Public health surveillance for smallpox - United States, 2003-2005.

In June 1987, nearly 10 years after the World Health Organization (WHO) declared smallpox eradicated, the Council of State and Territorial Epidemiologists (CSTE) recommended removal of smallpox, a highly contagious viral disease, from the National Notifiable Diseases Surveillance System (NNDSS). However, the attacks of September 11, 2001, raised concern that smallpox (variola) virus, might exist in laboratories other than two WHO-designated repositories and could be used as an agent of biologic terrorism. In response to this concern, CSTE and CDC recommended in June 2003 that smallpox again be made reportable through NNDSS and that all states, territories, and cities add smallpox to their lists of reportable diseases. In 2005, CSTE conducted a cross-sectional survey in the United States and its territories to assess key components for surveillance of suspected smallpox disease, including legal reporting requirements, laboratory testing, and training and education (e.g., oral presentations and guides). This report summarizes the results of that survey, which indicated that 100% had the capacity to receive and investigate reports, 94% of states had legal requirements to report suspected smallpox disease, 70% had mandatory laboratory reporting of results indicative of smallpox disease, and 68% were providing ongoing training and education of health-care providers and public health staff.

West Nile virus: a case study in how NY State Health Information infrastructure facilitates preparation and response to disease outbreaks.

New York's (NY) Health Information Network (HIN) provided timely access to West Nile Virus (WNV) data during the initial outbreak in the late Summer 1999. In December 1999, NY developed a plan to deal with WNV in 2000 that required an integrated surveillance system for humans, birds, mammals, and mosquitoes. The HIN infrastructure allowed NY to deploy this system statewide in three months. Local health departments throughout NY used the system to report, track, and retrieve surveillance data as WNV spread throughout NY in 2000. The HIN infrastructure includes partnerships, training/support, technical capacity and architecture similar to NEDSS as proposed by the US CDC.

What do pharmacists think about New York state's new nonprescription syringe sale program? Results of a survey.

Access to sterile syringes can prevent transmission of blood-borne diseases such as human immunodeficiency virus (HIV) and hepatitis B and C. We conducted survey of attitudes of pharmacists to aid in development of the Expanded Syringe Access Demonstration Program (ESAP) in New York State. ESAP is an HIV prevention initiative that authorizes nonprescription sale of hypodermic needles and syringes by registered pharmacies in New York State beginning January 1, 2001. As part of planning for program implementation, the New York State Department of Health (NYSDOH), in collaboration with the New York State Education Department, conducted mailed survey of all 4, 392 licensed pharmacies in New York State during the summer of 2000. Some surveys (171) were returned as undeliverable. Of the 4,221 eligible respondents, 874 (20.7%) completed surveys were received, of which 574 (65.7%) indicated that their pharmacy would likely participate in ESAP. An additional 11.0% were not sure. Only 139 (15.9%) indicated that they would definitely not participate; 7.4% left this question blank. There were 608 responses to questions on safe disposal practices. Of these, 315 (51.8%) respondents indicated that their pharmacy sold sharps containers, and an additional 29 made them available at no cost. Only 133 (21.9%) respondents to this question did not offer sharps containers and were not interested in doing so. In all, 54 responses indicated that they accepted used hypodermic needles and syringes for disposal. Some (170, 28%) that did not accept sharps for disposal were interested in doing so. More than half (382, 63.0%) did not wish to do so. NYSDOH considered respondent suggestions and minimized ESAP requirements. By March 31, 2001, only 3 months after ESAP became effective, more than half of all licensed pharmacies in New York State were registered for ESAP. Survey results provided useful information to NYSDOH and good indication of likelihood of registration. The high level of pharmacy participation in ESAP may be reflective of NYSDOH attention to issues raised by pharmacists, as well as the direct effects of outreach to pharmacy chains regarding ESAP.

Consented testing of newborns and childbearing women for human immunodeficiency virus through a newborn metabolic screening program.

OBJECTIVE: In this program a postpartum woman could consent to receive her newborn's human immunodeficiency virus test result from the New York State Newborn Screening Program. STUDY DESIGN: By state regulation each postpartum woman was counseled and offered her newborn's human immunodeficiency virus test result. With the mother's consent, newborn human immunodeficiency virus antibody test results from the Newborn Screening Program were sent to the baby's pediatrician; otherwise, test results were blinded. Data were analyzed for births from August 1, 1996, to January 31, 1997. RESULTS: Overall, 92.5% of women offered newborn human immunodeficiency virus testing consented to receive the result. Among 444 human immunodeficiency virus-positive women offered newborn testing, consented testing resulted in a 21.4% increase in knowledge of human immunodeficiency virus status from 72.3% (n = 321) at delivery to 93.7% (n = 416) after newborn testing; 6.3% (n = 28) of human immunodeficiency virus-positive women delivered of infants who did not consent apparently remained unaware of their human immunodeficiency virus status. CONCLUSION: Combined prenatal and consented newborn testing identified 94% of human immunodeficiency virus-positive mothers and exposed newborns, allowing early entry into care. Such testing may provide an opportunity for women not previously tested for the human immunodeficiency virus to learn their status but is not a substitute for universal prenatal human immunodeficiency virus counseling and consented human immunodeficiency virus testing.

Mobilizing a mass HIV counseling and testing program in Chautauqua County.

In October 1997, the staff of the New York State Department of Health's Anonymous HIV Counseling and Testing Program were mobilized to assist the Chautauqua County Department of Health to respond to an unprecedented demand for HIV counseling and testing. This demand followed the release of the name of an HIV-infected individual who was suspected of infecting 13 young women in Chautauqua County. This article reviews essential elements of New York's efforts to assist Chautauqua County in meeting increased demands for HIV counseling and testing services during the emergency response. New York's experience can help inform other jurisdictions that may encounter similar public health emergencies in the future.

Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of the human immunodeficiency virus.

BACKGROUND: The Pediatric AIDS Clinical Trials Group Protocol 076 reported a reduction in the rate of perinatal transmission of the human immunodeficiency virus (HIV) from 25.5 percent to 8.3 percent with a three-part regimen of zidovudine given ante partum, intra partum, and to the newborn. We examined the effects of abbreviated zidovudine regimens on perinatal HIV transmission using data from the HIV polymerase-chain-reaction (PCR) testing service of the New York State Department of Health. Pregnant women who received abbreviated regimens rather than the recommended regimens did so because of limited prenatal care or by choice. METHODS: The requisition form used by the PCR testing service included information on the demographic characteristics of the infants and the timing of any perinatal treatment with zidovudine. We also analyzed data on the timing of zidovudine prophylaxis collected by chart review in a subgroup of 454 infants as a means of validating the results in the entire cohort. RESULTS: From August 1, 1995, through January 31, 1997, specimens from 939 HIV-exposed infants who were 180 days of age or younger were submitted for PCR testing. The rates of perinatal HIV transmission varied depending on when zidovudine prophylaxis was begun. When treatment was begun in the prenatal period, the rate of HIV transmission was 6.1 percent (95 percent confidence interval, 4.1 to 8.9 percent); when begun intra partum, the rate was 10.0 percent (3.3 to 21.8 percent); when begun within the first 48 hours of life, the rate was 9.3 percent (4.1 to 17.5 percent); and when begun on day 3 of life or later, the rate was 18.4 percent (7.7 to 34.3 percent). In the absence of zidovudine prophylaxis, the rate of HIV transmission was 26.6 percent (21.1 to 32.7 percent). CONCLUSIONS: These results confirm the efficacy of zidovudine prophylaxis and suggest that there are reductions in the rates of perinatal transmission of HIV even with the use of abbreviated regimens that are begun intra partum or in the first 48 hours of life.

Human babesiosis in New York State: Review of 139 hospitalized cases and analysis of prognostic factors.

BACKGROUND: Babesiosis infections are infrequent, occur in limited geographic locations, and range from asymptomatic infection to severe illness and death. METHODS: Descriptive clinical and epidemiological information on human babesiosis cases was collated from state communicable disease reports and medical records of patients hospitalized from 1982 to 1993. Univariate and multivariate analyses were performed to determine prognostic factors associated with severe disease outcome (hospitalization ending in death, duration of hospitalization > 14 days, or intensive care unit stay > 2 days). RESULTS: Between 1982 and 1993, 139 patients were hospitalized with babesiosis in New York State. Nine patients (6.5%) died, 35 (25.2%) were admitted to the intensive care unit, and 35 (25.2%) required hospitalization for more than 14 days. Mean age at first hospitalization was 62.5 years. Sixty-two percent were male, and 91% resided in Suffolk County, Long Island. The most common symptoms were fatigue/malaise/weakness (91%), fever (91%), shaking chills (77%), and diaphoresis (69%). Past medical records showed that 52% of patients had a history of chronic disease; 12% had a history of Lyme disease; 12% had undergone a splenectomy; and 2% had undergone a blood transfusion. There was a 12- to 14-day delay between onset of symptoms and initiation of appropriate antibiotic treatment. Univariate analyses showed alkaline phosphatase levels greater than 125 U/L, white blood cell counts greater than 5 x 10(9)/L, history of cardiac abnormality, history of splenectomy, presence of heart murmur, and parasitemia values of 0.04 or higher to be significantly associated with disease severity. Multiple logistic regression analyses indicated that male sex, alkaline phosphatase values greater than 125 U/L, and white blood cell counts greater than 5 x 10(9)/L remained strong predictors of severe outcome. CONCLUSIONS: Human babesiosis is a rare but debilitating and potentially fatal illness, especially in the elderly. Prompt disease diagnosis and treatment are essential but are often delayed, as seen in our series. This delay reinforces the need for enhanced public and physician education targeted toward residents and visitors to the few high-risk geographic areas where disease and Ixodes scapularis ticks are endemic. Patients presenting with certain prognostic indicators (male sex, alkaline phosphatase values > 125 U/L, and white blood cell counts >5 x 10(9)/L) require comprehensive and aggressive medical care to prevent further deterioration. Since babesiosis is only 1 of 3 currently recognized diseases transmitted by I scapularis ticks, primary prevention recommendations will also reduce human exposure to Lyme disease and human granulocytic ehrlichiosis.

Human granulocytic ehrlichiosis in New York.

BACKGROUND: Human granulocytic ehrlichiosis (HGE), a potentially fatal tick-borne disease, was first described in the upper Midwest in 1994. Following reports of suspected cases of ehrlichiosis from New York physicians, descriptive and case-control studies were conducted to characterize the epidemiology and risk factors for HGE in New York residents. METHODS: Descriptive data were gathered from surveillance and laboratory reports and hospital records. A confirmed case was defined as either (1) a 4-fold change in total antibody titer to Ehrlichia equi by indirect immunofluorescence or (2) a polymerase chain reaction assay positive for Ehrlichia phagocytophila/E equi group DNA. A probable case was defined as an acute febrile illness and either (1) a single E equi titer greater than or equal to 80 or (2) morulae on a peripheral blood smear. The case-control study included patients with confirmed HGE 18 years of age or older with the onset of disease in 1995 and 2 to 3 neighborhood-matched controls. RESULTS: During 1994 and 1995, the New York State Department of Health, Albany, received reports of 241 residents who were tested for HGE; 30 met the confirmed case definition and 34 met the probable case definition. The median age of patients was 46 years (age range, 9-90 years), 35 (55%) were male, and 25 (45%) were hospitalized. Fever, headache, malaise, and myalgia were the most frequently reported symptoms. Fifty-six (88%) of the 64 patients resided in areas in which Lyme disease is hyperendemic. In the case-control analysis, cases were more likely than controls to have sustained a tick bite during 1995 (matched odds ratio, 5.0; 95% confidence interval, 0.9-49.8). Cases and controls did not differ by occupational exposure to ticks, underlying chronic diseases, or measures taken to prevent tick bites. CONCLUSIONS: This study, which, to our knowledge, is the first population-based study of HGE, demonstrates the recent recognition of HGE in the state of New York. Control measures should be integrated with those for Lyme disease and should focus on minimizing contact with ticks and obtaining early treatment for infection.

Effect of 2 urban emergency department immunization programs on childhood immunization rates.

BACKGROUND: Emergency departments (EDs) are recommended as sites for immunizing children. However, there is little information about the effect of ED immunization programs on immunization rates. OBJECTIVES: To assess the ability of 2 ED immunization programs to vaccinate children and to measure the effect of the programs on immunization rates after the ED visit and 6 months later. DESIGN: A prospective cohort study. Emergency department patients were screened for immunization status, and vaccinations were offered to patients who either were documented to be eligible or were eligible by age and had no documented records. A systematic, sequential sample of those accepting vaccinations (study patients) was compared with a systematic, sequential sample of those not vaccinated (control subjects). Telephone interviews and medical record reviews were performed 6 months after the ED visit to verify dates of immunizations. Results were weighted to reflect the sampling frames of patients screened by the 2 programs. SETTING: Two EDs in New York City (in Manhattan and the Bronx) and the surrounding primary care offices. PATIENTS: Children (aged 0-6 years) screened for immunization status by the ED immunization program during a 10-week period; these included 210 children from the Manhattan ED (106 vaccinated in the ED) and 274 children from the Bronx ED (129 vaccinated in the ED). INTERVENTION: Emergency department immunizations. MAIN OUTCOME MEASURES: Proportion of patients (vaccinated, not vaccinated, and ED population) up-to-date for immunizations (1) at the time of the ED visit, (2) 1 day later, and (3) 6 months later. RESULTS: Two thirds of the patients in each ED had Medicaid, and one tenth were uninsured. At the time of the ED visit, 20% of the vaccinated children in each ED were actually up-to-date and were unnecessarily vaccinated; 74% (Manhattan ED) and 72% (Bronx ED) of the not vaccinated children were up-to-date (the remainder were later determined to have been eligible for vaccinations). One day after the ED visit, and 6 months later, the immunization rates of the vaccinated and not vaccinated children were similar. The results of the weighted analysis were as follows: for the entire ED population screened for immunization status, compared with up-to-date rates at the time of the ED visit, rates 1 day later were 11% (Manhattan ED) and 8% (Bronx ED) higher in each ED (P < .05); and rates 6 months later were the same in the Manhattan ED and 10% lower in the Bronx ED (P < .01). Eighteen percent of all children screened for immunization status were vaccinated; 10 to 15 children were screened and 2 to 4 children were vaccinated per 8-hour ED shift. CONCLUSIONS: This ED immunization program temporarily improved the immunization rates of the ED population, but substantial personnel time was required to achieve these small gains. Urban ED immunization programs are unlikely to be cost-effective.

The impact of WIC and AFDC in screening and delivering childhood immunizations.

Two publicly funded programs, the Special Supplemental Food Program for Women, Infants and Children (WIC) and Aid to Families with Dependent Children (AFDC), serve large numbers of children who may be at risk for poor immunization status. A review of the literature as well as conference abstracts and program reports for studies of immunization initiatives carried out in these settings was conducted. Although the available literature is limited, it does indicate that children in these programs have low immunization levels and that interventions to improve their immunization status can be successful. Measures to improve immunization status should be implemented through WIC and AFDC.

Immunizations: the promise and the pitfalls.

Despite our success with eradicating smallpox and possibly poliomyelitis, the United States faces unacceptably low immunization levels among preschool-age children. The problems associated with ensuring complete protection of children from vaccine-preventable diseases are multifaceted. Many children remain at risk for potentially fatal diseases, and the easy transmissibility of these agents increases the threat of disease outbreaks. This commentary examines steps needed to improve immunization levels and pediatric primary care, access.

Measles vaccination levels of children enrolled in WIC during the 1991 measles epidemic in New York City.

OBJECTIVES: This study assessed measles vaccination rates and risk factors for lack of vaccination among preschool children enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC) during the 1991 measles epidemic in New York City. METHODS: Children aged 12 to 59 months presenting for WIC certification between April 1 and September 30, 1991, at six volunteer WIC sites in New York City were surveyed. RESULTS: Of the 6181 children enrolled in the study, measles immunization status was ascertained for 6074 (98%). Overall measles coverage was 86% (95% confidence interval [CI] = +/- 1%) and at least 90% by 21 months of age (95% CI = +/- 1%). Young age of the child, use of a private provider, and Medicaid as a source of health care payment were risk factors for lack of vaccination (P < .001). CONCLUSIONS: During the peak of a measles epidemic, measles immunization rates were more than 80% by 24 months of age in a sample of WIC children. The ease of ascertaining immunization status and the size of the total WIC population underscore the importance of WIC immunization initiatives.

An outbreak of hepatitis A associated with a bakery, New York, 1994: the 1968 "West Branch, Michigan' outbreak repeated.

In a community hepatitis A outbreak in the Rochester, New York area, 64 of 79 (81%) people with anti-hepatitis A IgM-antibodies and onset of symptoms from 9 April-31 May 1994, recalled eating food obtained from a retail buyer's club. Eleven (65%) of 17 households with cases contained club members compared with 7 (21%) of 34 neighbourhood-matched control-households (matched odds ratio 8.5; 95% CI 1.7-41.6). Club employees who ate sugar-glazed baked goods were at fourfold increased risk for hepatitis. The source of infection was an IgM-positive baker who contaminated baked goods while applying sugar glaze. Computer-generated purchase lists implicated 11-12 March and 21-24 March as the most likely dates when contamination occurred. This investigation demonstrates the importance of food workers adhering to established hygiene practices. Computer-generated commercial datasets can be useful in epidemiologic investigations.

Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York State nursing homes.

Institutional risk factors associated with the occurrence of nosocomial respiratory or gastrointestinal disease outbreaks in 1992 were examined in a case-cohort study of New York State nursing homes conducted in 1993. Facility size, staffing patterns, and employee sick leave policies were the principal effects found in an unconditional logistic regression model. The risk of having respiratory or gastrointestinal disease outbreaks was greater in larger nursing homes (adjusted risk ratio (RR) = 1.71 for each 100-bed increase in size, 95% confidence interval (CI) 1.20-2.42), for nursing homes with a single nursing unit (adjusted RR = 3.93, 95% CI 0.98-15.71), or those with multiple nursing units with shared staff (adjusted RR = 2.51, 95% CI 1.07-5.89). The risk was less for nursing homes with paid employee sick leave policies (adjusted RR = 0.38, 95% CI 0.15-0.99). Other potential risk factors examined in this study, such as the ratio of beds per unit, type of sponsorship, daily review of laboratory test results, and the proportion of private beds and patient-to-staff ratio, were not significantly associated with the risk of disease outbreaks. The results of this study have direct implications for control of nosocomial disease outbreaks in nursing homes.

Human and rodent hantavirus infection in New York State: public health significance of an emerging infectious disease.

BACKGROUND: A case of hantavirus pulmonary syndrome with possible exposure in New York and/or Rhode Island was confirmed in February 1994. OBJECTIVE: To conduct four studies to determine the historical and geographic distribution of human and small-mammal infection with hantaviruses in New York State. METHODS: Enzyme-linked immunosorbent assays were performed on serum samples obtained from 130 humans during a 1978 babesiosis survey, 907 small mammals collected in New York State since 1984, 12 rodents collected in 1994 near the residences of the patients with hantavirus pulmonary syndrome, and 76 New York patients with acute respiratory distress syndrome-like illness (as suspected cases of hantavirus pulmonary syndrome). RESULTS: None of the human serum samples from the 1978 serosurvey showed evidence of hantavirus exposure by enzyme-linked immunosorbent assay. Statewide historical serum samples from white-footed mice showed evidence of Sin Nombre virus infection in 12.0% (97/809) and Seoul-like virus infection in 9.6% (78/809). Site-specific seropositivity rates were as high as 48.5% with Sin Nombre virus during 1 year (1984). Two of 12 mice captured near the residences of a human patient were positive for Sin Nombre virus by enzyme-linked immunosorbent assay, yet were negative for viral RNA by polymerase chain reaction. None of the patients with suspected hantavirus pulmonary syndrome was serologically reactive for Sin Nombre virus. CONCLUSIONS: We provide serologic evidence of small-mammal infection with hantaviruses in New York State as long ago as 1984. Human cases of hantavirus pulmonary syndrome are rare in New York, and data indicate that transmission to humans is probably infrequent. A unique set of host, agent, and environmental factors may be necessary to cause hantavirus pulmonary syndrome in humans.