Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity--Georgia, 2000.

Emergency department (ED) staff caring for patients contaminated with toxic chemicals are at risk for developing toxicity from secondary contamination. This report describes three cases of occupational illnesses associated with organophosphate toxicity caused by exposure to a contaminated patient and underscores the importance of using personal protection equipment (PPE) and establishing and following decontamination procedures in EDs and other areas of acute care hospitals.

Human immunodeficiency virus seroprevalence trends: five hospitals in south Georgia, 1993 through 1997.

BACKGROUND: Human immunodeficiency virus (HIV) seroprevalence surveys help determine the extent of HIV and the need for routine HIV counseling and testing. We sought to describe trends in five south Georgia hospitals and compare two protocols for conducting anonymous HIV surveys. METHODS: From 1993 to 1997, each hospital tested approximately 1,400 anonymous, leftover blood specimens per year. Two hospitals (C and E) tested all specimens, and three hospitals (A, B, and D) excluded blood known to be HIV-related. RESULTS: The mean HIV seroprevalence at hospitals C and E was between 2.0% and 2.3% each year. The mean HIV seroprevalence at hospitals A, B, and D increased from 0.5% to 1.0% during 1993 to 1995, then decreased to 0.3% in 1997. CONCLUSIONS: In hospitals C and E, the level of HIV disease was constant. In hospitals A, B, and D, the HIV seroprevalence decreased to 0.3%, suggesting that routine HIV counseling and testing is not currently needed in these hospitals. Hospitals should consider conducting periodic anonymous HIV seroprevalence surveys, sampling from all patients and distinguishing between specimens known to be HIV-related and those that are not.

Missed opportunities for congenital syphilis prevention in an urban southeastern hospital.

BACKGROUND: Despite recent declines in syphilis rates nationally, recent outbreaks suggest that prevention of congenital syphilis remains an ongoing public health problem. GOALS: To identify missed opportunities for congenital syphilis prevention during prenatal care. STUDY DESIGN: Retrospective medical record review of 157 live birth or stillbirth deliveries that involved cases of congenital syphilis from Grady Memorial Hospital (Atlanta, GA). RESULTS: The hospital congenital syphilis prevalence was 8.2 cases per 1,000 live births. Six percent of case patients were HIV positive. Opportunities for earlier maternal screening, treatment, or diagnosis were missed in 60% of case patients who received timely prenatal care. Congenital syphilis cases attributable to preventable missed opportunities were significantly more common among case patients with fewer prenatal visits (66% versus 28%, P = 0.01). CONCLUSION: Provider efforts to reduce congenital syphilis in high-risk populations receiving prenatal care should focus on (1) screening patients at the first opportunity, at both the first prenatal visit and during the third trimester (i.e., 28 weeks); (2) performing on-site testing and same-day treatment; (3) providing appropriate treatment to infected women with penicillin allergy; (4) referring sex partners for treatment to prevent reinfection; and (5) screening all pregnant women attending emergency clinics.

Sexually transmitted diseases during pregnancy: screening, diagnostic, and treatment practices among prenatal care providers in Georgia.

BACKGROUND: Sexually transmitted diseases (STD) during pregnancy are associated with adverse outcomes. We conducted a prenatal care provider survey to determine STD screening, diagnosis, and treatment practices. METHODS: Standard questionnaires were mailed to Georgia-licensed obstetrician/ gynecologists, family practitioners, and nurse-midwives (N = 3,082) in 1998. RESULTS: Of the 1,300 care providers who returned the survey, 565 (44%) provided prenatal care, 390 (57%) were male, and 396 (70%) were obstetrician/ gynecologists. Overall, 553 prenatal care providers (98%) reported screening all pregnant patients for syphilis, 551 (98%) for hepatitis B, 501 (89%) for trichomonas, 474 (84%) for human immunodeficiency virus (HIV), 401 (71%) for gonorrhea, 403 (71%) for chlamydia, 475 (84%) for group B streptococci, and 130 (23%) for bacterial vaginosis (BV) (high risk). Less than 10% used amplification tests for chlamydia or gonorrhea. Most providers used appropriate regimens to treat STD in pregnant women. A written office policy on testing for BV or HIV was associated with increased screening. CONCLUSIONS: Provider education is needed about diagnosis and treatment of STD during pregnancy.

Factors influencing a communitywide campaign to administer hepatitis A vaccine to men who have sex with men.

OBJECTIVES: A hepatitis A outbreak among men who have sex with men (MSM) led to a publicly funded vaccination campaign. We evaluated the MSM community's response. METHODS: A cohort of MSM from 5 community sites was surveyed. RESULTS: Thirty-four (19%) of 178 potential vaccine candidates received the vaccine during the campaign. We found a linear relation between the number of exposures to campaign information and the likelihood of vaccination (P < .001). Vaccination was independently associated with awareness of the outbreak and the vaccine, having had sexual relations with men for 12 years or longer, having recently consulted a physician, and routinely reading a local gay newspaper. CONCLUSIONS: The difficult task of vaccinating MSM can be aided by repetitive promotional messages, especially via the gay media.

Syphilis in Atlanta during an era of declining incidence.

BACKGROUND: Syphilis transmission in Atlanta is ongoing despite declining incidence. OBJECTIVES: To identify risk factors and missed opportunities for prevention. STUDY DESIGN: A case-control study design was used. Twenty-five sexually transmitted disease (STD) clinic patients with primary or secondary syphilis by polymerase chain reaction and serology and 49 matched controls were interviewed. RESULTS: Persons with syphilis more frequently had HIV infection (24% versus 2%; P = 0.005), crack-using sex partners (52% versus 18%; odds ratio [OR] = 5.1; 95% CI = 1.7-15.5), and a history of incarceration (80% versus 57%; OR = 3.0; CI = 1.0-9.3). Many cases (48%) and controls (31%) had received drug-abuse treatment. Only 40% of previously incarcerated patients and 74% of those with a history of drug treatment reported receiving STD/HIV education in those settings. Among all patients reporting recent HIV education, 41% were told about STD recognition and treatment. Unprotected sex and delay in seeking care were common. CONCLUSION: To prevent syphilis and associated HIV, more extensive STD education is needed in jails and drug-treatment centers.

Consequences in Georgia of a nationwide outbreak of Salmonella infections: what you don't know might hurt you.

OBJECTIVES: This study assessed the impact in Georgia of a nationwide salmonellosis outbreak caused by ice cream products and the effectiveness of the subsequent warning against eating the implicated products. METHODS: A telephone survey of 250 randomly selected Georgia customers of the ice cream producer was conducted 13 to 17 days after the warning. RESULTS: Respondents from 179 households representing 628 persons were interviewed. The median date of first hearing the warning was 5 days after it was issued, and 16 respondents (9%) had not heard it. Among those who had heard the warning, 42 (26%) did not initially believe the products were unsafe. In 22 (31%) of the 72 households that had the implicated ice cream when the respondent heard the warning, someone subsequently ate the ice cream. Diarrhea was reported in 26% (121/463) of persons who had eaten the products but in only 5% (8/152) who had not (odds ratio [controlling for household clustering] = 3.8; 95% confidence interval = 2.0, 7.5). We estimate this outbreak caused 11,000 cases of diarrhea in Georgia, 1760 (16%) with exposure after the warning. CONCLUSIONS: A large outbreak occurred in Georgia, much of which might have been prevented by a more timely and convincing warning.

Human immunodeficiency virus partner notification. Cost and effectiveness data from an attempted randomized controlled trial.

OBJECTIVE: Determine the cost and effectiveness of partner notification for human immunodeficiency virus (HIV) infection. METHODS: Persons testing HIV positive in three areas were randomly assigned one of four approaches to partner notification. Analysis plans changed because disease intervention specialists notified many partners from the patient referral group. We dropped the patient referral group and combined the others to assess the cost and effectiveness of provider referral. RESULTS: The 1,070 patients reported 8,633 partners. Of those 1,035 were located via record search or in person. A previous positive test was reported by 248 partners. Of the 787 others, 560 were tested: 438 were HIV negative and 122 were newly identified as HIV positive. The intervention specialist's time totaled 197 minutes per index patient. The cost of the intervention specialist's time, travel, and overhead was $268,425: $251 per index patient, $427 per partner notified, or $2,200 per new HIV infection identified. No demographic characteristic of the index patient strongly predicted the likelihood of finding an infected partner. CONCLUSION: We could not compare the effectiveness of different partner notification approaches because of frequent crossover between randomized groups. The cost of partner notification can be compared with other approaches to acquired immunodeficiency syndrome prevention, but the benefits are not easily measured. We do not know the number of HIV cases prevented or the value of fulfilling the ethical obligation to warn partners of a potential threat to their health.

Public health response for the 1996 Olympic Games.

Extensive planning and preparation by public health agencies were required for the provision of public health services during the 1996 Centennial Olympic Games, which brought together more than 10000 athletes from 197 countries and more than 2 million visitors. Public health activities included the development and use of an augmented surveillance system to monitor health conditions and detect disease outbreaks; creation and implementation of 6 environmental health regulations; establishment of a central Public Health Command Center and response teams to coordinate response to public health emergencies; planning for potential mass casualties and the provision of emergency medical services; implementation of strategies for the prevention of heat-related illness; and distribution of health promotion and disease prevention information. Public health agencies should take the lead in organizing and implementing a system for preventing and managing public health issues at future large-scale public events such as the Olympics.

Using social network and ethnographic tools to evaluate syphilis transmission.

BACKGROUND AND OBJECTIVES: Partner notification has been the cornerstone for the prevention and control of syphilis in the United States. This technique may not make full use of contextual data that an ethnographic and social network approach can offer. GOALS OF THE STUDY: The occasion of a syphilis outbreak among young people was used to investigate the applicability of a social network approach and to test the validity of several traditional approaches to syphilis epidemiology. STUDY DESIGN: An outbreak of syphilis was investigated by interviewing both infected and noninfected people, by directing resources based on network association, by creating and evaluating network diagrams as an aid to the epidemiologic process, and by including ethnographic observations as part of outbreak management. RESULTS: Diagrammatic display of network growth provided a useful alternative to the traditional epidemic curve. Case prevention was demonstrated by identifying uninfected people with multiple concurrent exposures. Concurrent, overlapping exposure in infected people rendered traditional "source" and "spread" criteria moot. CONCLUSIONS: The current discussions of partner notification may be informed by recognizing that it is a subset of a broader and potentially more powerful approach. This approach calls some basic tenets of syphilis epidemiology into question.

Partner notification for syphilis: a randomized, controlled trial of three approaches.

OBJECTIVE: To determine the cost and effectiveness of three approaches to partner notification for infectious syphilis. STUDY DESIGN: People with syphilis were randomly assigned to: (1) notification of partners by patients themselves within 2 days or disease intervention specialists would notify them; (2) immediate notification by intervention specialist; or (3) immediate notification by intervention specialists, who had the option of drawing blood in the field. Costs of intervention specialists' time, travel, and overhead were measured. Intention-to-treat analysis measured outcomes per randomized index patient. RESULTS: From December, 1990 through March, 1993, 1,966 index patients with syphilis (primary 9%; secondary 18%; and early latent 73%) were randomized in Broward County (Ft. Lauderdale), Florida (1,191); Tampa, Florida (569); and Paterson, New Jersey (206). Index patients reported 11,272 potentially exposed partners and sufficient information to initiate investigations for 2,761. Of these, 2,236 were located, 367 had newly identified infections, and 870 others received preventive treatment. The three partner notification approaches had similar success locating partners (1.1-1.2 per index patient) and treating partners (0.61-0.67 per index). The cost was $317 to $362 per partner treated; the optimal strategy differed by study site. CONCLUSIONS: Partner notification identified many infected and potentially infected people. The cost and effectiveness of the three types of provider notification were similar. Alternative approaches are needed to reach infected partners who could not be notified.

Effect of a state law on reported bicycle helmet ownership and use.

OBJECTIVE: To evaluate the effect of a state law on reported bicycle helmet ownership and use. DESIGN: Multistage cluster random-digit-dialing telephone survey. SETTING: Georgia, June through November 1993. PARTICIPANTS: Adults who reported the behavior of bicyclists 4 through 15 years old. INTERVENTION: State law mandating helmet use after July 1, 1993, for all bicyclists aged younger than 16 years. MAIN OUTCOME MEASURES: Bicycle helmet ownership and use. RESULTS: Reported helmet ownership increased from 39% before the law took effect to 57% afterward (+ 46%, P = .06). Reported use increased from 33% before to 52% afterward (+ 58%, P < .05). About 7% of riders changed from "never-wearing" to "always-wearing" behavior. After the law took effect, in those households in which the law was known, 69% of riders owned and 64% used a helmet. By comparison, in those households in which the law was not known, only 30% owned and 25% used a helmet (P < .01). Reported ownership and use were 93% concordant, inversely related to rider age, and directly related to household income. Multivariable analysis indicated that race was an effect modifier of reported helmet ownership and use. In black riders, knowledge of the law appeared to be highly associated with both reported helmet ownership and use but was not significant in white riders. In white riders, though age and income were significantly associated with reported helmet ownership and use. CONCLUSIONS: This law appeared important in increasing reported helmet ownership and use, particularly in black riders. Since knowledge of the law was associated with increased ownership and use, additional publicity about the law might further increase helmet use. Because most riders who owned helmets used them, give-away programs targeting areas of low ownership may also increase use.

HIV risk behavior, street outreach, and condom use in eight high-risk populations.

In this paper we examine risk behavior, exposure to street outreach, and condom use in samples of injecting drug users (IDUs) and high-risk youth. We used systematic sampling methods to produce representative samples of injecting drug users IDUs (five sites) and high-risk youth (three sites). The populations surveyed engaged in high levels of sexual risk behavior: 20% to 46% reported two or more sex partners in the last month. The majority (62% to 97%) knew someone infected with HIV. Condom use rates approached national health promotion goals for nonsteady partners but not for steady or main partners. Having a condom at time of interview was the most consistent predictor of condom use at last intercourse. Many of the respondents have been in contact with street outreach programs and many acknowledged some personal risk for HIV infection. However, most of the injecting drug users and high-risk youth interviewed (and their sex partners) were still at risk through unprotected sex.

PIP: Samples of IV drug users (IVDUs) and high-risk youth were surveyed to gain insight into their HIV risk behavior, exposure to street outreach, and condom use. The IVDUs were sampled from Atlanta, Philadelphia, Chicago, New York, and Los Angeles; 69-77% are male; they are predominantly Hispanic and Black; and more than 50% were older than age 40 years. The high-risk youth were sampled from Los Angeles, San Diego, New York, and San Francisco. They were aged 12-23 years and had been recurrently without shelter during the past year, or had been without permanent shelter for the past two months, or had derived their livelihood from dealing drugs on the street, prostitution, panhandling, and crime. 65-81% are male, approximately 50% in New York are White and 78% in San Francisco, 39-54% were age 20 or older, and 52-73% were currently living on the street, although only 10-32% had stayed in a shelter during the past year. At least 75% were supported at least in part by the street economy and 15-33% identified themselves as gay or bisexual. Many of the youth covered in the survey in San Francisco were on tour with the Grateful Dead folk rock music group. 20-46% reported having two or more sex partners in the last month, up to one-third reported having no sex partner in the past month, 62-97% knew someone infected with HIV, and 18-26% of the IVDUs and 11-41% of youth reported sometimes exchanging sex for money, food, shelter, or other things. Among respondents who had sex during the past month, 17-44% reported using a condom during vaginal sex with main partners, and 55-75% with other partners. The highest rates of condom use were for anal sex, followed by vaginal and oral sex. In most categories, however, the majority of respondents were not using condoms to protect themselves from HIV or other sexually transmitted diseases. Having a condom at the time of interview was the most consistent predictor of condom use at last intercourse. Many of the respondents had been in contact with street outreach programs and many acknowledged some personal risk for HIV infection.

Barriers to prevention of perinatal group B streptococcal disease.

During 1992 the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) issued statements on prevention of group B streptococcal (GBS) disease. To assess prevention practices and identify barriers to preventing GBS disease, we surveyed obstetricians, family practitioners and general practitioners in Georgia during 1993. A standard questionnaire was mailed to 1190 clinicians in August and to nonresponders again in September. Of 436 (38%) physicians who responded, 192 (44%) provided obstetric care. Among these 192 obstetric care providers, 121 (63%) screened patients for GBS carriage antenatally. The most frequently cited reasons for not screening were "no clear guidelines" and "not cost-effective" (52 and 39%, respectively). Clinicians who screened patients were significantly more likely to believe that screening was cost-effective (P = 0.05). Of obstetric care providers who screened, only 9% obtained specimens using culture sites recommended by ACOG or AAP. Although most clinicians were aware that antenatal antibiotic treatment of carriers does not prevent perinatal GBS disease, 64% of those who screened reported that they gave oral antibiotics when carriage was detected during pregnancy. Of clinicians who reported using obstetric risk factors to guide prophylaxis choices, < 15% reported using intrapartum antibiotics for the conditions identified in the ACOG and AAP statements as those that suggest the need for prophylaxis when screening is not performed. Many Georgia obstetric care providers do not use effective practices to prevent perinatal GBS disease. Education on appropriate culture methods, obstetric risk factors and the cost effectiveness of prevention strategies might lead to more effective preventive practices.