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Objective: To investigate the effect of performance-based financial incentives on the influenza immunization rate in primary care physicians' offices. Design: Randomized controlled trial during the 1991 influenza immunization season. Setting: Rochester, New York, and surrounding Monroe County during the Medicare Influenza Vaccine Demonstration Project. Participants: A total of 54 solo or group practices that had participated in the 1990 Medicare Demonstration Project. Interventions: All physicians in participating practices agreed to enumerate their ambulatory patients aged 65 or older who had been seen during the 1990 or 1991 calendar years, and to track the immunization rate on a weekly basis using a specially designed poster from September 1991 to January 1, 1992. Additionally, physicians agreed to be randomized, by practice group, to the control group or to the incentive group, which could receive an additional $.80 per shot or $1.60 per shot if an immunization rate of 70% or 85%, respectively, was attained. Measurements: The main outcome measures are the 1991 immunization rate and the improvement in immunization rate from the 1990 to 1991 influenza seasons for each group practice. Results: For practices in the incentive group, the mean immunization rate was 68.6% (SD 16.6%) compared with 62.7% (SD 18.0%) in the control group practices (P = .22). The median practice-specific improvement in immunization rate was +10.3% in the incentive group compared with +3.5% in the control group (P = .03). Conclusions: Despite high background immunization rates, this modest financial incentive was responsible for ∼7% increase in immunization rate among the ambulatory elderly.

OBJECTIVE: To determine the incidence and risk factors associated with aspiration in a high risk group in a long-term care setting. DESIGN: A prospective study of demographic, nutritional, clinical, dental, and survival characteristics in 69 patients who suffered 98 aspiration events from May 1, 1990, to December 31, 1990. Demographic and nutritional data from 192 patients who did not aspirate were collected from September 1991 to December 1991. SETTING: A long-term care VA facility. PATIENTS: Long-term care residents, most of whom were neurologically debilitated. MEASUREMENTS: The incidence of aspiration was measured and the clinical and microbiological characteristics of aspiration-associated nosocomial pneumonia described. Mortality and demographic, clinical, and nutritional characteristics were compared between patients who aspirated and those who did not. MAIN RESULTS: Twenty-five percent of the study group aspirated during the 8-month observational period, and 56% of the aspiration events progressed to roentgenographically proven cases of nosocomial pneumonia. Six bacteremic episodes were documented, and results of sputum cultures were consistent with mixed Gram-positive and Gram-negative infections. During the study period, patients who aspirated were at three times the risk of dying compared with patients who did not aspirate. Three years later, only 17% of the original group of patients who aspirated were still alive compared with 60% of the patients who had not aspirated. Multivariate analysis identified tube feeding, presence of a hyperextended neck or contractions, malnutrition, and the use of benzodiazepines and anticholinergics as risk factors. CONCLUSIONS: Pulmonary aspiration is a common and serious event in neurologically impaired long-term care patients. Some risk factors are amenable to change.

Group A meningococcal disease has been an important public health problem in sub-Saharan Africa for over a century. Outbreaks occur there annually, and large epidemics occur at intervals ranging between 8 and 12 y. The Meningitis Vaccine Project was established in 2001 with funding from the Gates Foundation with the goal of developing, testing, licensing, and introducing an affordable group A meningococcal conjugate vaccine into Africa. From 2003 to 2009 a monovalent group A conjugate vaccine, MenAfriVac(TM) , was developed at the Serum Institute of India, Ltd through an innovative public/private partnership. Preclinical studies of the new conjugate vaccine were completed in 2004 and a Phase 1 study began in India in 2005. Phase 2/3 studies in African 1-29 y olds were completed in 2009 showing the new meningococcal A conjugate vaccine to be as safe as currently licensed meningococcal polysaccharide vaccines, but much more immunogenic. After Indian market authorization (December 2009) and WHO prequalification (June 2010), MenAfriVac(TM) was introduced at public health scale using a single 10 µg dose in individuals 1-29 y of age in Burkina Faso, Mali, and Niger in December 2010. We summarize the laboratory and clinical studies leading to prequalification of MenAfriVac(TM). The 2011 epidemic season ended with no reported case of group A meningitis in vaccinated individuals.

The conquest of poliomyelitis by killed and live poliomyelitis vaccines is arguably the most successful American public health project. In 1950, 20,000 cases of paralytic poliomyelitis were reported in the United States, whereas in recent years, fewer than 10 cases were reported. These few cases were largely associated with oral vaccine and despite their small number have led to a reconsideration of killed vaccine as a public health measure in the United States.

BARTLETT AND MUNDY,1in a recent update on community-acquired pneumonia, accurately commented that "few diseases are so characterized by disputes about diagnostic evaluation and therapeutic decisions." Two major problems that contribute to the controversy in the management of these infections are the lack of sensitive and specific tests to establish a causative diagnosis rapidly and the absence of rigorous outcome studies to help define pathways of care for patients with lower respiratory tract infections. Little progress has been made on the first problem, but considerable headway has occurred on the second, as exemplified by the 2 articles on admission and discharge criteria for patients with community-acquired lower respiratory tract infections that are in this issue of theArchives.2,3 The reasons for deciding whether patients with pneumonia should be hospitalized have, until recently, been arbitrary and poorly defined. This has led to great variability in who is hospitalized for

✓ Thirty-eight of 154 cases (25%) of bacterial meningitis seen by the authors during a 7-year period were due to non-pneumococcal Gram-positive cocci. Thirty cases (80%) resulted from neurosurgical manipulation; half of these were shunt infections and half were early postoperative complications. Only three cases (8%) occurred de novo in patients with presumably normal host defenses. Signs, symptoms, and laboratory data related more to predisposing factors than to infecting microorganisms. Fever, peripheral leukocytosis, abnormal cerebrospinal fluid (CSF), and positive Gram stain were the most reliable indicators of infection. Prognosis was good with antibiotic therapy and removal of CSF shunt equipment when present.

Center (NCDC) of the U.S. Public Health Service, collaborating with state epidemiologists, established a nationwide system of tetanus surveillance. The purpose of this system was to collect relevant clinical and epidemiologic data and, insofar as treatment was concerned, data on serologic and antimicrobial therapy on all cases of tetanus reported in the United States. The epidemiologic and clinical features of tetanus in the United

(1969). Epidemiologic Study of a Fatal Case of Inhalation Anthrax. Archives of Environmental Health: An International Journal: Vol. 18, No. 5, pp. 798-805.

We report a case of aortic valve homograft endocarditis secondary to preoperative contamination of the homograft. Candida precipitins, determined by double immunodiffusion, were an invaluable aid in diagnosis in the presence of negative venous blood cultures.

This study provides the background recommendations of the US Preventive Services Task Force for interventions by primary care physicians to prevent sexually transmitted diseases. Rationale for and data supporting use of barrier methods, epidemiologic treatment, contact tracing, patient education, prophylactic antibiotics, and disease reporting are discussed. Specific recommendations include those for gonorrhea, syphilis, human immunodeficiency virus infection, enteric infections, human papillomavirus infection, herpes simplex virus infection, andChlamydia trachomatisinfection. (JAMA1987;258:814-821)