamydial infection in public clinics: New Jersey.

OBJECTIVE: Our goals were to determine the prevalence of chlamydial infection, to identify criteria for selective screening, and to compare the sensitivity of selective screening to presumptive treatment criteria in different clinical settings. STUDY DESIGN: A total of 5128 women enrolled in a cross-sectional study in public clinics in New Jersey. Univariate and multivariate methods of statistical analysis were used. RESULTS: The prevalence of chlamydia varied across type of public clinic and ranged from 8% to 15%. Selective screening criteria were developed for women attending each type of public clinic by use of risk factors significant in the multivariate analyses. A combination of young age and attending an urban clinic was highly predictive of chlamydia infection and identified a minimum of 85% of infected women in all public clinic settings. The use of presumptive treatment criteria identified 78% of infected women in sexually transmitted disease clinics but only 4% to 9% of infected women in other clinical settings. CONCLUSIONS: A chlamydia program that includes presumptive treatment of women attending sexually transmitted disease clinics and selective screening of women in other clinical settings where women are more likely to asymptomatic is a clinically appropriate and economically feasible approach to directing treatment of women with chlamydial infection.

Learning to design new systems: communicable disease surveillance.

The basis for public health actions and its supporting information systems are being questioned. Problems with the New Jersey communicable disease surveillance system were examined. Inability to discriminate unusual disease patterns was disclosed. In addition, there was prolonged processing time, high costs, and lack of capability to identify emerging infections. A new approach for communicable disease surveillance using a hospital laboratory isolate-based reports is described. The project could have been completed faster and with less expense if the project could have benefited from other recent management experience dealing with similar problems.

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.

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.

Biliary complications in the treatment of unsubstantiated Lyme disease.

Treatment of unsubstantiated Lyme disease has led to serious complications in some cases. Two case-control studies, based on information in clinical records of patients discharged with a diagnosis of Lyme disease during 1990-1992, were conducted at a central New Jersey hospital. Twenty-five patients with biliary disease were identified, and 52 controls were selected from 1352 patients with suspected Lyme disease. Only 3% of 71 evaluatable subjects met the study criteria for disseminated Lyme disease. Patients with biliary disease were more likely than were antibiotic controls to have received ceftriaxone and more likely than ceftriaxone controls to have received a daily ceftriaxone dose > or = 40 mg/kg and to be < or = 18 years old. Fourteen of 25 biliary case-patients underwent cholecystectomy; all had histopathologic evidence of cholecystitis and 12 had gallstones. Thus, treatment of unsubstantiated diagnoses of Lyme disease is associated with biliary complications.

Hemolytic uremic syndrome in New Jersey.

In an 18-month study period, the authors identified 23 cases of hemolytic uremic syndrome (HUS) in New Jersey children. Increased identification and reporting of Escherichia coli O157:H7 are needed to prevent additional morbidity and mortality.

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.

Ability of clinical laboratories to detect antimicrobial agent-resistant enterococci.

To test the ability of clinical laboratories to detect antimicrobial resistance among enterococci, we sent four vancomycin-resistant enterococcal strains and one beta-lactamase-producing enterococcus to all 93 nongovernment, hospital-based clinical laboratories in New Jersey; 76 (82%) participated in the study. Each organism was tested by the laboratory's routine antimicrobial susceptibility testing method. The proportion of laboratories that correctly reported that an isolate was resistant to vancomycin varied according to the resistance level of the isolate: high-level resistance (MIC for Enterococcus faecium = 512 micrograms/ml), 96% of laboratories correct; moderate-level resistance (MIC for E. faecium = 64 micrograms/ml), 27% correct; low-level resistance (MIC for Enterococcus faecalis = 32 micrograms/ml), 16% correct; and intrinsic low-level resistance (MIC for Enterococcus gallinarum = 8 micrograms/ml), 74% correct. The beta-lactamase-producing E. faecalis isolate was identified as resistant to penicillin and ampicillin by 66 and 8% of laboratories, respectively, but only three laboratories recognized that it was a beta-lactamase producer. This survey suggests that many laboratories may fail to detect antimicrobial agent-resistant enterococci.

Early syphilis. Relationship to sex, drugs, and changes in high-risk behavior from 1987-1990.

A case-control study was conducted to evaluate two main questions: 1) which specific sex- and drug-use behaviors are associated with the acquisition of early syphilis; and 2) whether changes in sex- and drug-use behaviors from 1987-1990 associated with acquisition of early syphilis. Risk factors associated with significant odds ratio were greater than four sex partners and lack of condom use in the past 3 months. Crack use within the past 3 months was the only specific drug-related risk factor with a significantly elevated odds ratio. However, a number of risk factors associated with both sex and drugs had significantly elevated odds ratios: number of drug-using partners, number of partners exchanging sex for drugs and money, and number of partners with whom the respondent shares sex and drugs. Risk estimates for early syphilis were uniformly higher for women as compared with men. Women appeared to be at higher risk of syphilis than men when engaged in the same high-risk activities. From 1987-1990, there was a significant change from lower-risk to higher-risk behaviors among patients. Patients showed an increase in their number of sex partners, in drug use, and in other high-risk activities. Increasing rates of syphilis can be attributed to a particular set of sex- and drug-related behaviors, and an increase in the adoption of these behaviors has probably contributed significantly to the increased rate of early syphilis in Trenton, NJ, during the period from 1987-1990.

Outbreak of cholera associated with crab brought from an area with epidemic disease.

From 31 March through 3 April 1991, 8 New Jersey residents developed severe, watery diarrhea after eating crabmeat brought back in the suitcase of a traveler to Ecuador. Stool cultures yielded toxigenic Vibrio cholerae O1, serotype Inaba, biotype El Tor from 4 persons, and vibriocidal antibody titers were > or = 1:640 in 7 persons, indicating recent infection with Vibrio cholerae O1. Eating crab was statistically associated with illness (P = .006); however, no leftover crabmeat was available for testing. All 8 patients fully recovered and no cases of secondary transmission were reported. This was the first reported incident of cholera in the continental United States associated with food transported from an area with epidemic disease. Discouraging the transport of perishable souvenir seafood may prevent further outbreaks.

Postoperative group A beta-hemolytic Streptococcus outbreak with the pathogen traced to a member of a healthcare worker's household.

A cluster of four group A beta-hemolytic Streptococcus postoperative wound infections was investigated at a community hospital. The serotypes of the Streptococcus isolated from all four cases, an asymptomatic anesthesiologist and one of his household members were M nontypable T28. During the outbreak period, December 1988, the infection rate among the 40 patients of the anesthesiologist was 7.5%. Among other patients not having contact with this healthcare worker, it was 0.09% (p = .0002 Fisher's exact test). This is only the second reported Group A beta-hemolytic Streptococcus hospital outbreak in which the pathogen was traced to a member of a healthcare worker's household. Early outbreak detection and intervention limited the extent of the outbreak.

Epidemiology of congenital syphilis.

Between 1984 and 1987, the number of reported cases of congenital syphilis in New Jersey tripled. Findings indicate an increase in early syphilis among females of childbearing age living in areas of high syphilis morbidity, reflecting, possibly, lifestyle changes within populations already at risk for the disease. Future studies and interventions are needed.