Assessment of occupational risk for hantavirus infection in Arizona and New Mexico.

Differentiating occupational exposure from other potential domestic or recreational exposure(s) for Sin Nombre virus (SNV) infection is an epidemiologic challenge. Interviews on work-related activities were conducted, and serum specimens were obtained from 494 workers in Arizona and New Mexico. These workers may have been exposed to rodents and rodent excreta at work, but their primary occupation did not require rodent contact (National Park Service [n = 193]; Navajo Agricultural Product Industry [n = 65], utility companies [n = 169] and plumbing and heating contractors [n = 67]. Within each occupational group (farm workers [n = 57], laborers [n = 20], professionals [n = 70], repairers [n = 211], service industry workers [n = 83], and technicians [n = 53], the majority of workers reported working in areas that had rodent droppings (range, 75 to 95%); 70% of laborers and 64% of service industry workers reported handling rodents. More than 60% of workers in each group, except technicians, reported reopening and cleaning or working in closed spaces. Approximately 90% of laborers, repairers, and farm workers reported hand-plowing. Although the risk for occupationally related SNV infection appears to be low, workers frequently performed risk activities associated with hantavirus pulmonary syndrome (HPS). All workers were seronegative for SNV by enzyme-linked immunoassay or Western blot testing. These findings, the known occupational exposure of some HPS cases, and the high HPS case-fatality rate (52%) support the need for recommendations to reduce human contact with rodents in the workplace. Increased understanding of hantavirus transmission to humans will help focus future recommendations to minimize human exposures effectively.

A household-based, case-control study of environmental factors associated with hantavirus pulmonary syndrome in the southwestern United States.

During an outbreak of hantavirus pulmonary syndrome (HPS) in the southwestern United States, trained environmental assessment teams conducted surveys at 17 case-patient homes and matched controls from June through August 1993. Variables related to rodent abundance were quantified and standardized rodent trapping was conducted around and within households. The majority of households were located in pinon-juniper vegetation zones, and there were no significant differences in the type of house in which cases and controls lived. The only environmental factor that distinguished case households from controls was significantly higher small rodent densities (median trap success for case sites = 17.3%, 12.7% for near controls, and 8.3% for far controls). Frequency of hantaviral infection in deer mice (Peromyscus maniculatus) did not vary significantly among households of cases and controls, with a range of 27.5-32.5% antibody-positive. Indices of rodent fecal contamination were slightly higher in case houses. The data indicate that higher rodent densities were associated with households in which HPS cases occurred. Strategies that control rodent numbers and decrease rodent access to dwellings may reduce risk of human infection.

A case-control study of hantavirus pulmonary syndrome during an outbreak in the southwestern United States.

In May 1993, an outbreak of hantavirus pulmonary syndrome (HPS) occurred in the southwestern United States. A case-control study determined risk factors for HPS. Seventeen case-patients were compared with 3 groups of controls: members of case-patient households (household controls), members of neighboring households (near controls), and members of randomly selected households > or = 24 km away (far controls). Investigators trapped more small rodents at case households than at near (P = .03) or far control households (P = .02). After the number of small rodents was controlled for, case-patients were more likely than household controls to hand plow (odds ratio [OR], 12.3; 95% confidence interval [CI], 1.1-143.0) or to clean feed storage areas (OR, 33.4; 95% CI, 1.7-666.0). Case-patients were more likely than near controls to plant (OR, 6.2; 95% CI, 1.1-34.0) and more likely than far controls to clean animal sheds (OR, 11.9; 95% CI, 1.4-103.0). Peridomestic cleaning, agricultural activities, and an increased number of small rodents at the household were associated with HPS.

Cat-transmitted fatal pneumonic plague in a person who traveled from Colorado to Arizona.

Plague, primarily a disease of rodents and their infected fleas, is fatal in 50% of infected humans if untreated. In the United States, human cases have been concentrated in the southwest. The most common modes of plague transmission are through flea bites or through contact with infected blood or tissues; however, primary pneumonic plague acquired from cats has become increasingly recognized. We report on the case investigation of a patient, presumably exposed to a plague-infected cat in Colorado, who presented with gastrointestinal symptoms, and subsequently died of primary pneumonic plague. Public health officials should be vigilant for plague activity in rodent populations, veterinarians should suspect feline plague in ill or deceased cats, and physicians should have a high index of suspicion for plague in any person who has traveled to plague enzootic areas.

Quality assurance management methods applied to a local-level primary health care system in rural Nigeria.

Introduction. Management of primary health care (PHC) systems in less developed countries is often impeded by factors such as poorly trained personnel, limited financial resources, and poor worker morale. This study explored the ability of local-level PHC supervisors in rural Nigeria to use quality assurance (QA) management methods to improve the quality of the PHC system. Methods. PHC supervisors from Bama Local Government Area were trained for 3 days in the use of QA methods and tools. The supervisors targeted the supervisory system and the health information system (HIS) for improvement. Health worker performance in diarrhoea case management was assessed, using a simulated case, to measure the impact of supervision. A HIS audit assessed data collection forms used by 17 PHC facilities. Gaps in quality were monitored over a 2-month study period and flaws in work processes were modified. Results. PHC supervisors introduced a checklist during monthly visits to facilities to monitor how workers managed cases of diarrhoea. Performance in history-taking, physical examination, disease classification, treatment and counselling improved over the evaluation period. The HIS audit found that a variety of reporting forms were used at PHC facilities. After HIS reporting was standardized, the number of health facilities using a daily disease registry significantly improved during the study period. Conclusions. QA management methods were used by PHC supervisors in Nigeria to improve supervision and the HIS. QA management methods are appropriate for improving the quality of the PHC in Nigeria and in other less developed countries where at least a minimal PHC infrastructure exists.

Accreditation policies in occupational health care.

Occupational health practitioners have striven for 60 years to develop and implement appropriate accreditation policies and procedures to promote quality assurance of occupational health practice. In 1987 the American Occupational Medical Association affiliated with the Accreditation Association for Ambulatory Health Care, an independent ambulatory health care accreditation organization, to advance this movement. This paper explores the history of occupational health care accreditation and identifies potential incentives needed to encourage accreditation of occupational health care. The Occupational Safety and Health Administration, industry, labor, insurance carriers, and professional organizations collectively must develop strategies to promote accreditation and ensure that workers receive the maximum standard of occupational health care.

Community health worker competency in managing acute respiratory infections of childhood in Bolivia.

A competency-based training and evaluation method was developed to improve and assess the management of acute respiratory infections (ARI) in young children by community health workers (CHWs) in Bolivia. This method was used to evaluate three groups of Bolivian CHWs, provide them with a one-day refresher course in ARI management, and assess the effects of the course. The results showed the CHWs capable of acquiring the skills needed to effectively manage ARI cases in accordance with the World Health Organization's ARI case management strategy. It was found important, however, that their training emphasize how to count the respirations of children with tachypnea and how to identify chest indrawing. In general, the competency-based methods appeared to be effective in training and evaluating CHWs in the area of ARI case management; it is expected that these methods will prove useful in other community-based health interventions.

PIP: Acute respiratory infections (ARI) are a leading cause of child mortality in developing countries. With under-5 mortality due to ARI in Bolivia estimated at 172/1000 live births, these infections are the second largest cause of child mortality in the country. The World Health Organization (WHO) has developed a strategy for managing cases of child ARI with respect to treatment and community health worker (CHW) tasks. Bolivia adheres to these guidelines with some exceptions regarding the tasks of CHWs. This paper reports on the development and implementation and assess the management of ARI in young children by CHWs in Bolivia. 3 groups of Bolivian CHWs were evaluated, given a 1-day refresher course in ARI management, then reevaluated to assess the effects of the course. The short duration of the program and its focus on essential tasks had a significant impact on its participants. The CHWs were found to be capable of acquiring the skills needed to effectively manage ARI cases in accordance with the WHO ARI case management strategy. It was also found important that training emphasize how to count the respirations of children with tachypnea and how to identify chest indrawing. These competency-based methods should prove useful in other community-based health interventions.