Economic analysis of CDC's culture- and smear-based tuberculosis instructions for Filipino immigrants.

SETTING: In 2007, the US Centers for Disease Control and Prevention (CDC) revised its tuberculosis (TB) technical instructions for panel physicians who administer mandatory medical examinations among US-bound immigrants. Many US-bound immigrants come from the Philippines, a high TB prevalence country. OBJECTIVE: To quantify economic and health impacts of smear- vs. culture-based TB screening. DESIGN: Decision tree modeling was used to compare three Filipino screening programs: 1) no screening, 2) smear-based screening, and 3) culture-based screening. The model incorporated pre-departure TB screening results from Filipino panel physicians and CDC databases with post-arrival follow-up outcomes. Costs (2013 $US) were examined from societal, immigrant, US Public Health Department and hospitalization perspectives. RESULTS: With no screening, an annual cohort of 35 722 Filipino immigrants would include an estimated 450 TB patients with 264 hospitalizations, at a societal cost of US$9.90 million. Culture-based vs. smear-based screening would result in fewer imported cases (80.9 vs. 310.5), hospitalizations (19.7 vs. 68.1), and treatment costs (US$1.57 million vs. US$4.28 million). Societal screening costs, including US follow-up, were greater for culture-based screening (US$5.98 million) than for smear-based screening (US$3.38 million). Culture-based screening requirements increased immigrant costs by 61% (US$1.7 million), but reduced costs for the US Public Health Department (22%, US$750 000) and of hospitalization (70%, US$1 020 000). CONCLUSION: Culture-based screening reduced imported TB and US costs among Filipino immigrants.

Clinical outcomes of bacteremic pneumococcal pneumonia in the era of antibiotic resistance.

Limited data are available about the impact of antimicrobial resistance on clinical outcomes in cases of pneumococcal pneumonia. This was studied in 146 persons hospitalized with invasive pneumonia due to Streptococcus pneumoniae (minimum inhibitory concentration of cefotaxime, > or = .25 microg/mL) who were identified through population-based active surveillance for the period of November 1994 through April 1996. Compared with matched control subjects who had infection with more-susceptible S. pneumoniae, the proportion of subjects who died or who were admitted to an intensive care unit did not differ significantly. Multivariable analysis showed no significant contribution of antimicrobial resistance to mortality or the requirement for care in an intensive care unit. The ability to detect an effect of antimicrobial resistance on these important outcome measures may have been influenced by aggressive multidrug empirical therapy in this group of hospitalized patients. Factors other than resistance, such as severity of illness at presentation and advance directive status ("do not resuscitate" orders), appear to have a stronger influence on pneumococcal pneumonia outcomes.

Fever and multisystem organ failure associated with 17D-204 yellow fever vaccination: a report of four cases.

BACKGROUND: In 1998, the US Centers for Disease Control and Prevention was notified of three patients who developed severe illnesses days after yellow fever vaccination. A similar case occurred in 1996. All four patients were more than 63 years old. METHODS: Vaccine strains of yellow fever virus, isolated from the plasma of two patients and the cerebrospinal fluid of one, were characterised by genomic sequencing. Clinical samples were subjected to neutralisation assays, and an immunohistochemical analysis was done on one sample of liver obtained at biopsy. FINDINGS: The clinical presentations were characterised by fever, myalgia, headache, and confusion, followed by severe multisystemic illnesses. Three patients died. Vaccine-related variants of yellow fever virus were found in plasma and cerebrospinal fluid of one vaccinee. The convalescent serum samples of two vaccinees showed antibody responses of at least 1:10240. Immunohistochemical assay of liver tissue showed yellow fever antigen in the Kuppfer cells of the liver sample. INTERPRETATION: The clinical features, their temporal association with vaccination, recovery of vaccine-related virus, antibody responses, and immunohistochemical assay collectively suggest a possible causal relation between the illnesses and yellow fever vaccination. Yellow fever remains an important cause of illness and death in South America and Africa; hence, vaccination should be maintained until the frequency of these events is quantified.

Malaria, intestinal parasites, and schistosomiasis among Barawan Somali refugees resettling to the United States: a strategy to reduce morbidity and decrease the risk of imported infections.

In 1997, enhanced health assessments were performed for 390 (10%) of approximately 4,000 Barawan refugees resettling to the United States. Of the refugees who received enhanced assessments, 26 (7%) had malaria parasitemia and 128 (38%) had intestinal parasites, while only 2 (2%) had Schistosoma haematobium eggs in the urine. Mass therapy for malaria (a single oral dose of 25 mg/kg of sulfadoxine-pyrimethamine) was given to all Barawan refugees 1-2 days before resettlement. Refugees >2 years of age and nonpregnant women received a single oral dose of 600 mg albendazole for intestinal parasite therapy. If mass therapy had not been provided, upon arrival in the United States an estimated 280 (7%) refugees would have had malaria infections and 1,500 (38%) would have had intestinal parasites. We conclude that enhanced health assessments provided rapid on-site assessment of parasite prevalence and helped decrease morbidity among Barawan refugees, as well as, the risk of imported infections.

Impact of penicillin susceptibility on medical outcomes for adult patients with bacteremic pneumococcal pneumonia.

The impact of penicillin susceptibility on medical outcomes for adult patients with bacteremic pneumococcal pneumonia was evaluated in a retrospective cohort study conducted during population-based surveillance for invasive pneumococcal disease in the greater Atlanta region during 1994. Of the 192 study patients, 44 (23%) were infected with pneumococcal strains that demonstrated some degree of penicillin nonsusceptibility. Compared with patients infected with penicillin-susceptible pneumococcal strains, patients whose isolates were nonsusceptible had a significantly greater risk of in-hospital death due to pneumonia (relative risk [RR], 2.1; 95% confidence interval [CI], 1-4.3) and suppurative complications of infection (RR, 4.5; 95% CI, 1-19.3), although only risk of suppurative complications remained statistically significant after adjustment for baseline differences in severity of illness. Among adults with bacteremic pneumococcal pneumonia, infection with penicillin-nonsusceptible pneumococci is associated with an increased risk of adverse outcome.

An outbreak of acute respiratory disease caused by Mycoplasma pneumoniae and adenovirus at a federal service training academy: new implications from an old scenario.

Outbreaks of Mycoplasma pneumoniae and adenovirus have been reported in military institutions for several decades. During a recent outbreak in a federal service training academy, we performed an epidemiological and laboratory investigation to better characterize and control the outbreak. Of 586 students responding to a questionnaire, 317 (54%) reported having a respiratory illness during the outbreak period. Among 42 students who underwent complete laboratory testing, 24 (57%) had evidence of M. pneumoniae infection, 8 (19%) had evidence of adenovirus infection, and 4 (10%) had evidence of both. Polymerase chain reaction testing of oropharyngeal swabs revealed more acute M. pneumoniae infections (57% positive) than did serology or culture. Multivariate analysis revealed that visiting the campus health clinic >3 times for a nonrespiratory condition, such as injury, was a significant risk factor for illness among freshmen early in the course of the outbreak, whereas having an ill roommate was a risk factor throughout the duration of the outbreak.

Reduction in functional antibody activity against Streptococcus pneumoniae in vaccinated elderly individuals highly correlates with decreased IgG antibody avidity.

The pneumococcal polysaccharide vaccine is recommended as a means of preventing invasive disease in the elderly. We compared responses to the 23-valent polysaccharide vaccine in 46 previously unvaccinated, healthy, institutionalized elderly persons (mean age, 85.5 years) with those in 12 healthy younger adults (mean age, 37 years) by measuring prevaccination and postvaccination serum IgG antibody concentrations (by ELISA), functional antibody activity (by opsonophagocytosis), IgG antibody avidity, and passive protection in mice. Postvaccination IgG antibody concentrations for two serotypes (6B and 19F) of the five studied (4, 6B, 14, 19F, and 23F) were significantly lower in elderly than in younger adults; however, opsonophagocytic activity was significantly reduced for all serotypes in the elderly. Sera with reduced opsonophagocytic activity (titer, <64) correlated with low IgG antibody avidity and protected mice poorly against pneumococcal challenge. In elderly persons receiving polysaccharide vaccination, there was a significant reduction in the functionality of postvaccination antibodies, and this appeared to increase with advanced age.

GeoSentinel: the global emerging infections sentinel network of the International Society of Travel Medicine.

GeoSentinel is a network of 22 member travel/tropical medicine clinics (14 in the United States and 8 in other countries) initiated in 1995 by the International Society of Travel Medicine (ISTM). GeoSentinel is based on the concept that these clinics are ideally situated to effectively detect geographic and temporal trends in morbidity among travelers. The core surveillance tool is a single-page faxable form submitted to a central data site for each post-travel patient, including immigrants, refugees, and foreign visitors. Diagnoses are entered either as specific etiologies or as syndromes and are then linked to geographic locations, reference dates, and clinical presentations. In addition, electronic communication with the larger body of worldwide ISTM member clinics is periodically done to obtain broader data collection in response to specific inquiries. The scope of GeoSentinel has broadened from the initial vision of a provider-based sentinel network tracking emerging infections at their point of entry into developed countries. Its present goals are (1) to monitor global trends in disease occurrence among travelers; (2) to ascertain risk factors and morbidity in groups of travelers categorized by travel purpose and type of traveler; (3) to respond to urgent public health queries; (4) to develop educational priorities for travelers' health; and (5) to effect a rapid response by electronically disseminating alerts to surveillance sites, to all ISTM members in 55 countries, and to public health authorities. In addition, a major byproduct of the network, and now one of its strongest assets, has been the growth of partnerships between ISTM, Centers for Disease Control and Prevention and health-care providers around the world, as well as other medical societies, government, and private organizations. The demographic data, travel patterns, and clinical presentations for the first 2813 patient records analyzed from the GeoSentinel sites are summarized in this paper.

Pneumococcal drug resistance: the new "special enemy of old age".

Streptococcus pneumoniae is a leading cause of illness and death among the elderly. The recent emergence of drug-resistant strains has complicated selection of antimicrobial therapy for suspected pneumococcal infections. In some areas of North America, nearly 40% of pneumococcal isolates from the blood or cerebrospinal fluid of persons > or = 65 years old had reduced susceptibility to penicillin. Of all penicillin-resistant infections, >30% occur in persons > or = 65 years old. The increasing prevalence of drug-resistant pneumococci and recent outbreaks of pneumococcal disease in chronic-care facilities emphasize the importance of efforts to prevent these infections in the elderly. Limiting selection for drug-resistant strains through judicious use of antimicrobial drugs and preventing invasive pneumococcal infections through increased use of pneumococcal vaccine form the foundation of these efforts.

Geocoding and linking data from population-based surveillance and the US Census to evaluate the impact of median household income on the epidemiology of invasive Streptococcus pneumoniae infections.

The emergence of drug-resistant Streptococcus pneumoniae poses new clinical challenges and may also reflect a change in the epidemiology of S. pneumoniae infections. A variety of studies have shown that drug-resistant S. pneumoniae infections are linked to antimicrobial use. It has been hypothesized that persons of high socioeconomic status are at increased risk for a drug-resistant infection because of greater access to antimicrobial drugs. To assess whether median household income is associated with increased risk of penicillin-nonsusceptible S. pneumoniae infections, the authors geocoded and linked data from population-based surveillance for invasive pneumococcal disease with data from the 1990 US Census. Among invasive pneumococcal isolates from Atlanta, Georgia, in 1994, increasing proportions of penicillin-nonsusceptible isolates were associated with higher median household incomes (chi2 for trend, 15.17; p=0.002). Despite higher rates of invasive pneumococcal disease among blacks and persons who resided within lower median household income areas, white patients in areas with higher median household income had a higher risk of being infected with strains that were not susceptible to penicillin (Wilcoxon rank sum, Z=2.66, p=0.008). These findings demonstrated the utility of geocoding and US Census data in describing the epidemiology of drug-resistant S. pneumoniae and also provided more evidence that socioeconomic factors may influence the development of drug resistance.

Outbreak of pneumonia in a long-term care facility: antecedent human parainfluenza virus 1 infection may predispose to bacterial pneumonia.

OBJECTIVES: To determine the causes of an outbreak of lobar pneumonia. DESIGN: Matched (1:2) case-control study. SETTING: A 70-bed chronic care facility for older people. PARTICIPANTS: Residents of the facility. RESULTS: Ten residents developed pneumonia over a 10-day period. Two residents died. One case-patient had Streptococcus pneumoniae bacteremia; another had polymerase chain reaction evidence of S. pneumoniae infection. No other etiologic agent was identified. Only four of 10 case-patients had received routine diagnostic cultures of blood or sputum before the administration of antibiotics. Symptoms of upper respiratory illness (URI) among residents before the pneumonia outbreak corresponded with elevation of antibodies to human parainfluenza virus 1 (HPIV1). In a matched case-control study, six of 10 case-patients, compared with five of 20 controls, had symptoms of URI during the preceding month (matched odds ratio (MOR) = 4.5, 95% CI = 0.8-33). Nine case-patients had serum available, and five of these had both serologic evidence of recent HPIV1 infection and recent URI, compared with two of 18 controls (MOR = 9.0, 95% CI = 1.2-208). Only three residents had documentation of pneumococcal vaccination. CONCLUSIONS: Noninfluenza viral infections may play a role in the pathogenesis of some bacterial pneumonias. S. pneumoniae was the cause of at least two pneumonias; lack of preantibiotic cultures may have interfered with isolation of S. pneumoniae in others. Recent HPIV1 infection was epidemiologically linked to subsequently developing pneumonia. Spread of HPIV1 in the facility may have contributed to increased susceptibility to S. pneumoniae and, potentially, to other bacterial pathogens.

The use of Streptococcus pneumoniae nasopharyngeal isolates from healthy children to predict features of invasive disease.

BACKGROUND: The role of sampling nasopharyngeal carriage isolates of Streptococcus pneumoniae to determine characteristics of isolates causing invasive disease has not been established. METHODS: Data were compared from two 1995 studies of S. pneumoniae in Metropolitan Toronto and Peel Region (population, 3.1 million). The first was a prospective survey of nasopharyngeal (NP) carriage in child care centers. The second was a prospective surveillance for all cases of invasive disease. RESULTS: There were 545 NP S. pneumoniae isolates obtained from 532 children and 96 cases of invasive S. pneumoniae disease in children. The prevalences of reduced antibiotic susceptibility in the NP carriage and invasive studies, respectively, were: penicillin (16% vs. 11%, P=0.29); erythromycin (12% vs. 7%, P=0.25); and multiresistant (16% vs. 12%, P=0.34). The power to rule out a difference between the groups was <30% for each comparison. Trimethoprim/sulfamethoxazole resistance was more common in NP carriage isolates than invasive isolates (38% vs. 23%, P=0.02). Serotype 14 was more common in invasive isolates, whereas serogroup 6 was more common in NP carriage isolates. Antibiotic-resistant isolates were predominantly serogroups 6, 19 and 23 in both studies. CONCLUSIONS: Nasopharyngeal carriage isolates of S. pneumoniae reflect the antibiotic susceptibility rates of invasive isolates found in the same period for most antibiotics. However, even a large study like this may have limited power to detect a difference. The most common NP carriage serotypes are the same as the invasive isolates, although the rank order of specific serotypes is different. Routine surveys of S. pneumoniae NP carriage are not feasible because of the cost of serotyping and limited power of the observations, unless sample sizes are extremely large.

Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people.

CONTEXT: Clinical, epidemiologic, and policy considerations support updating the cost-effectiveness of pneumococcal vaccination for elderly people and targeting the evaluation only to prevention of pneumococcal bacteremia. OBJECTIVE: To assess the implications for medical costs and health effects of vaccination against pneumococcal bacteremia in elderly people. DESIGN: Cost-effectiveness analysis of pneumococcal vaccination compared with no vaccination, from a societal perspective. SETTING AND PARTICIPANTS: The elderly population aged 65 years and older in the United States in 3 geographic areas: metropolitan Atlanta, Ga; Franklin County, Ohio; and Monroe County, New York. MAIN OUTCOME MEASURES: Incremental medical costs and health effects, expressed in quality-adjusted life-years per person vaccinated. RESULTS: Vaccination was cost saving, ie, it both reduced medical expenses and improved health, for all age groups and geographic areas analyzed in the base case. For people aged 65 years and older, vaccination saved $8.27 and gained 1.21 quality-adjusted days of life per person vaccinated. Vaccination of the 23 million elderly people unvaccinated in 1993 would have gained about 78000 years of healthy life and saved $194 million. In univariate sensitivity analysis, the results remained cost saving except for doubling vaccination costs, including future medical costs of survivors, and lowering vaccination effectiveness. With assumptions most unfavorable to vaccination, cost per quality-adjusted life-year ranged from $35 822 for ages 65 to 74 years to $598 487 for ages 85 years and older. In probabilistic sensitivity analysis, probability intervals were more narrow, with less than 5% probability that the ratio for ages 85 years and older would exceed $100000. CONCLUSIONS: Pneumococcal vaccination saves costs in the prevention of bacteremia alone and is greatly underused among the elderly population, on both health and economic grounds. These results support recent recommendations of the Advisory Committee on Immunization Practices and public and private efforts under way to improve vaccination rates.

Secular trends in bloodstream infection caused by antimicrobial-resistant bacteria in New Jersey hospitals, 1991 to 1995.

INTRODUCTION: Antimicrobial resistance among bacteria is an increasing public health problem. In 1991, New Jersey was the first state to establish statewide, hospital-based surveillance for antimicrobial-resistant bacteria. METHODS: Each month, all 96 nonfederal New Jersey hospital laboratories complete a form listing the species identity and drug susceptibility results for selected antimicrobial-resistant bacteria isolated from blood cultures from hospital inpatients. Penicillin-resistant Streptococcus pneumoniae and aminoglycoside-resistant gram-negative rods were studied from 1991 to 1995. Vancomycin-resistant enterococci and imipenem-resistant gram-negative rods were studied from 1992 through 1995. RESULTS: From 1992 to 1995, the vancomycin-resistant enterococci bloodstream infection prevalence rate increased from 11 to 29 per 100,000 hospital admissions (p < 0.001); the rate was higher at larger hospitals, urban and inner-city hospitals, and teaching hospitals. From 1991 to 1995, the penicillin-resistant S. pneumoniae bloodstream infection rate increased from 1.1 to 9.9 per 100,000 admissions (p < 0.001). In contrast, bloodstream infection rates did not change significantly for imipenem-resistant (12.5 during 1992 and 14.1 during 1995, p = 0.4) or aminoglycoside-resistant (8.0 during 1991 and 6.8 during 1995, p = 0.4) gram-negative rods. CONCLUSIONS: We found that vancomycin-resistant enterococci and penicillin-resistant S. pneumoniae, but neither of two groups of antimicrobial-resistant gram-negative rods, are increasing rapidly in prevalence in New Jersey. Continued monitoring and interventions to slow these increases are needed.

The continued emergence of drug-resistant Streptococcus pneumoniae in the United States: an update from the Centers for Disease Control and Prevention's Pneumococcal Sentinel Surveillance System.

As part of ongoing national surveillance, serotyping and antimicrobial susceptibility testing were done on all pneumococcal isolates recovered from normally sterile body sites of patients at 12 hospitals in 11 states during 1993-1994. Of 740 isolates, 14.1% were penicillin-nonsusceptible Streptococcus pneumoniae (PNSP; MIC > or = 0.1 microgram/mL), 3.2% were penicillin-resistant (MIC > or = 2.0 micrograms/mL), and 25.5% were nonsusceptible to more than one antimicrobial agent. PNSP were more prevalent among children < 6 years old (18.4%) than patients > or = 18 years old (11.7%) and among white persons (16.2%) than black persons (12.1%). PNSP represented 15 serotypes, but 89% of PNSP were serotypes in the 23-valent pneumococcal vaccine. The proportion of isolates with reduced susceptibility and the number of serotypes of nonsusceptible strains are increasing in the United States. Improved local surveillance for PNSP infections, judicious use of antibiotics, and development and use of effective pneumococcal vaccines will be required to treat and prevent disease caused by these strains.

Schistosomiasis in Lake Malawi.

BACKGROUND: In 1992 two US Peace Corps volunteers (PCVs) developed central nervous system schistosomiasis due to infection with Schistosoma haematobium following recreational water exposure at Cape Maclear on Lake Malawi, an African lake considered by many to be free of schistosomiasis. To determine the transmission potential and risk for aquiring schistosomiasis in Lake Malawi, a cross-sectional survey of resident expatriates and visitors to Malawi was done during March and April, 1993. METHODS: A volunteer cohort of expatriates and visitors representing a cross-section of Malawi's foregn population answered detailed questions about freshwater contact and provided blood specimens to determine the seroprevalence of S haematobium and S mansoni by ELISA and immunoblot analyses. A survey for vector snails was conducted along Lake Malawi's southwestern shore. FINDINGS: The study population of 955 included 305 US citizens and 650 non-US foreign nationals. 303 of the study population had serological evidence of current or past schistosome infection. Seroprevalence was 32% (141/440) among expatriates whose freshwater exposure was limited to Lake Malawi; S haematobium antibodies were found in 135 of 141 (96%) seropositive specimens. Risk of seropositivity increased with the number of freshwater exposures at Lake Malawi resorts. Although many resort areas in the southwestern lake region posed a significant risk, Cape Maclear was the location most strongly associated with seropositivity (OR 2.9, 95% Cl 1.6-5.1). Schistosome-infected Bulinus globosus, the snail vector of S haematobium in Malawi, were found at Cape Maclear and other locations along the lakeshore. INTERPRETATION: S haematobium infection is highly prevalent among expatriates and tourists in Malawi. Recreational water contact at popular resorts on Lake Malawi is the most likely source of infection. Transmission of schistosomiasis is occurring in Lake Malawi, a previously under-recognised site of transmission.

PIP: Schistosomiasis is a parasitic infection caused by trematodes. Humans are infected through skin contact with free-swimming cercariae which develop in freshwater snails. Schistosomiasis has been endemic to Malawi for several decades, but the open waters and shores of Lake Malawi have long been thought to be risk-free with regard to schistosomiasis transmission. However, in 1992, two US Peace Corps volunteers developed central nervous system schistosomiasis due to infection with Schistosoma haematobium following recreational water exposure at Cape Maclear on Lake Malawi. In light of these infections, a cross-sectional survey of resident expatriates and visitors to Malawi was subsequently conducted during March-April 1993 to determine the transmission potential and risk for acquiring schistosomiasis in the lake. 305 US citizens and 650 non-US foreign nationals participated in the study. Serological evidence of current or past schistosome infection was identified in 303 subjects. Indeed, seroprevalence was 32% among expatriates whose freshwater exposure was limited to Lake Malawi; S. haematobium antibodies were found in 135 of 141 seropositive specimens. The risk of seropositivity increased with the number of freshwater exposures at Lake Malawi resorts. While many resort areas in the southwestern lake region posed a significant risk, Cape Maclear was the location most strongly associated with seropositivity. Schistosome-infected Bulinus globosus, the snail vector of S. haematobium in Malawi, were found at Cape Maclear and other locations along the lakeshore.

Outbreak of Legionnaires' disease among cruise ship passengers exposed to a contaminated whirlpool spa.

BACKGROUND: Outbreaks of travel-related Legionnaires' disease present a public-health challenge since rapid, sensitive, and specific diagnostic tests are not widely used and because detection of clusters of disease among travellers is difficult. We report an outbreak of Legionnaires' disease among cruise ship passengers that occurred in April, 1994, but that went unrecognised until July, 1994. METHODS: After rapid diagnosis of Legionnaires' disease in three passengers by urine antigen testing, we searched for additional cases of either confirmed (laboratory evidence of infection) or probable Legionnaires' disease (pneumonia of undetermined cause). A case-control study was conducted to compare exposures and activities on the ship and in ports of call between each case-passenger and two or three matched control-passengers. Water samples from the ship, from sites on Bermuda, and from the ship's water source in New York City were cultured for legionellae and examined with PCR. FINDINGS: 50 passengers with Legionnaires' disease (16 confirmed, 34 probable) were identified from nine cruises embarking between April 30 and July 9, 1994. Exposure to whirlpool spas was strongly associated with disease (odds ratio 16.2, 95% Cl 2.8-351:7); risk of acquiring Legionnaires' disease increased by 64% (95% Cl 12-140) for every hour spent in the spa water. Passengers spending time around the whirlpool spas, but not in the water, were also significantly more likely to have acquired infection. Legionella pneumophila serogroup 1 was isolated only from the sand filter in the ship's whirlpool spa. This isolate matched a clinical isolate from the respiratory secretions of a case-passenger as judged by monoclonal antibody subtyping and by arbitrarily primed PCR. INTERPRETATION: This investigation shows the benefit of obtaining a recent travel history, the usefulness or urine antigen testing for rapid diagnosis of legionella infection, and the need for improved surveillance for travel-related Legionnaires' disease. New strategies for whirlpool spa maintenance and decontamination may help to minimise transmission of legionellae from these aerosol-producing devices.

Minimizing the impact of drug-resistant Streptococcus pneumoniae (DRSP). A strategy from the DRSP Working Group.

Emergence of drug-resistant Streptococcus pneumoniae (DRSP) presents a challenge to the medical and public health communities since the magnitude of the problem is not known, the clinical impact of DRSP infections is not well described, national vaccination rates are low, and antimicrobial drugs are often used excessively and inappropriately. To address the problem of DRSP, a working group by Centers for Disease Control and Prevention was formed in June 1994 consisting of public health practitioners, health care providers, and clinical laboratorians representing state and federal agencies and various professional organizations. Through periodic open meetings, the working group has developed a strategy for surveillance, investigation, prevention, and control of infections due to DRSP. The strategy focuses on (1) implementing an electronic laboratory-based surveillance (ELBS) system for reporting invasive DRSP infections and providing clinically relevant feedback to clinicians, (2) identifying risk factors and outcomes of DRSP infection, (3) increasing pneumococcal vaccination, and (4) promoting judicious antimicrobial drug use. Data received through ELBS will be used to make timely estimates of the community-specific prevalence of drug-resistant pneumococci. National, regional, and local trends will be made available to health care providers and clinicians to promote optimal antimicrobial drug use and increased vaccination in targeted areas. Once in operation, the ELBS network will be adaptable to other diseases, improving the comprehensiveness and timeliness of public health surveillance. The intended outcome of the strategy is to reduce complications of DRSP infection, such as long-term sequelae of infection, health care expenditures, morbidity, and mortality.

Cutaneous manifestations of African trypanosomiasis.

BACKGROUND: Dermatologists may evaluate patients with African trypanosomiasis. The currently available dermatologic literature does not review the cutaneous manifestations of African trypanosomiasis. OBSERVATION: We describe an American man who acquired African trypanosomiasis while hunting in Tanzania, and we review and classify the cutaneous findings of this disease. This article reports the results of the first biopsy of a trypanid and depicts trypanosomes on the first touch preparation done from a trypanid biopsy specimen. Rare color photographs of trypanids are shown. CONCLUSIONS: Recognition of the unique cutaneous manifestations of African trypanosomiasis may allow dermatologists to make a rapid diagnosis that is essential for timely treatment and survival. Classifying the disease with primary chancriform, secondary hemolymphatic, and tertiary central nervous system stages should improve the understanding of the complex natural history of African trypanosomiasis.