Missed opportunities to prevent tuberculosis in foreign-born persons, Connecticut, 2005-2008.

SETTING: Factors that influence testing for latent tuberculosis infection (LTBI) among foreign-born persons in Connecticut are not well understood. OBJECTIVE: To identify predictors for LTBI testing and challenges related to accessing health care among the foreign-born population in Connecticut. DESIGN: Foreign-born Connecticut residents with confirmed or suspected tuberculosis (TB) disease during June 2005-December 2008 were interviewed regarding health care access and immigration status. Predictors for self-reported testing for LTBI after US entry were determined. RESULTS: Of 161 foreign-born persons interviewed, 48% experienced TB disease within 5 years after arrival. One third (51/156) reported having undergone post-arrival testing for LTBI. Although those with established health care providers were more likely to have reported testing (aOR 4.49, 95%CI 1.48-13.62), only 43% of such persons were tested. Undocumented persons, the majority of whom lacked a provider (53%), were less likely than documented persons to have reported testing (aOR 0.20, 95%CI 0.06-0.67). Hispanic permanent residents (immigrants and refugees) and visitors (persons admitted temporarily) were more likely than non-Hispanics in the respective groups to have reported testing (OR 5.25, 95%CI 1.51-18.31 and OR 7.08, 95%CI 1.30-38.44, respectively). CONCLUSIONS: The self-reported rate of testing for LTBI among foreign-born persons in Connecticut with confirmed or suspected TB was low and differed significantly by ethnicity and immigration status. Strategies are needed to improve health care access for foreign-born persons and expand testing for LTBI, especially among non-Hispanic and undocumented populations.

Evaluation of Gram-positive rod surveillance for early anthrax detection.

Since 2003, Connecticut laboratories have reported Gram-positive rod (GPR) isolates detected within 32 h of inoculation from blood or cerebrospinal fluid. The objectives were to rapidly identify inhalational anthrax and unusual Clostridium spp. infections, and to establish round-the-clock laboratory reporting of potential indicators of bioterrorism. From 2003 to 2006, Connecticut's GPR surveillance system identified 1134 isolates, including 657 Bacillus spp. (none B. anthracis) and 241 Clostridium spp. Reporting completeness and timeliness improved to 93% and 92%, respectively. Baseline rates of Bacillus spp., Clostridium spp. and other GPR findings have been established and are stable. Thus far, no cases of anthrax and no unusual clusters of Clostridium spp. have been detected by the GPR surveillance system. This system would probably have confirmed the inhalational anthrax case in Pennsylvania in 2006 3 days sooner than traditional reporting. Using audits and ongoing evaluation, the system has evolved into a highly functional 24/7 laboratory telephone reporting system with almost complete reporting.

Outbreak of tuberculosis in a correctional facility: consequences of missed opportunities.

In May 2006, the Department of Public Health investigated a tuberculosis (TB) outbreak at a correctional facility after two recently discharged inmates were diagnosed with TB. Based on epidemiological and genotyping data, one infectious patient was determined to be the source of infection for the other. Despite prolonged symptoms and abnormal chest radiographs, the index patient was not diagnosed while incarcerated. Among the estimated 910 exposed inmates tested, 53 (5.8%) had newly positive tuberculin skin tests (TSTs). Ten (2.1%) of 485 corrections staff tested converted their TSTs. This investigation highlights the consequences of missed TB diagnoses in prisons.

Tuberculosis in a low-incidence US area: local consequences of global disruptions.

SETTING: Tuberculosis (TB) in the United States is increasingly concentrated among foreign-born persons. The northeastern states, including Connecticut, are among those with the highest proportion of foreign-born patients. METHODS: This retrospective analysis of surveillance data from Connecticut for 1996 through 2005 compared TB case rates and risk factors among US-born and foreign-born persons. RESULTS: Between 1996 and 2005, TB cases declined by 8.7% in foreign-born persons and by 53.6% in US-born persons. The median annual incidence rate for foreign-born persons was 19.7 cases per 100000 population compared with 1.5 for US-born persons. Refugees had the highest TB rate (116 cases/100000) in the first year of their arrival. Resistance to any drug was more common among foreign-born persons (15.0%) than among US-born persons (9.3%). Although the proportion of multidrug-resistant TB was highest among foreign-born persons with prior TB (5.6%), most cases occurred in those without prior TB. Risk factors for TB, such as human immunodeficiency virus infection, drug use, incarceration and homelessness, were more common among US-born TB patients than among foreign-born patients. CONCLUSIONS: Although TB case rates for US-born persons in Connecticut have declined dramatically, foreign-born persons, including refugees fleeing conflict, contribute disproportionately to the TB burden. Future efforts to eliminate TB must be directed toward immigrants and refugees.

Hemolytic-Uremic Syndrome and Escherichia coli O121 at a Lake in Connecticut, 1999.

OBJECTIVE: Non-O157 Shiga toxin-producing Escherichia coli (STEC) have emerged as an important public health problem. Outbreaks attributed to non-O157 STEC rarely are reported. In 1999, follow-up of routine surveillance reports of children with hemolytic- uremic syndrome (HUS) identified a small cluster of 3 cases of HUS, all of whom had spent overlapping time in a Connecticut lake community in the week before onset of symptoms. We conducted an investigation to determine the magnitude and source of the outbreak and to determine risk factors associated with the transmission of illness. METHODS: We conducted a cohort study and an environmental investigation. The study population included all people who were at the lake in a defined geographic area during July 16-25, 1999. This time and area were chosen on the basis of interviews with the 3 HUS case-patients. A case was defined as diarrhea (>/=3 loose stools/d for >/=3 days) in a person who was at the lake during July 16-25, 1999. Stool samples were requested from any lake resident with diarrheal illness. Stools were cultured for Salmonella, Shigella, Campylobacter, and E coli O157. Broth cultures of stools were tested for Shiga toxin. Case-patients were asked to submit a serum specimen for antibody testing to lipopolysaccharides of selected STEC. Environmental samples from sediment, drinking water, lake water, and ice were obtained and cultured for E coli and tested for Shiga toxin. An environmental evaluation of the lake was conducted to identify any septic, water supply system, or other environmental condition that could be related to the outbreak. RESULTS: Information was obtained for 436 people from 165 (78%) households. Eleven (2.5%) people had illnesses that met the case definition, including the 3 children with HUS. The attack rate was highest among those who were younger than 10 years and who swam in the lake on July 17 or 18 (12%; relative risk [RR]: 7.3). Illness was associated with swimming (RR = 8.3) and with swallowing water while swimming (RR = 7.0) on these days. No person who swam only after July 18 developed illness. Clinical characteristics of case-patients included fever (27%), bloody diarrhea (27%), and severe abdominal cramping (73%). Only the 3 children with HUS required hospitalization. No bacterial pathogen was isolated from the stool of any case-patient. Among lake residents outside the study area, E coli O121:H19 was obtained from a Shiga toxin-producing isolate from a toddler who swam in the lake. Serum was obtained from 7 of 11 case-patients. Six of 7 case-patients had E coli O121 antibody titers that ranged from 1:320 to >1:20 480. E coli indicative of fecal contamination was identified from sediment and water samples taken from a storm drain that emptied into the beach area and from a stream bed located between 2 houses, but no Shiga toxin-producing strain was identified. CONCLUSIONS: Our findings are consistent with a transient local beach contamination in mid-July, probably with E coli O121:H19, which seems to be able to cause severe illness. Without HUS surveillance, this outbreak may have gone undetected by public health officials. This outbreak might have been detected sooner if Shiga toxin screening had been conducted routinely in HUS cases. Laboratory testing that relies solely on the inability of an isolate to ferment sorbitol will miss non-O157 STEC, such as E coli O121. Serologic testing can be used as an adjunct in the diagnosis of STEC infections. Lake-specific recommendations included education, frequent water sampling, and alternative means for toddlers to use lake facilities.

Population-based incidence and characteristics of community-onset Staphylococcus aureus infections with bacteremia in 4 metropolitan Connecticut areas, 1998.

This study retrospectively analyzed the magnitude and epidemiology of community-onset Staphylococcus aureus (COSA) infections and methicillin-resistant S. aureus (MRSA) infections in 4 Connecticut metropolitan areas (population, 1.1 million). The study looked at hospital medical records of persons admitted with S. aureus bacteremia in 1998. COSA was categorized as "health care associated," "with underlying medical condition," or "no underlying medical condition." Overall, 48% of S. aureus bacteremic infections were COSA (incidence, 17 cases/100,000 persons). Incidence increased with age and higher population density. In all, 62% of infections were health care associated; 85% of the remaining cases had underlying medical conditions. MRSA accounted for 16% of health care-associated cases and cases with underlying conditions but no cases with no underlying conditions. COSA bacteremic infections are as common as those due to pneumococci. MRSA is a well-established cause of COSA among persons at high medical risk for S. aureus infection. Additional study to understand community-onset MRSA acquisition is needed.

Retrospective validation of a surveillance system for unexplained illness and death: New Haven County, Connecticut.

OBJECTIVES: This study investigated retrospective validation of a prospective surveillance system for unexplained illness and death due to possibly infectious causes. METHODS: A computerized search of hospital discharge data identified patients with potential unexplained illness and death due to possibly infectious causes. Medical records for such patients were reviewed for satisfaction of study criteria. Cases identified retrospectively were combined with prospectively identified cases to form a reference population against which sensitivity could be measured. RESULTS: Retrospective validation was 41% sensitive, whereas prospective surveillance was 73% sensitive. The annual incidence of unexplained illness and death due to possibly infectious causes during 1995 and 1996 in the study county was conservatively estimated to range from 2.7 to 6.2 per 100,000 residents aged 1 to 49 years. CONCLUSIONS: Active prospective surveillance for unexplained illness and death due to possibly infectious causes is more sensitive than retrospective surveillance conducted through a published list of indicator codes. However, retrospective surveillance can be a feasible and much less labor-intensive alternative to active prospective surveillance when the latter is not possible or desired.

West Nile virus serosurvey and assessment of personal prevention efforts in an area with intense epizootic activity: Connecticut, 2000.

West Nile virus (WNV) can cause large outbreaks of febrile illness and severe neurologic disease. This study estimates the seroprevalence of WNV infection and assesses risk perception and practices regarding potential exposures to mosquitoes of persons in an area with intense epizootics in 1999 and 2000. A serosurvey of persons aged > or = 12 years was conducted in southwestern Connecticut during October 10-15, 2000, using household-based stratified cluster sampling. Participants completed a questionnaire regarding concern for and personal measures taken with respect to WNV and provided a blood sample for WNV testing. Seven hundred thirty persons from 645 households participated. No person tested positive for WNV (95% CI: 0-0.5%). Overall, 44% of persons used mosquito repellent, 56% practiced > or = two personal precautions to avoid mosquitoes, and 61% of households did > or = two mosquito-source reduction activities. In multivariate analyses, using mosquito repellent was associated with age < 50 years, using English as the primary language in the home, being worried about WNV, being a little worried about pesticides, and finding mosquitoes frequently in the home (P<0.05). Females (OR = 2.0; CI = 1.2-2.9) and persons very worried about WNV (OR = 3.8; CI = 2.2-6.5) were more likely to practice > or = two personal precautions. Taking > or = two mosquito source reductions was associated with persons with English as the primary language (OR = 2.0; CI = 1.1-3.5) and finding a dead bird on the property (OR = 1.8; CI = 1.1-2.8). An intense epizootic can occur in an area without having a high risk for infection to humans. A better understanding of why certain people do not take personal protective measures, especially among those aged > or = 50 years and those whose primary language is not English, might be needed if educational campaigns are to prevent future WNV outbreaks.

Epidemiology of primary varicella and herpes zoster hospitalizations: the pre-varicella vaccine era.

To determine the epidemiology and costs of hospitalization with primary varicella and herpes zoster in the prevaccine era and the usefulness of hospital discharge data to determine the population impact of vaccination on these conditions, statewide hospital discharge data in Connecticut from 1986 to 1995 were analyzed. Annual hospitalizations for herpes zoster were 4-fold higher than for primary varicella (16.1 vs. 4.1/100,000). Overall, 69% and 83%, respectively, had no underlying immunosuppressive conditions. Regarding primary varicella, 53% of patients were aged <15 years, there was a marked winter-spring seasonality, and Hispanics and blacks were 4.1 and 2.6 times more likely than whites to be hospitalized. Regarding herpes zoster, 66.9% of patients were aged >64 years, and there was no seasonality. The mean patient charges in 1995 were $12,819 for primary varicella and $15,583 for herpes zoster. Analysis of population-based hospital discharge data is a feasible means of monitoring the impact of varicella immunization on severe morbidity due to primary varicella and herpes zoster.

Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis.

BACKGROUND: Group B streptococcal infections are a leading cause of neonatal mortality, and they also affect pregnant women and the elderly. Many cases of the disease in newborns can be prevented by the administration of prophylactic intrapartum antibiotics. In the 1990s, prevention efforts increased. In 1996, consensus guidelines recommended use of either a risk-based or a screening-based approach to identify candidates for intrapartum antibiotics. To assess the effects of the preventive efforts, we analyzed trends in the incidence of group B streptococcal disease from 1993 to 1998. METHODS: Active, population-based surveillance was conducted in selected counties of eight states. A case was defined by the isolation of group B streptococci from a normally sterile site. Census and live-birth data were used to calculate the race-specific incidence of disease; national projections were adjusted for race. RESULTS: Disease in infants less than seven days old accounted for 20 percent of all 7867 group B streptococcal infections. The incidence of early-onset neonatal infections decreased by 65 percent, from 1.7 per 1000 live births in 1993 to 0.6 per 1000 in 1998. The excess incidence of early-onset disease in black infants, as compared with white infants, decreased by 75 percent. Projecting our findings to the entire United States, we estimate that 3900 early-onset infections and 200 neonatal deaths were prevented in 1998 by the use of intrapartum antibiotics. Among pregnant girls and women, the incidence of invasive group B streptococcal disease declined by 21 percent. The incidence among nonpregnant adults did not decline. CONCLUSIONS: Over a six-year period, there has been a substantial decline in the incidence of group B streptococcal disease in newborns, including a major reduction in the excess incidence of these infections in black infants. These improvements coincide with the efforts to prevent perinatal disease by the wider use of prophylactic intrapartum antibiotics.

Reporting of vancomycin-resistant enterococci in Connecticut: implementation and validation of a state-based surveillance system.

OBJECTIVE: To assess state-based surveillance for isolation from a sterile site of vancomycin-resistant enterococci (VRE) in Connecticut. DESIGN: Clinical laboratory reporting (passive surveillance) of VRE isolates to the Connecticut Department of Public Health (CDPH) was followed by state-initiated validation, laboratory proficiency testing, and review of hospital demographic characteristics. SETTINGS: All 45 clinical laboratories and all 37 (36 for 1995 and 1996) acute-care hospitals in Connecticut were included in the study. MAIN OUTCOME MEASURES: The outcome measures included determination of the statewide incidence of VRE and the accuracy of passive reporting, determination of clinical laboratory proficiency in detecting VRE, and analysis of hospital characteristics that might be associated with an increased incidence of VRE. RESULTS: During 1994 through 1996, 29 (78%) of 37 hospital-affiliated clinical laboratories and 1 (11%) of 9 commercial or other laboratories in Connecticut reported to the CDPH the isolation of VRE from sterile sites; 158 isolates were reported for these 3 years. Based on verification, we discovered that these laboratories actually detected 58 VRE isolates in 1994, 104 in 1995, and 104 in 1996 (total, 266). The age-standardized incidence rate of VRE was 14.1 cases per million population in 1994 and 26.8 cases per million population for both 1995 and 1996. Laboratory proficiency testing revealed that high-level vancomycin resistance was identified accurately and that low- and moderate-level resistance was not detected. The incidence of VRE isolates was three times greater in hospitals with over 300 beds compared with categories of hospitals with fewer beds. Increases in the number of VRE isolates were at least twice as likely in hospitals located in areas with a higher population density, or with a residency program or trauma center in the hospital. CONCLUSIONS: Passive reporting of VRE isolates from sterile sites markedly underestimated the actual number of iso lates, as determined in a statewide reporting system. Statewide passive surveillance systems for routine or emerging pathogens must be validated and laboratory proficiency ensured if results are to be accurate and substantial underreporting is to be corrected.

Use of state hospital discharge data to assess the morbidity from rotavirus diarrhea and to monitor the impact of a rotavirus immunization program: A pilot study in Connecticut.

OBJECTIVES: Now that rotavirus vaccines have been licensed and recommended for routine immunization of US infants, there is an urgent need for data to assess the morbidity from rotavirus diarrhea and to monitor the impact of a rotavirus immunization program. In a pilot study, we have assessed the usefulness of state hospital discharge data on diarrhea in children to provide this information by examining data from Connecticut. DESIGN: Retrospective analysis of discharge records from acute care, nongovernmental hospitals in Connecticut. Patients. Children 1 month through 4 years of age with a diarrhea-associated diagnosis listed on the discharge record. Setting. Connecticut, 1987 through 1996. RESULTS: During the 10-year study period, a total of 11 324 diarrhea-associated hospitalizations (49.4 hospitalizations per 10,000 children) were reported. Diarrhea-associated hospitalizations peaked during February through April, especially among children 4 to 35 months of age. The seasonality and age distribution of diarrhea-associated hospitalizations of presumed noninfectious and viral etiologies resembled those of rotavirus-associated hospitalizations. During 1993 to 1996, rotavirus was coded for 10.4% of diarrhea-associated hospitalizations increasing from 8.6% in 1993 to 14.7% in 1996. The unadjusted median cost of a diarrhea-associated hospitalization during 1987 to 1996 and 1993 to 1996 was $1,941 and $2,428, respectively. CONCLUSIONS: Diarrhea causes substantial morbidity in children from Connecticut. The winter seasonal peak of diarrhea-associated hospitalizations in children 4 to 35 months of age coinciding with the peak of rotavirus-specific hospitalizations suggests that rotavirus is an important contributor to the overall morbidity. Although our findings suggest incomplete coding of rotavirus cases, state hospital discharge data should provide sensitive and timely information to monitor the impact of a rotavirus immunization program in Connecticut.

A multistate outbreak of Escherichia coli O157:H7 infections associated with consumption of mesclun lettuce.

BACKGROUND: An outbreak of Escherichia coli O157:H7 infections in Connecticut and Illinois during May 28 to June 27, 1996, was investigated to determine the source of infections. METHODS: Independent case-control studies were performed in both states. Pulsed-field gel electrophoresis (PFGE) was performed on E. coli O157:H7 isolates. A case-patient was defined as a Connecticut or northern Illinois resident with diarrhea whose stool culture yielded E. coli O157:H7 of the outbreak-associated PFGE subtype. Controls were town-, age-, and sex-matched to case-patients. We traced implicated lettuce to the farm level and performed environmental investigations to identify unsafe lettuce production practices. RESULTS: In Connecticut and Illinois, infection was associated with consumption of mesclun lettuce (Connecticut matched odds ratio [MOR], undefined; 95% confidence interval [CI], 3.4 to infinity; and Illinois MOR, undefined; 95% CI, 1.4 to infinity). We traced implicated lettuce to a single grower-processor. Cattle, a known E. coli O157:H7 reservoir, were found near the lettuce fields. Escherichia coli (an indicator of fecal contamination) was cultured from wash water and finished lettuce. A trace-forward investigation identified 3 additional states that received implicated lettuce; E. coli O157:H7 isolates from patients in 1 of these states matched the outbreak-associated PFGE subtype. CONCLUSIONS: This multistate outbreak of E. coli O157:H7 infections was associated with consumption of mesclun lettuce from a single producer. Molecular subtyping facilitated the epidemiological investigation. This investigation increased the knowledge about current production practices that may contribute to the contamination of lettuce by microbial pathogens. Lettuce production practices should be monitored for microbiological safety.

Suspected Brazilian purpuric fever in a toddler with overwhelming Epstein-Barr virus infection.

We describe a toddler from Connecticut who developed purulent conjunctivitis, fever, and a morbilliform rash. Blood cultures were positive for Haemophilus influenzae biogroup aegyptius; further investigation was performed to assess the possibility that the illness was consistent with Brazilian purpuric fever, which, to our knowledge, has not been reported in the United States. This isolate shared morphological and some biochemical characteristics with previously studied H. influenzae biogroup aegyptius strains but differed according to slide agglutination testing, plasmid characterization, and ribotyping. Blood and tissue samples obtained during his hospitalization were also positive for Epstein-Barr virus. The child died 8 days after hospitalization. Fifty other cases of invasive H. influenzae infection were identified by active surveillance studies. Of the 49 viable surveillance isolates, 10 were biotype III (two of which had the same ribotype as the strain from our case.

Public awareness of rabies and compliance with pet vaccination laws in Connecticut, 1993.

OBJECTIVE: To determine the degree of public awareness of rabies and compliance with cat and dog vaccination laws in Connecticut in 1993. DESIGN: Monthly telephone surveys. SAMPLE POPULATION: 1,810 households. PROCEDURE: A telephone interview was conducted, using rables-related questions contained in the Behavioral Risk Factor Surveillance System, with an adult member from households randomly selected statewide by telephone number. Results of the surveys for the year were aggregated, and weighted data were analyzed. RESULTS: Ninety percent of respondents had heard about rabies during the preceding year, and 84% considered it a problem in Connecticut. Forty-seven percent of households surveyed owned dogs or cats. Ninety-three percent of dogs and 80% of cats were reported to be vaccinated against rabies. Twenty-two percent of households with cats had at least 1 cat that was not current on rabies vaccination. CLINICAL RELEVANCE: In Connecticut, an epizootic of rabies in raccoons was accompanied by a high degree of awareness of rabies and rate of reported vaccination of dogs and cats. However, vaccination of cats was less common than that of dogs. Public education efforts should emphasize the necessity to vaccinate cats and to avoid contact with unknown cats in rabies epizootic or enzootic areas. A surveillance system can be used to help evaluate public health programs.

Determining the burden of human illness from food borne diseases. CDC's emerging infectious disease program Food Borne Diseases Active Surveillance Network (FoodNet).

Food borne diseases cause a significant burden of illness in the United States. The Food Borne Diseases Active Surveillance Network (FoodNet), established in 1995, continues to monitor the burden and causes of food borne diseases and provide much of the data to address this public health problem.

A recurrent outbreak of nosocomial legionnaires' disease detected by urinary antigen testing: evidence for long-term colonization of a hospital plumbing system.

BACKGROUND: In 1994, a hospital reported an increase in nosocomial legionnaires' disease after implementing use of a rapid urinary antigen test for Legionella pneumophila serogroup 1 (Lp-1). This hospital was the site of a previous nosocomial legionnaires' disease outbreak during 1980 to 1982. METHODS: Infection control records were reviewed to compare rates of nosocomial pneumonia and the proportion of cases attributable to legionnaires' disease during the 1994 outbreak period with those during the same period in 1993. Water samples were collected for Legionella culture from the hospital's potable water system and cooling towers, and isolates were subtyped by monoclonal antibody (MAb) testing and arbitrarily primed polymerase chain reaction (AP-PCR). RESULTS: Nosocomial pneumonia rates were similar from April through October 1993 and April through October 1994: 5.9 and 6.6 per 1,000 admissions, respectively (rate ratio [RR], 1.1; P=.56); however, 3.2% of nosocomial pneumonias were diagnosed as legionnaires' disease in 1993, compared with 23.9% in 1994 (RR, 9.4; P<.001). In 1994, most legionnaires' disease cases were detected by the urinary antigen testing alone. MAb testing and AP-PCR demonstrated identical patterns among Lp-1 isolates recovered from a patient's respiratory secretions, the hospital potable water system, and stored potable water isolates from the 1980 to 1982 outbreak. CONCLUSIONS: There may have been persistent transmission of nosocomial legionnaires' disease at this hospital that went undiscovered for many years because there was no active surveillance for legionnaires' disease. Introduction of a rapid urinary antigen test improved case ascertainment. Legionella species can be established in colonized plumbing systems and may pose a risk for infection over prolonged periods.

Trends in infant mortality in Connecticut, 1981-1992.

Assessing infant mortality rates (IMRs) is important in public health planning. However, single year fluctuations in IMRs often receive attention without consideration of long-term trends. Trends in IMR over 12 years in Connecticut were examined using linked birth and death files. Overall, there was an exponential decline in IMR from 12.2/1,000 live births in 1981 to 7.3/1,000 live births in 1992. However, differential declines in IMRs resulted in an increased relative risk of infant death over time for infants of Black women compared with infants of White women. IMRs were also higher for infants of Black, teenaged, and less educated mothers. Targeted local maternal and child health programs are needed if IMRs are to continue to decline for all sections of the population in Connecticut.