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An estimated 115,000 firearm injuries occur annually in the United States, and approximately 70% are nonfatal (1). Retained bullet fragments (RBFs) are an infrequently reported, but important, cause of lead toxicity; symptoms are often nonspecific and can appear years after suffering a gunshot wound (2,3). Adult blood lead level (BLL) screening is most commonly indicated for monitoring of occupational lead exposure; routine testing of adults with RBFs is infrequent (3). States collaborate with CDC's National Institute for Occupational Safety and Health (NIOSH) to monitor elevated BLLs through the Adult Blood Lead Epidemiology and Surveillance (ABLES) program (4,5). To help assess the public health burden of RBFs, data for persons with BLLs ≥10 μg/dL reported to ABLES during 2003-2012 were analyzed. An RBF-associated case was defined as a BLL ≥10 μg/dL in a person with an RBF. A non-RBF-associated case was defined as a BLL ≥10 μg/dL without an RBF. During 2003-2012, a total of 145,811 persons aged ≥16 years with BLLs ≥10 μg/dL were reported to ABLES in 41 states. Among these, 457 RBF-associated cases were identified with a maximum RBF-associated BLL of 306 μg/dL. RBF-associated cases accounted for 0.3% of all BLLs ≥10 μg/dL and 4.9% of BLLs ≥80 μg/dL. Elevated BLLs associated with RBFs occurred primarily among young adult males in nonoccupational settings. Low levels of suspicion of lead toxicity from RBFs by medical providers might cause a delay in diagnosis (3). Health care providers should inquire about an RBF as the potential cause for lead toxicity in an adult with an elevated BLL whose lead exposure is undetermined.

Background.In September 1999, a pertussis outbreak was detected among surgical staff of a 138-bed community hospital. Patients were exposed toBordetella pertussisduring the 3-month outbreak period.Objective.To describe the outbreak among surgical staff, to evaluate implemented control measures, and to determine whether nosocomial transmission occurred.Methods.Clinical pertussis was defined as acute cough illness with a duration of 14 days or more without another apparent cause; persons with positive culture, PCR, or serologic test results were defined as having laboratory-confirmed pertussis. Surgical healthcare workers (HCWs) were interviewed regarding pertussis symptoms, and specimens were obtained for laboratory analysis. Patients exposed toB. pertussisduring an ill staff member's 3-week infectious period were interviewed by phone to determine the extent of nosocomial spread.Participants.A total of 53 HCWs assigned to the surgical unit and 146 exposed patients. HCWs with pertussis were defined as case subjects; HCWs without pertussis were defined as non-case subjects.Results.Twelve (23%) of 53 HCWs had clinical pertussis; 6 cases were laboratory confirmed. The median cough duration in the 12 case subjects was 27 days (range, 20-120 days); 10 (83%) had paroxysms. Eleven (92%) of 12 case subjects and 28 (86%) of 41 non-case subjects received antibiotic treatment or prophylaxis. Seven case subjects (58%) reported they always wore a mask when near patients. Of 146 patients potentially exposed to pertussis from the 12 case subjects, 120 (82%) were interviewed; none reported a pertussis-like illness.Conclusions.Surgical staff transmittedB. pertussisamong themselves; self-reported data suggests that these HCWs did not transmitB. pertussisto their patients, likely because of mask use, cough etiquette, and limited face-to-face contact. Control measures might have helped limit the outbreak once pertussis was recognized.

Previous studies of pertussis (whooping cough) that have derived diagnostic cut-off points for pertussis antibody levels have assumed a single distribution for antibody levels and have used small sample sizes. In a recent study of 5409 serum samples from the Third National Health and Nutrition Examination Survey (NHANES III), a finite mixture model was developed to examine the distribution of immunoglobulin G (IgG) antibody levels against pertussis toxin (PT), an antigen specific to the Bordetella pertussis bacterium. The mixture model identified three component populations with antibody levels greater than the quantitative assay's lower limit of quantitation (LLQ) and included a point distribution located at or below the LLQ to account for the excess number of antibody values that fell below the LLQ. The mixture model analysis accounted for the NHANES III design. A cut-off point for anti-PT IgG levels was chosen to have a 99 per cent model specificity based on the two overlapping normal distributions assumed for the two component populations with the highest antibody levels. This cut-off point may have a higher diagnostic sensitivity for acute B. pertussis infection than other cut-off points derived by assuming a single distribution for antibody levels.

An outbreak of pertussis in a US elementary school with high vaccination coverage was investigated to evaluate vaccine effectiveness and to identify potential contributing factors.Survey and cohort study of all 215 students of an elementary school (including 36 case patients) and 16 secondary cases among contacts.Fifty-two pertussis cases were identified (attack rate among students, 17%). Receipt of3 doses of pertussis-containing-vaccine compared with receipt of complete vaccination series was a significant risk factor for pertussis [relative risk, 5.1; 95% confidence interval (CI), 3 to 8.6]. The effectiveness of the complete vaccination series was 80% (95% CI 66 to 88). No evidence of waning immunity among students was found. The following contributing factors for the outbreak were identified: multiple introductions of pertussis from the community; delays in identification and treatment of early cases; and high contact rates among students. Antimicrobial treatment initiated14 days after cough onset was associated with increased risk of further transmission of pertussis (relative risk, 10.1; 95% CI 1.5 to 70.3) compared with treatment within 14 days of onset.This investigation demonstrated the potential for pertussis outbreaks to occur in well-vaccinated elementary school populations. Aggressive efforts to identify cases and contacts and timely antimicrobial treatment can limit spread of pertussis in similar settings. High vaccination coverage should be maintained, because vaccination significantly reduces the risk of the disease throughout the elementary school years, and to ensure timely diagnosis and treatment health care providers should maintain a high index of suspicion for pertussis among elementary school age children.

Objective: Researchers for this project evaluated compliance with the sequential poliovirus immunization schedule that uses inactivated poliovirus vaccine (IPV) for the first 2 doses of the polio immunization series, and assessed immunization coverage rates before and after implementation of this schedule at 6 public health clinics serving 1 county in Georgia. Design: Immunization histories for 3 birth cohorts of infants were compared: (1) the baseline cohort, born January 1 through June 30, 1995; (2) the evaluation cohort, born January 1 through June 30, 1997, after implementation of the schedule change; and (3) the dose-3 cohort, born August 1 through November 30, 1996 (i.e., old enough to be eligible for a third dose of poliovirus vaccine following implementation of the sequential schedule). Results: Following implementation of the new poliovirus immunization recommendations, 94% (534 of 567) of infants who received their first dose of poliovirus vaccine by age 3 months received IPV. Among these infants, 99.6% (532 of 534) were also up to date (UTD) for first doses of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTP1/DTaP1), 99.6% (532 of 534) were UTD for first doses of hemophilus influenza type b (Hib 1), and 98.6% (527 of 534) had received at least one dose of Hepatitis B. Among infants visiting the clinics for their first or second dose of poliovirus vaccine, DTaP/DTP, and/or Hib, 76% received 3 or 4 simultaneous injections. In the dose-3 cohort, 78% (145 of 185) of infants who received a third dose of poliovirus vaccine had received 2 doses of IPV and 1 dose of oral poliovirus vaccine. Conclusions: Compliance with the recommended use of IPV for the first 2 poliovirus immunization doses as part of the sequential schedule was very high in this low-income and ethnically diverse population. Furthermore, the need for additional injections did not impede the delivery of recommended childhood immunizations.

Background: A massive diphtheria epidemic which began in the former Soviet Union in 1990 is the first large-scale diphtheria epidemic in developed countries in more than 30 years and has primarily affected adults. In response, health authorities attempted to maximize vaccination for children and conducted an unprecedented campaign to vaccinate adults. Methods: We analyzed diphtheria surveillance data (case report forms and diphtheria vaccine coverage data) from three Russian regions from January 1994 to December 1996 and estimated vaccine effectiveness by the screening method. Results: We reviewed records from 2243 (97.2%) of 2307 reported cases. The highest cumulative incidence in the period was among children aged 5 to 9 years (106 cases per 100,000 population); adults aged 40–49 years had the highest adult incidence for disease (88 cases per 100,000) and the highest incidence of any age group of clinically severe disease (29 cases per 100,000) and death (5.1 deaths per 100,000). The incidence among women aged 20–49 years (82 per 100,000 women) was higher than among men (47 per 100,000, p

We analyzed national Haemophilus influenzae (Hi) surveillance data from 1994 and 1995 to describe the epidemiology of Hi invasive disease among persons of all ages. Serotype data were available for 376 (56%) of 669 reported Hi cases among children aged 4 years or younger; 184 (49%) were H. influenzae type b (Hib). Among children aged 4 or younger, incidence (per 100,000) of all Hi invasive disease was 1.8 in 1994 and 1.6 (p < 0.05) in 1995. Children aged 5 months or younger had the highest average annual incidence rate of Hib invasive disease (2.2 per 100,000); children aged 6 to 11 months had the next highest rate (1.2 per 100,000) (p < 0.05). Of 181 children with Hib invasive disease whose age in months was known, 85 (47%) were too young (aged 5 months or younger) to have completed a primary series with an Hib-containing vaccine. Of the 83 children with known vaccination status who were eligible to receive a primary series (aged 6 months or older), 52 (63%) were undervaccinated, and the remaining 31 (37%) had completed a primary series in which vaccine failed. Among persons aged 5 years or older with Hi invasive disease, the lowest average annual incidence was among those 20 to 39 years of age (0.15 per 100,000), and the highest was among those aged 80 years or older (2.26 per 100,000). Among persons aged 5 years or older, serotype data were available for 1,372 (71%) of the 1,940 Hi invasive disease cases; 159 (28%) of the 568 Hi cases with known serotype were due to Hib.

OBJECTIVES: The purpose of this study was to describe the epidemiologic, laboratory, and clinical features of respiratory diphtheria cases reported in the United States during 1980 through 1995. METHODS: Respiratory diphtheria cases reported to the Centers for Disease Control and Prevention were reviewed. Cases were defined as physician-diagnosed cases with signs and symptoms compatible with respiratory diphtheria, including the presence of a pseudomembrane without other apparent cause. RESULTS: From 1980 through 1994, 41 respiratory diphtheria cases were reported; none were reported in 1995, and no secondary cases were identified. Nine (22%) case patients were 4 years of age or younger, and 28 (68%) were 15 years of age or older. None of the case patients were up to date with diphtheria vaccination; 4 unvaccinated children died. Seventeen (43%) of 40 case patients had positive culture results. CONCLUSIONS: Available surveillance data suggest that respiratory diphtheria has become a rare disease in the United States. However, importation and circulation of toxigenic strains continue to present a threat and require achieving and maintaining high coverage with diphtheria toxoid-containing vaccines in both children and adults.

Most studies are unable to follow nonrespondents prospectively to determine whether their disease rates are comparable with those of the respondents. The authors followed respondents and nonrespondents to a mailed questionnaire, sent to a random sample of Iowa women aged 55-69 years in 1986 (total sample, 98,029; 43% response), to characterize 5-year mortality rates for myocardial infarction and all causes, and attack rates for breast, endometrial, colon, lung, and all-site cancers. Compared with respondents, nonrespondents had higher myocardial infarction (1.47 vs. 0.93 per 1,000 person-years) and all-cause (12.32 vs. 7.89 per 1,000 person-years) mortality. They also had substantially higher attack rates for lung cancer (1.45 vs. 1.10 per 1,000 person-years), and slightly higher attack rates for all-site cancer (11.86 vs. 10.89 per 1,000 person-years). The associations of reported body mass index (weight/height2) with the study endpoints were generally similar among respondents and the total eligible sample, except for a more pronounced U-shaped total mortality association for the nonrespondents. Thus, although the occurrence of several diseases, especially those related to smoking, differed among respondents and nonrespondents, the association of body mass index with cancer occurrence was not appreciably affected by nonresponse bias.

Background:During a hospital obstetric rotation, a medical student demonstrated classic symptoms of pertussis. The diagnosis was confirmed by isolation ofBordetella pertussis. Because this exposure occurred in a high-risk hospital setting, control measures were undertaken to prevent transmission and illness.Objectives:To identify secondary cases of pertussis, to determine compliance with chemoprophylaxis recommendations, and to monitor for adverse events associated with chemoprophylaxis following a hospital exposure to pertussis.Patients:More than 500 individuals were potentially exposed, including 168 neonates; antimicrobial chemoprophylaxis was administered to 281 individuals. Fifty-eight neonates and 194 adults began azithromycin chemoprophylaxis; 18 neonates and 2 adults began erythromycin chemoprophylaxis.Methods:Active surveillance was instituted for (1) secondary cases of pertussis among healthcare coworkers, obstetric patients, their neonates, and labor companions and (2) antibiotic compliance and tolerance.Results:No secondary cases of pertussis were confirmed by laboratory tests; however, 26 suspected cases and 5 clinically compatible cases were identified. Antibiotic courses were completed by 95% of the individuals who initiated therapy. Neonates taking azithromycin had statistically significantly less gastrointestinal distress compared with neonates taking erythromycin (12% vs 50%;P= .002); there were no cases of infantile hypertrophic pyloric stenosis.Conclusions:Although it was not possible to assess the effectiveness of the antibiotic regimens, the lack of laboratory-confirmed secondary cases suggests control measures were successful. Data from the 58 neonates who received azithromycin suggest it may be well tolerated in this age group.

In the United States in the 1990s, the incidence of reported pertussis in adults, adolescents and infants increased; infants younger than 1 year of age had the highest reported incidence.In 4 states with Enhanced Pertussis Surveillance, we examined the epidemiology of reported pertussis cases to determine the source of pertussis among infants. A source was defined as a person with an acute cough illness who had contact with the case-infant 7-20 days before the infant's onset of cough.The average annual pertussis incidence per 100,000 infants younger than 1 year of age varied by state: 22.9 in Georgia; 42.1 in Illinois; 93.0 in Minnesota; and 35.8 in Massachusetts. Family members of 616 (80%) of 774 reported case-infants were interviewed; a source was identified for 264 (43%) of the 616 case-infants. Among the 264 case-infants, mothers were the source for 84 (32%) and another family member was the source for 113 (43%). Of the 219 source-persons with known age, 38 (17%) were age 0-4 years, 16 (7%) were age 5-9 years, 43 (20%) were age 10-19 years, 45 (21%) were age 20-29 years and 77 (35%) were ageor =30 years.The variation in reported pertussis incidence in the 4 states might have resulted from differences in awareness of pertussis among health care providers, diagnostic capacity and case classification. Among case-infants with an identifiable source, family members (at any age) were the main source of pertussis. Understanding the source of pertussis transmission to infants may provide new approaches to prevent pertussis in the most vulnerable infants.

ContextReported cases of pertussis among adolescents and adults have increased since the 1980s, despite increasingly high rates of vaccination among infants and children. However, severe pertussis morbidity and mortality occur primarily among infants.ObjectiveTo describe the trends and characteristics of reported cases of pertussis among infants younger than 12 months in the United States from 1980 to 1999.Design, Setting, and ParticipantsCases of pertussis in infants younger than 12 months in the United States reported to the National Notifiable Disease Surveillance System of the Centers for Disease Control and Prevention between 1980 and 1999, and detailed case data from the Supplementary Pertussis Surveillance System.Main Outcome MeasuresIncidence and demographic and clinical characteristics of cases.ResultsThe incidence of reported cases of pertussis among infants increased 49% in the 1990s compared with the incidence in the 1980s (19 798 vs 12 550 cases reported; 51.1 cases vs 34.2 cases per 100 000 infant population, respectively). Increases in the incidence of cases and the number of deaths among infants during the 1990s primarily were among those aged 4 months or younger, contrasting with a stable incidence of cases among infants aged 5 months or older. The proportion of cases confirmed by bacterial culture was higher in the 1990s than in the 1980s (50% and 33%, respectively); the proportion of hospitalized cases was unchanged (67% vs 68%, respectively). Receipt of fewer doses of vaccine was associated with hospitalization, when cases were stratified by age in months.ConclusionsThe incidence of reported cases of pertussis among infants increased in the 1990s compared with the 1980s. The limited age group affected, the increased rate of bacteriologic confirmation, and the unchanged severity of illness suggest that an increase in infant pertussis has occurred apart from any change in reporting. Strategies are needed to prevent the morbidity and mortality from pertussis among infants too young to be fully vaccinated, according to the current recommended schedules of vaccination in the United States.

As part of a mailed health survey, we investigated the effect on the response rate of a request to explain refusal to participate. Subjects (N = 1,240) were randomized either to receive or not to receive, with the first mailing, a letter requesting an explanation of their decision not to fill out the questionnaire, if they chose that option. There was a slightly higher cumulative response during most of the study from subjects who had been sent the request, but little difference between the two study groups in the ultimate response rate [80% from the intervention group vs 83% from the control group; response rate difference = -3%; 95% confidence limits (CL) = -7%, 1%]. Of 209 individuals who were sent the request and did not return the questionnaire, only 15 (7%) sent back an explanation. A request to explain a refusal to participate in a mail survey neither jeopardized the response rate nor enhanced it.

The re-emergence of diphtheria in the Newly Independent States of the former Soviet Union in the 1990s raised global awareness of the potential for resurgent disease in countries with long-standing immunization programs. In the United States, the large population of susceptible adults and the possibility of a reintroduction of toxigenic strains of diphtheria create a setting in which diphtheria could spread. In addition, at least one focus of continued circulation of endemic toxigenic Corynebacterium diphtheriae has been identified. Few physicians now have expertise in the diagnosis and treatment of persons with diphtheria, and laboratory capacity is lacking throughout the country. These concerns highlight the importance of maintaining high levels of age-appropriate diphtheria toxoid vaccination, surveillance, accessible and reliable laboratory testing, and training of health care providers. Although the risk of resurgence of diphtheria in the United States is low, public health authorities must ensure that the capacity to recognize, diagnose, and control diphtheria is maintained. After 30 years of control, epidemic diphtheria, caused by toxigenic strains of Corynebacterium diphtheriae, re-emerged in the early 1990s in the Newly Independent States (NIS) of the former Soviet Union. The epidemic peaked in 1994‐1995 and was on the decline by 1996. This article reviews the diphtheria epidemic in the NIS, the epidemiology of diphtheria in the United States, and the implications of the NIS diphtheria epidemic for prevention of diphtheria in the United States. The Diphtheria Epidemic in the NIS In the late 1950s, universal childhood immunization with diphtheria toxoid was begun throughout the former Soviet Union, and the immunization program successfully controlled diphtheria for almost 30 years. In 1976, reported cases in the Soviet Union fell to !200 (incidence rate, 0.08/100,000 population) [1], compared with 1955, when 1100,000 cases were reported in Russia alone. During the 1970s, most of the reported cases were from the Central Asian Republics. In the mid-1980s, there was a small resurgence of almost 2000 cases per year, mostly in Russia, which was then followed by a decrease to 839 cases in 1989. a Deceased.

To determine correlates of and recent trends in aspirin use in middle-age men and women, we analyzed data from population-based samples selected in four U.S. communities. Aspirin use (during a 2-week period preceding the study examination) was more prevalent in whites than in blacks (30% vs 11%; p < 0.001) and in men than in women among whites (31% vs 28%; p < 0.002) but not blacks (10% in both sexes). In all four race and sex groups, there was a graded positive relation between estimated coronary heart disease (CHD) risk and age-adjusted prevalence of aspirin use. For example, 33% of CHD-free white men who reported diagnoses of hypercholesterolemia and hypertension and had ever smoked reported aspirin use as compared with 25% of their risk factor-free counterparts (p < 0.001). Among men with symptomatic CHD or at high risk for CHD, aspirin use increased by four percentage points between 1987 and 1989 in conjunction with the publication of results from the aspirin primary prevention trials. However, nearly 50% of participants reporting a history of myocardial infarction apparently did not take aspirin regularly.