Two Storm-Related Carbon Monoxide Poisoning Outbreaks­Connecticut, October 2011 and October 2012.

Storm-related carbon monoxide (CO) poisoning outbreaks occurred in Connecticut in 2011 and 2012, despite efforts to improve public messaging. We describe the cases and incidents and identify possible preventive interventions. We defined cases as blood carboxyhemoglobin ≥9.0% among persons exposed to alternative power or heat sources because of storm-related losses. We identified 133 cases, including 3 deaths, in 2011 and 30 in 2012, associated with 72 and 11 incidents, respectively. Racial/ethnic minorities were overrepresented (60% of 2011 patients; 48% in 2012), compared with Connecticut's minority population (29%). Generator or charcoal misuse (83% in 2011; 100% in 2012) caused the majority of incidents. Few CO-source operators recalled media or product CO warnings. Incorrect generator and charcoal use, racial/ethnic disparities, and incomplete penetration of warning messages characterized both outbreaks. A multifaceted approach is needed to decrease postdisaster CO poisonings.

Vascular access hemorrhages contribute to deaths among hemodialysis patients.

In 2007 the Maryland Medical Examiner noted a potential cluster of fatal vascular access hemorrhages among hemodialysis patients, many of whom died outside of a health-care setting. To examine the epidemiology of fatal vascular access hemorrhages, we conducted a retrospective case review in District of Columbia, Maryland, and Virginia from January 2000 to July 2007 and a case-control study. Records from the Medical Examiner and Centers for Medicare and Medicaid Services were reviewed, from which 88 patients were identified as fatal vascular access hemorrhage cases. To assess risk factors, a subset of 20 cases from Maryland was compared to 38 controls randomly selected among hemodialysis patients who died from non-vascular access hemorrhage causes at the same Maryland facilities. Of the 88 confirmed cases, 55% hemorrhaged from arteriovenous grafts, 24% from arteriovenous fistulas, and 21% from central venous catheters. Of 82 case-patients with known location of hemorrhage, 78% occurred at home or in a nursing home. In the case-control analysis, statistically significant risk factors included the presence of an arteriovenous graft, access-related complications within 6 months of death, and hypertension; presence of a central venous catheter was significantly protective. Psychosocial factors and anticoagulant medications were not significant risk factors. Effective strategies to control vascular access hemorrhage in the home and further delineation of warning signs are needed.

Outbreak of lower respiratory tract illness associated with human enterovirus 68 among American Indian children.

Human enterovirus 68 (EV68) infections are rarely reported. We describe a respiratory outbreak associated with EV68 among 18 children admitted to a remote Indian Health Service facility during August 11, 2010 through September 14, 2010. Clinical illness was characterized by pneumonia and wheezing. EV68 should be considered as an etiology in outbreaks of lower respiratory tract illness.

Association between swimming pool operator certification and reduced pool chemistry violations--Nebraska, 2005-2006.

Previous studies have recommended mandatory education for all public pool operators, but substantiating data are limited. This study evaluates associations between pool operator certification and chemistry violations by using 2005-2006 Nebraska routine pool inspection reports. Training and certification for nonmunicipal pool operators are only required in two Nebraska counties. Free chlorine violations for nonmunicipal pool inspections were compared in counties with and without certified operator requirements. To control for water supply pH, inspections from nonmunicipal pools with shared-source water in two counties (one requiring certification) were compared for concurrent pH and free chlorine violations. Compared with locations that require certified operators, free chlorine violations and concurrent pH and free chlorine violations were twice as likely in locations without certification. As a result, pools without required operator certification might pose greater health risks. These results demonstrate the benefit of requiring pool operator certification to help prevent recreational water illnesses.

Health effects associated with indoor swimming pools: a suspected toxic chloramine exposure.

OBJECTIVES: A cohort and environmental study tested the hypothesis that suspected exposure to chloramines (by-products of chlorine for disinfection and ammonia from human sources) from a hotel's indoor swimming pool was associated with an outbreak among children who had attended a party at the pool. STUDY DESIGN: Retrospective cohort study. METHODS: A case was defined as any hotel guest/visitor on 5-6 October 2002 who experienced three or more symptoms typical of chloramine exposure on either day after visiting the hotel. A cohort study and an environmental assessment were performed to determine the association between pool exposure and illness. RESULTS: Of 128 individuals interviewed, 32 met the case definition. Common symptoms among case patients were cough (84%), eye irritation (78%) and rash (34%). Illness was associated with entering the pool area [odds ratio (OR) 19.9; 95% confidence interval (CI) 2.3-172], but more strongly with swimming (OR 72.0; 95% CI 9.1-568). Pool chloramine levels on 6 October 2002 were > or = 0.7ppm (optimal level=0ppm; state maximum=0.5ppm). The pool operator lacked formal training in pool maintenance. CONCLUSIONS: High chloramine levels may have caused illness in individuals who were either in or near the pool. This outbreak underscores the need for regular pool maintenance, improved air quality, education and certification for all operators of public and semipublic pools, and education about healthy swimming practices.

Lyme disease knowledge, beliefs, and practices of New Hampshire primary care physicians.

BACKGROUND: Lyme disease is the most commonly reported vectorborne illness in the United States and is endemic in many counties in the Northeast, including counties in New Hampshire. Previous studies conducted elsewhere on Lyme disease have indicated substantial differences between physician practices and published consensus guidelines for diagnosis and treatment. METHODS: During 1999, we mailed a 21-item questionnaire to 600 randomly selected family practice physicians, internists, and pediatricians in New Hampshire. RESULTS: Respondents answered a median of 10 (76.9%) of 13 knowledge items correctly. Most physicians (73.6%) underestimated the incidence of erythema migrans among Lyme disease patients, and 41.2% would either test or offer treatment to an asymptomatic patient with deer-tick bite. When surveyed, most respondents (72.4%) planned to recommend Lyme disease vaccine to high-risk persons. Approximately one half (44.8%) reported giving empiric antibiotic treatment of Lyme disease solely because of patient concern. CONCLUSIONS: New Hampshire primary care physicians indicated good knowledge about Lyme disease. Lack of awareness about Lyme disease diagnostic criteria, however, could contribute to misdiagnosis through overreliance on laboratory testing. Lyme disease vaccine appeared to be well accepted by physicians, although the vaccine has since been withdrawn from the US market. Both inappropriate management of tick bite and empiric treatment of unsubstantiated Lyme disease diagnoses were common.