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Supplemental Digital Content is available in the text, Objective: To estimate the association between weather and COVID-19 fatality rates during US stay-at-home orders. Methods: With a county-level longitudinal design, this study analyzed COVID-19 deaths from public health departments’ daily reports and considered exposure as the 18 to 22 day-period before death. Models included state-level social distancing measures, Census Bureau demographics, daily weather information, and daily air pollution. The primary measures included minimum and maximum daily temperature, precipitation, ozone concentration, PM2.5 concentrations, and U.V. light index. Results: A 1 °F increase in the minimum temperature was associated with 1.9% (95% CI, 0.2% to 3.6%) increase in deaths 20 days later. An ozone concentration increase of 1 ppb (part per billion) decreased daily deaths by 2.0% (95% CI, 0.1% to 3.6%); ozone levels below 38 ppb negatively correlated with deaths. Conclusions: Increased mobility may drive the observed association of minimum daily temperature on COVID-19 deaths.

Wearing a facial mask can limit COVID-19 transmission. Measurements of communities’ mask use behavior have mostly relied on self-report. This study’s objective was to devise a method to measure the prevalence of improper mask use and no mask use in indoor public areas without relying on self-report. A stratified random sample of retail trade stores (public areas) in Louisville, Kentucky, USA, was selected and targeted for observation by trained surveyors during December 14–20, 2020. The stratification allowed for investigating mask use behavior by city district, retail trade group, and public area size. The total number of visited public areas was 382 where mask use behavior of 2,080 visitors and 1,510 staff were observed. The average prevalence of mask use among observed visitors was 96%, while the average prevalence of proper use was 86%. In 48% of the public areas, at least one improperly masked visitor was observed and in 17% at least one unmasked visitor was observed. The average prevalence of proper mask use among staff was 87%, similar to the average among visitors. However, the percentage of public areas where at least one improperly masked staff was observed was 33. Significant disparities in mask use and its proper use were observed among both visitors and staff by public area size, retail trade type, and geographical area. Observing unmasked and improperly masked visitors was more common in small (less than 1500 square feet) public areas than larger ones, specifically in food and grocery stores as compared to other retail stores. Also, the majority of the observed unmasked persons were male and middle-aged.

The proliferation of webinars and other similar web-based educational offerings attests to the interest in this instructional modality on the part of educators and learners in the public health workforce. While certain advantages of Internet-based training, including time and costs savings for learners, are evident, it is important to establish the impact of this medium on a variety of health care disciplines. To this end, a search was performed of individual studies and review articles published since 2005 that discuss the use of these methodologies by several disciplines in the domain of public health, with particular attention on randomized controlled trials and meta-analytic studies. Reports over the past decade support the belief that the health care workforce is generally satisfied with Internet-based training and that this type of training yields measurable changes in knowledge and behavior. Overall, the data strongly suggest that these techniques are better than no intervention and essentially equivalent to conventional instructional techniques. However, the specific elements that actually improve the educational value of web-based educational technologies and the evidence base for best practices in the field have yet to be identified.

Background: In 1995, a yearly drive-thru immunization program was initiated in Louisville, KY. Since then, more than 50,000 doses of influenza vaccine have been administered, with no reports of syncopal episodes or vehicular accidents. This report aimed to identify reported adverse events from other areas that could threaten drive-thru mass immunization approaches.Methods: To identify reported adverse events in any drive-thru mass immunization event, the authors queried the following sources: 1) the vaccine adverse event reporting system, 2) court cases, 3) healthcare risk management databases, 4) MEDLINE, and 5) communication with vaccine experts. The authors also calculated the probability of syncopal episodes using data from our past immunization experiences to further elucidate the possibility of these events occurring.Results: No adverse events due to a drive-thru mass immunization event were identified in any of the sources queried. In our data, the forecasted probability of one adverse event was 0.8 percent for a 2-day event (20,000 immunizations).Conclusions: Although syncope may occur following immunization, it is a risk that can be managed, and due to the rarity of these events, should not be used as a reason to avoid drive-thru administration of influenza vaccine.

In September 2003, a consortium of bioterrorism and health education experts from the University of Louisville, the University of Kentucky, the Kentucky Department for Public Health, and the Louisville Metro Health Department received funding from the Health Resources and Services Administration (HRSA) to develop a broadly based bioterrorism education program for health professionals in the Commonwealth of Kentucky and the surrounding region. This grant will fund a series of presentations tailored to the needs of professionals in medicine, dentistry, public health, nursing, behavioral medicine, allied health, pharmacy, veterinary medicine, and agriculture, providing coordinated training both on site and through distance learning technology. This article outlines the major grant-funded activities envisioned for the grant years 2003 through 2005, focusing on the use of standardized patients and computerized biosimulators, the transdisciplinary partnerships of the universities involved, and the essential collaboration provided by the state and local health departments.

ContextInfluenza vaccination lowers, but does not eliminate, the risk of influenza. Making a reliable, rapid clinical diagnosis is essential to appropriate patient management that may be especially important during shortages of antiviral agents caused by high demand.ObjectivesTo systematically review the precision and accuracy of symptoms and signs of influenza. A secondary objective was to review the operating characteristics of rapid diagnostic tests for influenza (results available in

Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely. The lack of the classic migration of pain, right lower quadrant pain, guarding, or fever makes appendicitis less likely. This article reviews the literature evaluating the operating characteristics of the most useful elements of the history and physical examination for the diagnosis of appendicitis.

Background Healthcare-associated infections are a major source of morbidity and mortality in the United States. Infection Preventionists (IPs) are healthcare workers tasked at overseeing the prevention and control of these infections, but they may have difficulties obtaining up-to-date information, primarily in rural states. The objective of this study was to evaluate the importance of public health involvement on the knowledge-sharing network of IPs in a rural state. Findings A total of 95 attendees completed our survey. The addition of public health professionals increased the density of the network, reduced the number of separate components of the network, and reduced the number of key players needed to contact nearly all of the other network members. All network metrics were higher for public health professionals than for IPs without public health involvement. Conclusions The addition of public health professionals involved in healthcare infection prevention activities augmented the knowledge sharing potential of the IPs in Iowa. Rural states without public health involvement in healthcare-associated infection (HAI) prevention efforts should consider the potential benefits of adding these personnel to the public health workforce to help facilitate communication of HAI-related information.

Background Guidelines exist that recommend specific vaccines for health care personnel and supporting documents provide guidance for program development and implementation, but the extent to which those guidelines have been implemented in health care personnel immunization programs has not been fully explored. This project aimed to evaluate current practices in US health care facilities concerning health care personnel immunization programs. Methods A Web-based survey was deployed to 13,670 infection preventionists to assess 5 major program areas: (1) immunization program management; (2) vaccines provided to health care personnel; (3) vaccine handling practices; (4) training provided for the individual(s) responsible for the program; and (5) quality indicators for the program. A scoring scale was developed that demonstrated an overall measure of program performance. Results The Web-based survey resulted in 1,006 completed responses. When assessing overall program performance, the median vaccine program score was 47.6%. Respondents certified in infection prevention (CIC) scored significantly higher in overall program performance than respondents not certified (54% vs, 43%, respectively, P = .003). Conclusion Results of the survey have identified a number of education and training opportunities that can be addressed by professional associations using available evidence-based and proven implementation materials as resource documents.

To attempt to validate a previously reported clinical prediction rule derived to assist in distinguishing between acute bacterial meningitis and acute viral meningitis.Retrospective chart review of patients treated at five hospitals between 1981 and 1990. The criterion standard for bacterial meningitis was a positive cerebrospinal fluid (CSF) or blood culture or a positive test for bacterial antigen in the CSF. For viral meningitis, the criterion standard was a positive viral culture from CSF, stool, or blood or a discharge diagnosis of viral meningitis with no other etiology evident.Two Department of Veterans Affairs (VA) hospitals, two county hospitals, and one private hospital, each affiliated with one of two medical schools.All persons aged more than 17 years who were hospitalized over a ten-year period at one of five academically affiliated hospitals for the management of acute meningitis.Sixty-two cases of bacterial meningitis and 98 cases of viral meningitis were confirmed. With all patients included, the discriminatory power of the model as measured by the area under the receiver operating characteristic curve (AUC) was 0.977 (95% CI, 0.957-0.997), compared with the AUC of 0.97 in the derivation set of the original publication. The AUCs (95% CIs) for data subsets were: Dallas cases 0.994 (0.986-1.0). Milwaukee cases 0.912 (0.834-0.990); ages 18-39 years 0.952 (0.892-1.0), ages 40-59 years 0.99 (0.951-1.0), and ageor = 60 years 0.955 (0.898-1.0).The authors conclude that the clinical prediction rule proved robust when applied to a geographically distinct population comprised exclusively of adults. There was sustained performance of the model when applied to cases from each city and from three age strata. Prospective validation of this prediction rule will be necessary to confirm its utility in clinical practice.

Hurricane Katrina of August 2005 forced more than one million people to evacuate the Gulf Coast of the United States. This study examines the psychological health and well-being of a subset of evacuees to determine the prevalence of ongoing mental health problems. Interviews were conducted with 101 adults who evacuated to Louisville, Kentucky, and were living in the state at the one-year anniversary of the event or had recently returned to the Gulf Coast. The psychological health and well-being of respondents was evaluated using several well-validated measures. More than one-half met the criteria for post-traumatic stress disorder and a majority were suffering from depression and anxiety. The mean quality of life score was 0.6 on a scale from 0-1, suggesting that adaptation and return to pre-hurricane well-being had not occurred 12 months after the storm. The potential for long-term psychological damage exists in this sample of Hurricane Katrina evacuees. Results suggest other evacuees may also be at heightened risk.

To determine the frequency of ACE inhibitor cough in an outpatient medical clinic population, a cross-sectional epidemiologic survey using mailed questionnaires was done. Patients were randomly selected from a computerized hospital pharmacy data base. The overall prevalence of cough was 19 percent in the ACE inhibitor groups compared with 9 percent in the hydrochlorothiazide-treated group. The observed odds ratio for cough among ACE inhibitor users was 2.3 (95 percent CI, 1.02 to 5.00). This study is the first systematic investigation of frequency and characteristics of ACE inhibitor cough that includes a control group. Our results suggest that cough may more frequently accompany treatment with ACE inhibitors than has been previously reported. We recommend that physicians specifically inquire about cough in patients taking an ACE inhibitor. Recognition of this side effect may prevent unnecessary testing and treatment of patients receiving ACE inhibitors. (Chest 1991; 99:36–39)

To determine the current level of use, characteristics, and perceived value of the clinicopathologic conference (CPC), we sent a 22-item survey questionnaire to the program directors of internal medicine residency training programs. Of the 278 residency training programs that returned questionnaires, 221 (80%) indicated that they held CPCs regularly. The conference received a mean rating (Likert scale 1 = best to 5 = worst) of 2.2 (95% confidence interval 2.2, 2. 3) for both its perceived educational value and its popularity. The CPC remains widely used in internal medicine training programs. Although relatively few programs have rigorous guidelines for preparation and evaluation of their presentations, the CPC is generally viewed as being popular and having sound educational value.

The objective of this paper was to determine predictors of complementary and alternative medicine (CAM) use among individuals with specific health problems. Data were derived from the 1998 Medical Expenditure Panel Survey (MEPS). After adjustment for potential confounders, individuals with perceived barriers to obatining care were more likely to use any CAM treatment (OR 2.16), herbal therapy (OR 2.70) and spiritual care (OR 3.99) for a specific health problem. Individuals dissatisfied with their family's access to care were more likely to use acupuncture (OR 3.43). Dissatisfaction with quality of care was associated with increased use of spiritual therapy (OR 4.74). Perceptions of inadequate access to health care may contribute to utilization of CAM therapies; such therapies in this instance appear to be used as an alternative to mainstream medicine.

To establish rates of and risk factors for cardiac complications after noncardiac surgery in veterans.Prospective cohort study.A large urban veterans affairs hospital.One thousand patients with known or suspected cardiac problems undergoing 1,121 noncardiac procedures.Patients were assessed preoperatively for important clinical variables. Postoperative evaluation was done by an assessor blinded to preoperative status with a daily physical examination, electrocardiogram, and creatine kinase with MB fraction until postoperative day 6, day of discharge, death, or reoperation (whichever occurred earliest). Serial electrocardiograms, enzymes, and chest radiographs were obtained as indicated. Severe cardiac complications included cardiac death, cardiac arrest, myocardial infarction, ventricular tachycardia, and fibrillation and pulmonary edema. Serious cardiac complications included the above, heart failure, and unstable angina.Severe and serious complications were seen in 24% and 32% of aortic, 8.3% and 10% of carotid, 11.8% and 14.7% of peripheral vascular, 9.0% and 13.1% of intraabdominal/intrathoracic, 2.9% and 3.3% of intermediate-risk (head and neck and major orthopedic procedures), and 0.27% and 1.1% of low-risk procedures respectively. The five associated patient-specific risk factors identified by logistic regression are: myocardial infarction6 months (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.9 to 12.9), emergency surgery (OR, 2.6; 95% CI, 1.2 to 5.6), myocardial infarction6 months (OR, 2.2; 95% CI, 1.4 to 3.5), heart failure ever (OR, 1.9; 95% CI, 1.2 to 3.0), and rhythm other than sinus (OR, 1.7; 95% CI, 0.9 to 3.2). Inclusion of the planned operative procedure significantly improves the predictive ability of our risk model.Five patient-specific risk factors are associated with high risk for cardiac complications in the perioperative period of noncardiac surgery in veterans. Inclusion of the operative procedure significantly improves the predictive ability of the risk model. Overall cardiac complication rates (pretest probabilities) are established for these patients. A simple nomogram is presented for calculation of post-test probabilities by incorporating the operative procedure.

Human sexual intercourse, or coitus, is one of the most common sexual outlets among adults. Sexual intercourse generally refers to penile penetration of the vagina, the most common sexual expression between opposite-sexed partners practiced in the United States. In a large national survey study of more than 3,000 participants, Laumann, Gagnon, Michael, and Michaels (1994) found that 95% of men and 97% of women report that they have experienced vaginal intercourse. Other sexual techniques with opposite-sex partners include mutual masturbation, anal intercourse, and oral sex (both cunnilingus, i.e., male mouth on female genitalia, and fellatio, i.e., female mouth on male genitalia). Although less common than vaginal intercourse both in terms of life incidence and most recent experience, these sexual expressions are more openly discussed in the media and more frequently practiced than in the past, especially among adolescents (Weiss & Bullough, 2004). Keywords: coitus; intimacy; sexual standards

The revised international health regulations recognise the importance of shortening the time from a disease outbreak to its detection and notification to the international public health community so that effective responses that enhance global biosecurity can be taken. The new international health regulations aim at requiring countries to issue alerts early enough so that responses can be initiated in a timely manner. But these regulations represent a real challenge for achieving early detection and translating notification into effective public health actions that reduce the risks of mass casualties from emerging infectious diseases and bioterrorism. Coordinated early warning mechanisms to facilitate rapid recognition of a disease outbreak are needed so that an effective response within the medical and public health communities can be initiated. Effective training is essential for early recognition of rare biothreat diseases; such training needs to be realistic to achieve an effective response. Responder and system capabilities should be verified periodically through the use of full-scale exercises or virtual drills. Such training and skills are critical for achieving biosecurity.

The cumulative risk of human immunodeficiency virus (HIV) infection over a healthcare career has rarely been estimated, but is more relevant to the description of an occupational hazard than the risk of seroconversion from a single exposure. We describe a model for assessing the individualized risk for HIV infection after multiple potential exposures over many years for surgeons and other operating room personnel, a high-risk group. For the average surgeon operating over a 30-year career on patients with an HIV seroprevalence of 0.01, the cumulative risk is estimated at 1%. The same surgeon operating on patients with a seroprevalence of 0.10 has an estimated cumulative risk of 10%. These risks may vary dramatically depending on the assumed rate of skin punctures during surgery. Healthcare workers need to be aware of the cumulative risk from multiple exposures to infectious blood and body fluids, to follow proposed suggestions for the reduction of percutaneous blood exposures and to assist in developing new technology to further reduce these risks. Failure to protect these professionals could result in the reduction of services for the approximately 1 to 1.5 million HIV-infected persons in the United States.

It has been shown that potential exposure to patients infected with the human immunodeficiency virus (HIV) should be a concern for emergency services personnel, based on the seroprevalence of HIV among severely injured or critically ill patients.1 Moreover, emergency services personnel have been surveyed about their knowledge and attitudes toward the acquired immunodeficiency syndrome (AIDS) and hepatitis B, revealing substantial fears about contracting AIDS but an underestimate of the occupational risk of hepatitis B virus (HBV) infection.2 However, to this author's knowledge, there are no published accounts of the evacuation of HIV-infected patients during an actual hospital fire and its infection control consequences. This article was written to provide infection control practitioners with information on how to reduce the potential for chaos and unwarranted concern resulting from such an emergency.

Objective. —To determine the optimal method to increase influenza immunization rates of medical house staff and students. Design. —Prospective randomized trial and cross-sectional survey. Study Group. —Four hundred forty-two internal medicine, obstetricsgynecology, and general surgery residents and junior medical students. Measurements. —The four interventions employed were (1) an educational memorandum outlining vaccine indications sent to all study group members, (2) a personal letter mailed to a random sample of half of the remaining unimmunized persons, (3) a telephone call to half of the unimmunized letter recipients, and (4) vaccine offered directly to the remaining unimmunized persons in clinics and conferences. In addition, a questionnaire was administered to all persons requesting or offered vaccine. Main Results. —During the 3 weeks after the memorandum, 87 (20%) of 442 persons were immunized. Five weeks after the letter, 61 (34%) of persons receiving a letter and 30(17%) of the no-letter controls ( P =.0005) had been immunized. After the telephone call, there was a statistically insignificant trend toward increased compliance. In clinics and conferences, 90% of persons reached were immunized and 10% refused, largely extinguishing the effect of prior interventions. At completion of the study, 275 (62%) of 442 participants were immunized, 29 (7%) refused, and 138(31%) were not reached. Questionnaire results revealed that only 32% had ever been previously immunized against influenza, yet 70% stated that they had worked despite having influenzalike symptoms. Conclusion. —A high rate of immunization of house staff and medical students can be achieved most effectively by offering vaccine in clinics and conferences. Continued education about influenza immunization is necessary for physicians and medical students. ( JAMA . 1992;267:1377-1380)

Varicella-zoster virus (VZV) transmission poses a major infection risk for health care workers in the hospital environment. Immunologically normal adults who contract varicella have 9 to 25 times the risk of major morbidity or death from infection compared with healthy children. Moreover, varicella infection during pregnancy is associated with a high rate of complications and the risk of the congenital varicella syndrome. To evaluate susceptibility to VZV infection among hospital workers, the employee health service screened 241 personnel for VZV antibody by the indirect fluorescent antibody technique. Overall, 7 (2.9%) of 241 personnel lacked VZV antibody and were therefore presumed susceptible to infection. Susceptibility varied dramatically by age and was significantly higher among persons 35 years of age and younger (7/93 = 7.5%) than among those aged 36 years and older (0/148 = 0%, p = 0.001). Persons 35 years old or younger with a clinical history of chickenpox or herpes zoster were much less likely to lack immunity (3/71 = 4.2%) than those stating they had no history of either (4/11 = 36.4%, p = 0.005). Screening strategies for VZV immunity in hospital employees could be made more efficient by performing serologic tests only on those persons aged 35 years or younger with a negative or uncertain history of the disease. Persons who lack antibody may be considered for preexposure immunization with live attenuated varicella vaccine as an alternative to varicella-zoster immune globulin or enforced absence from patient care after exposure to a VZV-infected patient.

The perceptual stability of visual targets in the left vs. right visual fields was investigated by having Ss report the perceptual fragmentation of dim stimuli. The right visual field was found more stable than the left. This difference was not related to handedness but was significantly related to ocular dominance. Monocular results yielded significant laterality differences for the left eye, but not the right eye. An interpretation based on sensory cerebral dominance and retinal sensitivity was advanced to account for the results.

To the Editor.— While the risk to immunocompetent persons for acquiring meningococcal meningitis in the United States is low, an increased risk for this potentially fatal infection is recognized in several areas of the world. Most recently, pretravel immunization has been recommended by the Centers for Disease Control for Americans traveling to (1) New Delhi 1 ; (2) the so-called meningitis belt of sub-Saharan Africa 2 (stretching from Mauretania in the west to Ethiopia in the east); (3) Saudi Arabia following the 1987 pilgrimages to Mecca and Medina 3 ; and (4) Nepal, especially for Himalayan trekkers. 4 Meningococcal vaccine administered as a single 0.5-mL subcutaneous dose has been shown to have 85% to 95% clinical efficacy in preventing illness due to serogroup A, the most common cause of epidemics outside the United States. 2 Vaccine reactions are usually mild and consist mainly of local erythema for 24 to 48 hours, with