Environmental sources of community-acquired legionnaires' disease: A review.

BACKGROUND: Most Legionnaires' disease in the US and abroad is community-acquired and believed to be sporadic, or non-outbreak associated. Most patients are exposed to numerous water sources, thus making it difficult to focus environmental investigations. Identifying known sources of sporadic community-acquired Legionnaires' disease will inform future sporadic Legionnaires' disease investigations as well as highlight directions for research. The objective is to summarize and rank sporadic Legionnaires' disease sources based on the level of linkage between the environmental source and cases. METHODS: A PubMed search was conducted using the search terms legion* and (origins or source or transmission) and (sporadic or community-acquired). Studies of nosocomial and/or outbreak-associated disease were excluded from this review. Definite, probable, possible and suspect ranks were assigned to sources based on evidence of linkage to sporadic Legionnaires' disease. RESULTS: The search yielded 196 articles and 47 articles were included in the final review after application of exclusion criteria. A total of 28 sources were identified. Of these, eight were assigned definite rank including residential potable water and car air-conditioner water leakage. Probable rank was assigned to five sources including solar-heated potable water and soil. Possible rank was assigned to nine sources including residential potable water and cooling towers. Suspect rank was assigned to 20 sources including large building water systems and cooling towers. CONCLUSION: Residential potable water, large building water systems and car travel appear to contribute to a substantial proportion of sporadic Legionnaires' disease. Cooling towers are also a potentially significant source; however, definitive linkage to sporadic cases proves difficult. The sources of sporadic Legionnaires' disease cannot be definitively identified for most cases.

Escherichia coli O157:H7 Outbreak Associated with Restaurant Beef Grinding.

Escherichia coli O157:H7 is a common cause of foodborne illness in the United States. Beef ground at establishments regulated by the U.S. Department of Agriculture, Food Safety and Inspection Service is routinely tested for E. coli O157:H7. Prior to December 2013, boxed beef product (wholesale cuts of beef, such as beef loin, packaged into bags and boxed for shipping) was not always tested for this pathogen. Downstream processors or retailers may grind the product; and, if the ground beef is not cooked to the recommended temperature, pathogens on the exterior of the beef introduced to the interior through grinding may survive. On 18 October 2013, the Allegheny County Health Department identified two E. coli O157:H7 cases, both of whom were food handlers at restaurant A, a restaurant that ground locally produced boxed beef for hamburgers on site. Case finding was conducted through public messaging, employee surveys, and disease surveillance. All potential cases were interviewed using a standard questionnaire. A confirmed case was defined as laboratory-confirmed E. coli O157:H7 with exposure to restaurant A. A probable case was defined as a patient with compatible symptoms and exposure to restaurant A but without laboratory confirmation. All human and food isolates were characterized by pulsed-field gel electrophoresis and multilocus variable-number tandem repeat analysis. The analysis identified 14 confirmed and 10 probable cases of E. coli; 18 nonintact ground beef samples tested positive for E. coli O157:H7. Nine confirmed cases were restaurant A employees. All confirmed cases recalled eating a restaurant A hamburger in the 10 days before illness onset; most cases reported consuming medium to rare hamburgers. Multiple pulsed-field gel electrophoresis and multilocus variable-number tandem repeat analysis patterns were identified among both the human and ground beef isolates, and the patient isolates matched those found in ground beef samples. Restaurant A voluntarily closed for 1.5 days, changed beef suppliers, ceased grinding beef in-house, and has had no new cases since reopening.

Chronic myelogenous leukemia in eastern Pennsylvania: an assessment of registry reporting.

BACKGROUND: Chronic myelogenous leukemia (CML) has been reportable to the Pennsylvania Cancer Registry (PCR) since the 1980s, but the completeness of reporting is unknown. This study assessed CML reporting in eastern Pennsylvania where a cluster of another myeloproliferative neoplasm was previously identified. METHODS: Cases were identified from 2 sources: 1) PCR case reports for residents of Carbon, Luzerne, or Schuylkill County with International Classification of Diseases for Oncology, Third Edition (ICD-O-3) codes 9875 (CML, BCR-ABL+), 9863 (CML, NOS), and 9860 (myeloid leukemia) and date of diagnosis 2001-2009, and 2) review of billing records at hematology practices. Participants were interviewed and their medical records were reviewed by board-certified hematologists. RESULTS: PCR reports included 99 cases coded 9875 or 9863 and 9 cases coded 9860; 2 additional cases were identified by review of billing records. Of the 110 identified cases, 93 were mailed consent forms, 23 consented, and 12 medical records were reviewed. Hematologists confirmed 11 of 12 reviewed cases as CML cases; all 11 confirmed cases were BCR/ABL positive, but only 1 was coded as positive (code 9875). CONCLUSIONS: Very few unreported CML cases were identified, suggesting relatively complete reporting to the PCR. Cases reviewed were accurately diagnosed, but ICD-0-3 coding often did not reflect BCR-ABL-positive tests. Cancer registry abstracters should look for these test results and code accordingly.

Underrepresentation of heroin involvement in unintentional drug overdose deaths in Allegheny County, PA.

Drugs contributing to overdose deaths are listed on death certificates, but their validity is rarely studied. To assess the accuracy of "morphine" and "codeine" listings on death certificates for unintentional overdose deaths in Allegheny County, PA, investigative and laboratory reports were reviewed. Deaths were reclassified as heroin-related if documentation showed 6-monoacetylmorphine in blood or urine, "stamp bags" or drug paraphernalia at scene, history of heroin use, or track marks. Deaths were considered morphine-related if notes indicated morphine use, prescription, or morphine at scene, or codeine-related if the codeine blood level exceeded morphine. Of 112 deaths with morphine but not heroin listed on the death certificate, 74 met heroin criteria and 21 morphine criteria. Of 20 deaths with both morphine and heroin listed, only one met morphine criteria. Of 34 deaths with codeine listed, only five were attributed to codeine. Consideration of patient history, death scene evidence, and expanded toxicology testing may improve the accuracy of death certificate drug listings.

Cancer incidence in elderly West Virginians.

West Virginia has one of the oldest populations in the nation. Cancer is a common disease among the elderly. With the projected growth of the elderly population (defined as 65 years and older), cancer will become a major public health burden. This article provides a summary of cancer incidence in elderly West Virginians. Incidence data were obtained from the West Virginia Cancer Registry. Approximately 6,262 elderly persons are diagnosed with some form of reportable cancer in West Virginia each year. Among those aged 65 and older, the four leading primary cancer sites in the order of their relative frequency were lung and bronchus cancer (21.8%), prostate cancer (14.6%), colorectal cancer (12.7%), and female breast cancer (9.6%). In general, the burden of cancer was greater in elderly men than in elderly women. Knowledge of the epidemiology of cancer in the elderly can potentially help guide statewide cancer prevention and control efforts and be used for anticipating future health care needs in the state.

Estimation of short-term effects of air pollution on stroke hospital admissions in Wuhan, China.

BACKGROUND AND OBJECTIVE: High concentrations of air pollutants have been linked to increased incidence of stroke in North America and Europe but not yet assessed in mainland China. The aim of this study is to evaluate the association between stroke hospitalization and short-term elevation of air pollutants in Wuhan, China. METHODS: Daily mean NO2, SO2 and PM10 levels, temperature and humidity were obtained from 2006 through 2008. Data on stroke hospitalizations (ICD 10: I60-I69) at four hospitals in Wuhan were obtained for the same period. A time-stratified case-crossover design was performed by season (April-September and October-March) to assess effects of pollutants on stroke hospital admissions. RESULTS: Pollution levels were higher in October-March with averages of 136.1 µg/m(3) for PM10, 63.6 µg/m(3) for NO2 and 71.0 µg/m(3) for SO2 than in April-September when averages were 102.0 µg/m(3), 41.7 µg/m(3) and 41.7 µg/m(3), respectively (p<.001). During the cold season, every 10 µg/m(3) increase in NO2 was associated with a 2.9% (95%C.I. 1.2%-4.6%) increase in stroke admissions on the same day. Every 10 ug/m(3) increase in PM10 daily concentration was significantly associated with an approximate 1% (95% C.I. 0.1%-1.4%) increase in stroke hospitalization. A two-pollutant model indicated that NO2 was associated with stroke admissions when controlling for PM10. During the warm season, no significant associations were noted for any of the pollutants. CONCLUSIONS: Exposure to NO2 is significantly associated with stroke hospitalizations during the cold season in Wuhan, China when pollution levels are 50% greater than in the warm season. Larger and multi-center studies in Chinese cities are warranted to validate our findings.

Morbidity associated with golf-related injuries among children: findings from a pediatric trauma center.

OBJECTIVE: To describe injuries due to golf-related activities among pediatric patients requiring hospital admission. METHODS: We conducted a retrospective analysis of all sports-related injuries from 2000 to 2006 using a level 1 trauma center database. RESULTS: Of 1005 children admitted with sports-related injuries, 60 (6%) had golf-related injuries. The mean injury severity score was significantly higher for golf-related injuries (11.0) than that for all other sports-related injuries (6.8). Most golf-related injuries occurred in children younger than 12 years (80%), at home (48%), and by a strike from a club (57%) and resulted in trauma to the head or neck (68%). CONCLUSIONS: Golf-related injuries, although an infrequent cause of sports-related injuries, have the potential to result in severe injuries, especially in younger children. Preventive efforts should target use of golf clubs by younger children in the home setting.

Falls among adults: the association of cardiorespiratory fitness and physical activity with walking-related falls.

BACKGROUND: Falls are a major cause of deaths, hospitalizations, and emergency room visits in the U.S., but circumstances surrounding falls are not well described. Among the elderly, balance and gait disorders and muscle weakness are associated with increased risk for falling, but the relationship of cardiorespiratory fitness and physical activity with falls is unclear. PURPOSE: This purpose of this study is to describe characteristics of falls among adults and assess the association of cardiorespiratory fitness and physical activity with walking-related falls. METHODS: Data on participants enrolled in the Aerobics Center Longitudinal Study (ACLS) from 1970 through 1989 who responded to questions on falls on the 1990 follow-up survey were analyzed in 2008-2009. The percentage of participants reporting at least one fall during the year before the follow-up survey was calculated and the activities at the time of falling were described. The relative risk and 95% CIs for the association of baseline fitness and physical activity with walking-related falls were calculated and logistic regression models for walking-related falls were developed. RESULTS: Of 10,615 participants aged 20-87 years, 20% (95% CI=19%, 21%) reported falling during the past year. Of those falling, 54% (95% CI=52%, 56%) fell during sports or exercise; 15% (95% CI=14%,17%) while walking; and 4% (95% CI=3%, 5%) from a stool or ladder. People aged >or=65 years were no more likely than younger people to report falling in general, but they were more likely than people aged <45 years to report falling while walking (RR=1.9, 95% CI=1.2, 3.0 for men; RR=2.2, 95% CI=1.3, 3.9 for women). Men with a low level of fitness were more likely to fall while walking than men who were highly fit (RR=2.2, 95% CI=1.5, 3.3). In the multivariate analysis, walking-related falls were associated with low levels of fitness (AOR=1.8, 95% CI=1.1, 2.8) and with physical inactivity (AOR=1.7, 95% CI=1.1, 2.7) in men but not in women. CONCLUSIONS: Falls are common throughout adulthood but activities at time of falls differ by age. Low fitness levels and physical inactivity may increase risk for walking-related falls.

Characteristics of Black and White suicide decedents in Fulton County, Georgia, 1988-2002.

OBJECTIVES: We compared the prevalence of risk factors for Black and White suicide decedents in Fulton County, Georgia, from 1988-2002. METHODS: We used data from the Fulton County Medical Examiner's Office to compile information on suicides that occurred in Fulton County between 1988 and 2002. We used the chi(2) test and logistic regression to identify associations between suicide risk factors and race. RESULTS: Black suicide decedents were more likely than White suicide decedents to be male (odds ratio [OR]=2.06; 95% confidence interval [CI]=1.38, 3.09), to be younger, (>or=24 y [OR = 4.74; 95% CI = 2.88, 7.81]; 25-34 y [OR = 2.79; 95% CI = 1.74, 4.47]; 35-44 y [OR = 1.86; 95% CI = 1.13, 3.07]), and to hurt others in a suicide (OR = 4.22; 95% CI = 1.60, 11.15) but less likely to report depression (OR=0.63; 95% CI=0.48, 0.83), to have a family history of suicide (OR=0.08; 95% CI=0.01, 0.61), or to leave a suicide note (OR=0.37; 95% CI=0.26, 0.52). CONCLUSIONS: Future research should consider that Black suicide decedents are less likely to report depression than White suicide decedents. This suicide risk difference is important when developing effective suicide prevention programs.

Changes in motorcycle-related head injury deaths, hospitalizations, and hospital charges following repeal of Pennsylvania's mandatory motorcycle helmet law.

To evaluate the 2003 repeal of Pennsylvania's motorcycle helmet law, we assessed changes in helmet use and compared motorcycle-related head injuries with non-head injuries from 2001-2002 to 2004-2005. Helmet use among riders in crashes decreased from 82% to 58%. Head injury deaths increased 66%; nonhead injury deaths increased 25%. Motorcycle-related head injury hospitalizations increased 78% compared with 28% for nonhead injury hospitalizations. Helmet law repeals jeopardize motorcycle riders. Until repeals are reversed, states need voluntary strategies to increase helmet use.

Characteristics of black and white suicide decedents in Fulton County, Georgia, 1988-2002.

OBJECTIVES: We compared the prevalence of risk factors for Black and White suicide decedents in Fulton County, Georgia, from 1988-2002. METHODS: We used data from the Fulton County Medical Examiner's Office to compile information on suicides that occurred in Fulton County between 1988 and 2002. We used the chi2 test and logistic regression to identify associations between suicide risk factors and race. RESULTS: Black suicide decedents were more likely than White suicide decedents to be male (odds ratio [OR]=2.06; 95% confidence interval [CI]=1.38, 3.09), to be younger, (< or =24 y [OR = 4.74; 95% CI = 2.88, 7.81]; 25-34 y [OR = 2.79; 95% CI = 1.74, 4.47]; 35-44 y [OR = 1.86; 95% CI = 1.13, 3.07]), and to hurt others in a suicide (OR = 4.22; 95% CI = 1.60, 11.15) but less likely to report depression (OR=0.63; 95% CI=0.48, 0.83), to have a family history of suicide (OR=0.08; 95% CI=0.01, 0.61), or to leave a suicide note (OR=0.37; 95% CI=0.26, 0.52). CONCLUSIONS: Future research should consider that Black suicide decedents are less likely to report depression than White suicide decedents. This suicide risk difference is important when developing effective suicide prevention programs.

Asthma management practices among children in Georgia.

BACKGROUND: Asthma self-management, the involvement of patients or their caregivers in the management of their disease, reduces healthcare visits and costs. We assessed selected asthma self-management practices among a representative sample of children in Georgia to guide statewide asthma control programs. METHODS: A random-digit-dialed telephone survey of 2,121 households with 3,896 children 17 years of age or younger was conducted. Primary caretakers were asked about asthma and medication use of their children. Child data were weighted according to the number of telephone lines in the household and to the 2000 Georgia Census population. RESULTS: Approximately 10 percent of children in Georgia had asthma. Among children with asthma, 30 percent did not have regular asthma checkups and 66 percent did not have a written management plan; 19 percent filled 2 or more prescriptions per year for quick-relief medicine but did not take control medication. For children with asthma for whom tobacco exposure was a known trigger, 35 percent were exposed to tobacco smoke in the home. CONCLUSIONS: Opportunities exist to improve self-management, pharmacotherapy, and exposure to triggers for children with asthma. These data can be used to guide organizations and agencies working to reduce the burden of asthma.

A survey of sexually transmitted diseases/HIV coinfection testing and reporting practices among health care providers in New Jersey.

OBJECTIVES: A survey was conducted to ascertain the adherence of health care providers (HCPs) to national guidelines recommending human immunodeficiency virus (HIV) testing among persons with sexually transmitted diseases (STDs) and STD testing among HIV-infected persons. STUDY: A random sample of HCPs reporting STD and HIV cases in New Jersey were surveyed regarding their STD/HIV testing and reporting practices. RESULTS: Questionnaires were returned by 90 of 162 (55.5%) STD and 73 of 135 (54.1%) HIV HCPs. Sixty-six percent of STD HCPs reported offering HIV testing to persons with gonorrhea, chlamydia, or syphilis. However, up to 42.1% of HIV HCPs who managed HIV-positive patients never or almost never performed initial STD screening in these patients. Among HIV-infected patients, 36.4% of HIV HCPs reported that they never or almost never conducted annual gonorrhea or chlamydia screening in women; 48.6% never conducted screening in men. CONCLUSIONS: Further efforts are needed to optimize the implementation of national guidelines for STD/HIV coinfection testing.

Administrative data as a tool for arthritis surveillance: estimating prevalence and utilization of services.

The public health burden of arthritis and related conditions is incompletely described by commonly used public health surveillance systems. We examined the potential of administrative data as a supplement. The administrative data sources we used underestimated the prevalence of arthritis and overestimated service utilization for persons with arthritis when data from only one year were used. The use of five year's data doubled the prevalence estimate and reduced the service utilization estimate by half. The demographics of the population covered by administrative data also influence the prevalence estimate. Administrative data may usefully supplement routine public health surveillance systems but must be used with caution.

Findings from STD screening of adolescents and adults entering corrections facilities: implications for STD control strategies.

BACKGROUND: Persons entering corrections facilities are at high risk for sexually transmitted diseases (STDs) because of risky sexual behavior and lack of access to routine screening. GOAL: The goal of the study was to develop a national picture of STD prevalence in this population. STUDY DESIGN: We analyzed information on age, race/ethnicity, urethral symptoms (men only), and test results for approximately 85,000 chlamydia, 157,000 gonorrhea, and 293,000 syphilis tests for persons entering 23 jails and 12 juvenile detention centers in 13 US counties from 1996 through 1999. RESULTS: At adult jails in nine counties, the median percentage of persons with reactive syphilis tests by county was 8.2% (range, 0.3-23.8%) for women and 2.5% (range, 1.0-7.8%) for men. At juvenile detention facilities in five counties, the median positivity for chlamydial infection was 15.6% (range, 8.0-19.5%) for adolescent girls and 7.6% (range, 2.8-8.9%) for adolescent boys; the median positivity for gonorrhea was 5.2% (range, 3.4-10.0%) for adolescent girls and 0.9% (range, 0.7-2.6%) for adolescent boys. Of adolescent boys testing positive for chlamydial infection at three juvenile facilities, approximately 97% did not report symptoms; of adolescent boys positive for gonorrhea, 93% did not report symptoms. CONCLUSION: STD positivity among persons entering corrections facilities is high. Most chlamydial and gonococcal infections are asymptomatic and would not be detected without routine screening. Monitoring the prevalence of STDs in this population is useful for planning STD prevention activities in corrections facilities and elsewhere in the community.

Screening women in jails for chlamydial and gonococcal infection using urine tests: feasibility, acceptability, prevalence, and treatment rates.

BACKGROUND: Women entering jails are at high risk for sexually transmitted diseases; however, screening for chlamydial and gonococcal infection is not routinely performed in most jails. New urine tests have made it easier to screen for these infections in nonclinical settings. GOAL: The feasibility and acceptability of urine-based screening for women entering jails and the prevalence of and treatment rates for chlamydial and gonococcal infections were determined. STUDY DESIGN: Women entering jails in Chicago, Illinois; Birmingham, Alabama; and Baltimore, Maryland, who signed consent forms were tested for chlamydial and gonococcal infection by means of the urine ligase chain reaction assay. Those testing positive were treated in jail; health department staff members attempted to contact those already released. RESULTS: Most women who were approached agreed to be tested (range, 87-98%, depending on city), and most of these women provided a specimen (range, 92-100%). Among 5364 women aged 16 to 75 years who were tested, the prevalence of chlamydial and gonococcal infections was high, especially among those <25 years of age (range, 15.3-21.5% for chlamydial infection and 8.2-9.2% for gonorrhea, depending on city). The majority of women testing positive were treated in jail or outside of jail (61-85%). CONCLUSIONS: Screening women in jails for chlamydial and gonococcal infection with urine tests is feasible, is acceptable to most women, and leads to detection and treatment of many infections. Routine screening should reduce medical complications in this population and should prevent transmission in the community, given that many women are soon released.