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.

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.

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.

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.

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.

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.

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.

Risk factors for infection with plasmid-mediated high-level tetracycline resistant Neisseria gonorrhoeae.

This study was done to determine whether the increase in high-level tetracycline resistant Neisseria gonorrhoeae (TRNG) was associated with increased tetracycline use. From 547 persons with positive cultures seen consecutively at a sexually transmitted disease (STD) clinic, 51 (9%) isolates were resistant to tetracycline. Of these 51 isolates, 37 (73%) had high-level resistance (TRNG) which was mediated by the tetM determinant located on a 25.2-megadalton plasmid. Women were twice as likely as men to have TRNG. Previous visits to an STD clinic and oral antibiotic use for a sexually transmitted disease within a one to five month period were used as surrogates for prior tetracycline use. Patients who had been to an STD clinic were almost twice as likely to have TRNG (RR = 1.9, 95% CI: 1.01, 3.46), and those who took an oral antibiotic had a relative risk of 1.8. The authors postulate that previous tetracycline use selects for tetM-containing microorganisms in the genitourinary tract that, at the time of gonococcal infection, have the ability to transfer the determinant to N. gonorrhoeae. The above findings might have implications for modifying the current Centers for Disease Control (CDC) recommendation to prescribe tetracycline for suspected Chlamydia infection among patients with gonorrhea.

Foodborne Snow Mountain agent gastroenteritis in a school cafeteria.

In 1984, an outbreak of gastroenteritis occurred at a school with 1,860 students in Brooklyn, NY. In a single-stage cluster sample of 375 students, 129 (34%) had illnesses that met our case definition of vomiting or diarrhea. The mean incubation period was 26 hours, and the mean illness duration was 24 hours. All case students had eaten in the cafeteria on at least one day between Nov 13 and 16, compared with 174/214 (81%) noncase students (P = 10(-8), Fisher exact test). Foods implicated were french fries (relative risk 1.7, 95% confidence limits 1.4, 2.0) and hamburgers (relative risk 1.6, 95%, confidence limits 1.2, 2.1). Two cafeteria employees had served those foods while affected by diarrhea. By a recently developed blocking enzyme-linked immunosorbent assay, six of 11 (55%) case students showed fourfold antibody increases between acute- and convalescent-phase serum samples for Snow Mountain agent, a Norwalk-like virus, compared with one of ten (10%) noncase students (P = .04, Fisher exact test). We strongly suspect, but cannot document conclusively, that the Snow Mountain agent was spread to students on a vector of hot foods contaminated by ill food handlers. Implicated foods conferred low relative risks and could only have accounted for 74% of cases of illness. The strong association between cafeteria exposure and illness, therefore, suggests that additional modes of spread occurred.

Tuberculosis in employees at a Vermont furniture plant.

In a case-contact investigation of a patient (A) with smear- and culture-positive pulmonary tuberculosis, we found that co-workers in one room of a furniture factory had a higher prevalence of significant reactions to 5 Tu PPD tuberculin than other furniture factory workers. One co-worker also had active pulmonary tuberculosis. It was concluded that Patient A probably transmitted mycobacteria in a well-ventilated, spacious work setting; and that Patient A's disease and the subsequent outbreak could have been prevented.

Pontiac fever associated with a whirlpool spa.

In March 1981, an outbreak of 34 cases of Pontiac fever occurred among 74 members of a social club who visited an inn in south-central Vermont. Environmental and epidemiologic investigations were done to identify the causes of the illness. The outbreak of Pontiac fever was most likely caused by L. pneumophila, serogroup 6, which was identified in a whirlpool spa at the inn. This is the first reported instance of an outbreak of Pontiac fever associated with a whirlpool spa.

Drinking-water-induced copper intoxication in a Vermont family.

Three of four family members reported recurrent episodes of gastrointestinal illness while residing in a house in a small northwestern Vermont village. The father and two daughters repeatedly experienced episodes of emesis and abdominal pain after drinking water drawn from their kitchen faucet. One early-morning water sample taken from the family household contained a copper level of 7.8 mg/L, which is above the standard for drinking water (1.0 mg/L). Values for the second daughter's copper in hair analysis (1,200 micrograms/g) and copper in nail analysis (100 micrograms/g) were elevated (normal range 11 to 53 micrograms/g). The household was at the end of a 3/4-in (19.05-mm) copper main, and it is suspected that copper levels increased in water when the water remained stagnant in the main. All symptoms of the family resolved when they stopped drinking water in their home. This is the first report of copper-induced gastrointestinal illness attributable to a public supply of drinking water.

National survey on outbreaks associated with whirlpool spas.

A national survey of state epidemiologists sought information on reported outbreaks of illness associated with non-residential whirlpool spas for the period April 1972-July 1, 1982. Reports were received from 49 states. Of the 74 whirlpool-associated outbreaks reported, 72 were characterized as having patients with papular or pustular rash and two were associated with cases of Pontiac fever.