Simulation of Legionnaires' disease prospective spatiotemporal cluster detection, Allegheny County, Pennsylvania, USA.

Legionnaires' disease (LD) incidence in the USA has quadrupled since 2000. Health departments must detect LD outbreaks quickly to identify and remediate sources. We tested the performance of a system to prospectively detect simulated LD outbreaks in Allegheny County, Pennsylvania, USA. We generated three simulated LD outbreaks based on published outbreaks. After verifying no significant clusters existed in surveillance data during 2014-2016, we embedded simulated outbreak-associated cases into 2016, assigning simulated residences and report dates. We mimicked daily analyses in 2016 using the prospective space-time permutation scan statistic to detect clusters of ⩽30 and ⩽180 days using 365-day and 730-day baseline periods, respectively. We used recurrence interval (RI) thresholds of ⩾20, ⩾100 and ⩾365 days to define significant signals. We calculated sensitivity, specificity and positive and negative predictive values for daily analyses, separately for each embedded outbreak. Two large, simulated cooling tower-associated outbreaks were detected. As the RI threshold was increased, sensitivity and negative predictive value decreased, while positive predictive value and specificity increased. A small, simulated potable water-associated outbreak was not detected. Use of a RI threshold of ⩾100 days minimised time-to-detection while maximizing positive predictive value. Health departments should consider using this system to detect community-acquired LD outbreaks.

Updated and expanded study of polycythemia vera and other myeloproliferative neoplasms in the tri-county area.

INTRODUCTION: The results of a 2001-2005 polycythemia vera (PV) investigation in Eastern Pennsylvania revealed a disease cluster plus underreporting and false reporting to the Pennsylvania Cancer Registry (PCR). PURPOSE: The objectives of this study were 1) to assess PV reporting to the PCR in 2006-2009, 2) to determine whether a cancer cluster persisted, and 3) to determine whether other myeloproliferative neoplasms (MPNs), including essential thrombocytopenia (ET), were subject to similar reporting problems. METHODS: Cases were identified from: 1) PCR records from the Tri-County, 2) reviewing billing records at Tri-County hematologist/oncologist offices, and 3) self-identification. An expert panel of physicians reviewed medical records and determined "true," "false," or "indeterminate" cases reported to the PCR. The analyses were conducted to determine sensitivity and positive predictive value (PPV) of case reporting to the PCR, estimate cancer incidence rates, and evaluate the presence of cancer clusters. RESULTS: Of 290 cases identified, 90% were from the original PCR, 9% from billing records, and 1% from self-report. Fifty-five cases consented to participate, and medical records were obtained for 44. The expert panel determined that 45% were true cases, 32% were false cases, and 23% were indeterminate. PV had 100% (95% CI, 59-100) sensitivity, but only 47% PPV (95% CI, 20-70): ET had 78% (95% CI, 47-99) sensitivity and 100% PPV (95% CI, 59-100). Low participation and chart review rates led to rates with wide confidence intervals. We did not identify any PV cancer clusters, but we did identify a cluster of 9 ET cases in the Wilkes-Barre, Pennsylvania area. CONCLUSION: The current study was limited by the low response rate (22%) from MPN patients in the Tri-County area. This study identified 47% PPV for PV reporting and 100% PPV for ET.

Effects of feeding yeast and propionibacteria to dairy cows on milk yield and components, and reproduction*.

To determine the effect of supplemental feeding of Diamond V-XP yeast (XPY) alone or in combination with propionibacteria strain P169 on milk production, milk components, body weight, days to first and second ovulation, plasma insulin, and plasma and milk glucose, 31 primiparous and multiparous (MP) Holstein cows were fed one of three dietary treatments between 2 weeks prepartum to 30 weeks postpartum: (i) control (n = 10), fed a corn silage-based total mixed ration (TMR); (ii) XPY (n = 11), fed control TMR plus XPY (at 56 g/head/day); and (iii) P169+XPY (n = 10), received control TMR plus XPY plus P169 (at 6 x 10(11) cfu/head/day). After parturition, daily milk weights were recorded, and milk samples were collected twice weekly for milk component analyses. Daily uncorrected milk, solids-corrected milk, and 4% fat-corrected milk production for MP cows fed P169+XPY was 9-16% greater than control MP cows, but these increases were only evident during mid lactation (9-30 weeks). The percentage of milk fat was 8-18% greater in control than XPY and P169+XPY groups. Milk lactose percentage in MP cows fed P169+XPY was 3-5% greater than in control and XPY MP cows. Primiparous and MP cows fed P169+XPY had 28-32% greater milk glucose levels than control and XPY-fed cows. Diurnal plasma glucose concentration was not affected by diet in MP cows. Plasma insulin levels in MP cows fed P169+XPY were 30-34% greater than in other groups of MP cows. Milk glucose and plasma insulin responses to P169+XPY feeding suggest that P169+XPY might have enhanced gluconeogenesis and increased glucose uptake by the mammary gland in Holstein cows. Thus, a combined feed supplement of P169 and XPY may hold potential as a natural feed alternative to hormones and antibiotics to enhance lactational performance.

Effects of propionibacteria and yeast culture fed to steers on nutrient intake and site and extent of digestion.

The effects of feeding Propionibacterium strain P169 (P169), yeast culture (XPY), and their combination on nutrient intake, site and extent of digestion, and ruminal kinetics were evaluated in a completely randomized experimental design. Ruminally and duodenally cannulated Angus x Hereford steers (n = 12) were assigned to 1 of 4 treatments in each of 2 periods: 1) control, fed a sorghum silage-based total mixed ration; 2) P169, fed the control plus P169 (6 x 10(11) cfu/steer per d); 3) XPY, fed the control plus XPY (56 g/steer per d); and 4) P169 + XPY, fed the control plus P169 and XPY (at 6 x 10(11) cfu/steer per d and 56 g/steer per d, respectively). Each period lasted 21 d; d 1 to 15 were used for diet adaptation and d 16 to 21 were used for fecal, duodenal, ruminal, and blood sample collection. Steers were individually housed and fed. Feeding XPY tended to decrease intake of organic matter, acid detergent fiber, and N, and decreased intake of neutral detergent fiber. However, feeding XPY alone tended to increase total tract digestibility of organic matter, N, neutral detergent fiber, and acid detergent fiber. Ruminal digestibility, duodenal flow, microbial N synthesis, microbial efficiency, and fluid and particulate passage rates were not affected by dietary treatments. Feeding P169 tended to decrease molar proportion of acetate, increased molar proportion of propionate (by 9.7%), and tended to decrease acetate:propionate ratio compared with control steers. No other effects of XPY or P169 on ruminal fermentation were observed. Plasma glucose and insulin concentrations were not affected by dietary treatment. Our results suggest that feeding P169 alters ruminal metabolism toward increased propionate without affecting feed intake or ruminal kinetics, whereas feeding XPY alone tended to increase total tract digestibilities of nutrients.

Effect of longitude and latitude on fecal egg and oocyst counts in cow-calf beef herds from the United States Northern Great Plains.

This study evaluated potential relationships between parasite egg/oocyst outputs in cow-calf beef herds located within the United States Northern Great Plains and herd longitude and latitude. Management of study herds was typical of herds from this region. Parasite egg/oocyst counts were measured from 10 cows and 5 calves selected from each herd near the end of the traditional grazing season (October 1993). The types and numbers of eggs and oocysts recovered from both cows and spring-born calves were consistent with those described in other studies. No significant relationship between fecal egg/oocyst counts and latitude was observed in calves or cows. Monezia egg output exhibited no significant correlation with longitude for calves or cows. In cows, a significant negative correlation was detected between coccidian oocyst counts and herd longitude but not between helminth egg counts and longitude. In calves, Nematodirus, trichostrongyle and Trichuris egg output and coccidian oocyst output were all negatively correlated with longitude. This negative correlation suggests that nematode populations within the study area decreased slightly from an east to west direction.

Prevalence of genital chlamydial infection in young women entering a national job training program, 1990-1997.

OBJECTIVES: This analysis describes trends in the prevalence of genital chlamydial infection in economically disadvantaged young women entering a national job training program. METHODS: We examined chlamydia test data for May 1990 through June 1997 for women aged 16 to 24 years who enrolled in the program. The significance of trends was evaluated with the chi 2 test for trend. RESULTS: Prevalence of chlamydial infection declined 32.9%, from 14.9% in 1990 to 10.0% in 1997 (P < .001). Prevalence decreased significantly in all age groups, racial/ethnic groups, and geographic regions. CONCLUSIONS: The decrease in prevalence of chlamydial infection suggests that prevention activities have reached disadvantaged women across the United States; however, prevalence of chlamydial infection remains high, and enhanced prevention efforts in disadvantaged communities are urgently needed.

Gonorrhea in male adolescents and young adults in Newark, New Jersey: implications of risk factors and patient preferences for prevention strategies.

BACKGROUND: Although the national rate of gonorrhea declined 68% from 1975 to 1995, rates remain high in many inner-city areas. In 1995, the gonorrhea rate in Newark, NJ, was five times the US rate. OBJECTIVE: To determine factors associated with acquisition of gonorrhea by men in Newark. STUDY DESIGN: A case-control study conducted at the sexually transmitted disease (STD) clinic in Newark, comparing males 15 to 29 years with culture-confirmed gonorrhea to controls with no STD. RESULTS: Compared with controls, males with gonorrhea more frequently reported at least 1 casual sex partner within the preceding month (adjusted odds ratio [OR], 3.2; 95% CI, 1.8-5.7), sex after using marijuana during the preceding month (OR, 2.4; 95% CI, 1.1-5.3), and a history of incarceration (OR, 2.1; 95% CI, 1.2-3.7). Of males with casual partners, having a new casual sexual relationship (onset within the past month) was particularly risky for gonorrhea (OR, 3.9; 95% CI, 1.2-12.7). Incorrect condom use was highly prevalent for both cases and controls. Many persons with gonorrhea reported that they were not willing to consistently use condoms or to have only one partner. CONCLUSIONS: Sex with casual partners is associated with gonorrhea in males, and may be a difficult practice to change. Condoms are often used incorrectly, if at all, in this population. Prevention strategies, in addition to the promotion of condom use and monogamy, may be necessary.

The transmission dynamics of gonorrhoea: modelling the reported behaviour of infected patients from Newark, New Jersey.

A survey of the sexual behaviour of gonorrhoea patients in Newark was undertaken to evaluate parameters within a model of gonorrhoea transmission. Modelling work aimed to explain observed epidemiological patterns and to explore the potential impact of interventions. Reported behaviours, along with values derived from the literature, were used within a standard deterministic model of gonorrhoea transmission, where the population was stratified according to sex and rates of sex-partner change. The behaviours reported, particularly among women, are insufficient by themselves to explain the continued existence of gonorrhoea within the population. The majority of symptomatic patients seek treatment within a few days, and report that they do not have unprotected sex while symptomatic. The proportion of patients with low numbers of sex partners suggests that sexual mixing between people categorized according to sexual behaviour is near random. To explain the persistence of gonorrhoea, there must be some patients who, when infected, do not seek care in public clinics. In addition, gonorrhoea incidence in the model is sensitive to change, such that very small reductions in risk behaviour could lead to its elimination. This does not accord with the observed failure of many interventions to eliminate infection, suggesting that the modelled infection is too sensitive to change. The model, which has been influential in gonorrhoea epidemiology, is not consistent with the observed epidemiology of gonorrhoea in populations. Alternative models need to explore the observed stability of gonorrhoea before robust modelling conclusions can be drawn on how best to control infection. However, the current results do highlight the potential importance of asymptomatic infections and infections in those who are diseased and do not attend public health services. Screening and contact-tracing to identify asymptomatic infections in both men and women will be more effective in reaching those who maintain the infection within the community rather than simply treating symptomatic cases.

Molecular characterization of Haemophilus ducreyi strains from Jackson, Mississippi, and New Orleans, Louisiana.

Chancroid, a sexually transmitted disease caused by Haemophilus ducreyi, is one of the most common genital ulcer diseases in developing countries. In the United States, while less common, the disease has been associated with outbreaks in inner cities, particularly among persons who engage in sex for drugs or money. Two outbreaks of chancroid were recently studied in the United States, one in New Orleans (from 1990 to 1992) and one in Jackson, Mississippi (from 1994 to 1995). By use of ribotyping, plasmid content, and antibiotic susceptibility, the chancroid cases in New Orleans were found to be due to a limited number of strains, consistent with a limited introduction of H. ducreyi into this community. The H. ducreyi isolates from New Orleans and Jackson had different ribotype patterns, suggesting that the two outbreaks were probably not linked.

An investigation of genital ulcers in Jackson, Mississippi, with use of a multiplex polymerase chain reaction assay: high prevalence of chancroid and human immunodeficiency virus infection.

In 1994, an apparent outbreak of atypical genital ulcers was noted by clinicians at the sexually transmitted disease clinic in Jackson, Mississippi. Of 143 patients with ulcers tested with a multiplex polymerase chain reaction (PCR) assay, 56 (39%) were positive for Haemophilus ducreyi, 44 (31%) for herpes simplex virus, and 27 (19%) for Treponema pallidum; 12 (8%) were positive for > 1 organism. Of 136 patients tested for human immunodeficiency virus (HIV) by serology, 14 (10%) were HIV-seropositive, compared with none of 200 patients without ulcers (P < .001). HIV-1 DNA was detected by PCR in ulcers of 6 (50%) of 12 HIV-positive patients. Multivariate analysis indicated that men with chancroid were significantly more likely than male patients without ulcers to report sex with a crack cocaine user, exchange of money or drugs for sex, and multiple sex partners. The strong association between genital ulcers and HIV infection in this population highlights the urgency of preventing genital ulcers in the southern United States.

Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease Surveillance Group.

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.

A pilot study of the prevalence of chlamydial infection in a national household survey.

BACKGROUND: The prevalence of Chlamydia trachomatis genital infection in the United States population is unknown. Using a new urine test for C. trachomatis, we conducted a pilot survey as part of the National Health and Nutrition Examination Survey III (NHANES III). GOAL: To determine whether the prevalence of chlamydial infection in a convenience sample of NHANES participants was high enough to justify testing for C. trachomatis in a national survey. STUDY DESIGN: NHANES III, conducted from 1988 to 1994, was based on a stratified multistage probability sample of the United States population. Non-Hispanic blacks and Mexican-Americans were oversampled. Using the ligase chain reaction assay for C. trachomatis, we tested urine from participants 12 to 39 years of age from 10 of the 89 sites of NHANES III. The prevalence of infection was calculated by racial or ethnic group. RESULTS: We tested 1,144 study participants, of whom 65% were female, 30% were non-Hispanic blacks, and 30% were Mexican-American. Prevalence was higher for non-Hispanic blacks (7%) than for Mexican-Americans (3%) and non-Hispanic whites (2%). Prevalence was higher for women than men in non-Hispanic blacks (7% vs. 6%), Mexican-Americans (5% vs. 2%), and non-Hispanic whites (2% vs. 1%). In 15- to 19-year-old women, prevalence was 13% in non-Hispanic blacks, 11% in Mexican-Americans, and 5% in non-Hispanic whites. CONCLUSION: The prevalence of C. trachomatis genital infection was high enough to suggest that a reliable national prevalence estimate could be obtained in a national probability sample survey.

Screening women for gonorrhea: demographic screening criteria for general clinical use.

OBJECTIVES: The purpose of this analysis was to derive potential gonorrhea screening criteria for women. METHODS: Data corresponding to 44,366 gonorrhea cultures from women 15 through 44 years of age in Columbus, Ohio, were analyzed. RESULTS: Characteristics that were associated with gonococcal infection and were suitable for screening decisions included patient's age and marital status and previous prevalence of gonorrhea at provider site. Probabilities of infection ranged from .001 for married women 25 through 44 years of age at low-prevalence provider sites to .078 for unmarried women 15 through 19 years of age at high-prevalence sites. CONCLUSIONS: Patient's age and marital status and prevalence of gonorrhea at provider site can be used as indicators to ensure testing of high-prevalence groups.

Comparison of enzyme immunoassays for antibodies to Haemophilus ducreyi in a community outbreak of chancroid in the United States.

The performance of two EIAs (adsorption EIA and lipooligosaccharide [LOS] EIA) that detect antibodies to Haemophilus ducreyi was evaluated with serum specimens obtained from 163 patients (96 with genital ulcer disease [GUD]). Paired serum specimens (initial and follow-up) were obtained from 52 of the GUD patients. By use of initial serum specimens from 82 GUD patients whose etiologic agents for their ulcers had been identified, the adsorption EIA had a sensitivity and specificity for chancroid of 53% and 71%, while the LOS EIA had a sensitivity and specificity of 48% and 89%, respectively. Sensitivity and specificity of the adsorption EIA increased to 78% and 84%, respectively, when the results of follow-up serum specimens were used to calculate optimal performance. The proportion of patients testing positive for H. ducreyi who had anti-H. ducreyi IgG antibodies, as determined by adsorption EIA, increased with the duration of infection, thus limiting the role of EIAs in the diagnosis of chancroid.

Trends in the prevalence of chlamydial infections. The impact of community-wide testing.

BACKGROUND: Evaluation of existing testing programs should guide the national effort to expand programs for the prevention of chlamydial infections. The Columbus (Ohio) Health Department instituted community-wide testing for Chlamydia trachomatis in 1988. GOALS: To assess trends in the prevalence of chlamydial infection, the coverage of screening, and concurrent trends in the prevalence of gonorrhea. STUDY DESIGN: This was a cross-sectional study of women 15 to 44 years of age tested for C. trachomatis at over 50 provider sites in Columbus, Ohio, from 1989 to 1992. RESULTS: The prevalence of chlamydial infection among all women tested decreased by 33% from 1989 to 1992. Prevalence decreased least (19%) among black women 15 to 19 years of age, the group with the highest initial prevalence (20.2%), even though 42% of this population in the city was tested. Prevalence did not decrease at all among prenatal patients 15 to 19 years of age. For women tested for both gonorrhea and chlamydia, gonorrhea decreased by 39% during the 4-year period. CONCLUSIONS: Screening appeared to have limited effect on the prevalence of chlamydial infection for groups with highest initial prevalence, despite the relatively high percentage of the population tested. Expanding screening programs to include men and instituting behavioral interventions may be necessary to reduce more rapidly the prevalence of chlamydia among these women.

Pregnancy-related mortality in New Jersey, 1975 to 1989.

OBJECTIVES: National data are thought to underestimate pregnancy-related mortality in the United States. A multisource surveillance system for pregnancy-associated deaths in New Jersey offers an opportunity to identify the magnitude of and the trends in pregnancy-related mortality at the state level. METHODS: Data from all reported pregnancy-related deaths in the state from 1975 to 1989 were studied, and pregnancy mortality ratios were calculated. RESULTS: The New Jersey pregnancy mortality ratio decreased from the late 1970s to the early 1980s but began to rise in the late 1980s. The pregnancy mortality ratio for non-Whites was 3.6 times that for Whites for the 15-year period. The causes of pregnancy-related deaths changed over the 15-year period, with direct obstetrical causes playing a decreasing role. AIDS has become the major cause of pregnancy-related mortality in New Jersey. Finally, approximately 44% of the pregnancy-related deaths were considered to be preventable by the physician or patient or both. CONCLUSIONS: New efforts must be made to combat the recent rise in pregnancy-related deaths, with special attention to preventing deaths among non-White women.