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Laboratory investigations were conducted to study potential mechanisms for prolonged survival of Pseudomonas aeruginosa in poloxamer-iodine (PxI). P. aeruginosa organisms isolated from PxI and adapted for growth in distilled water or found as part of a mixed microbial population from water in a manufacturing plant did not survive more than 15 s after challenge in stock PxI solution. Batches of PxI were compounded in the laboratory to determine the survival and growth of P. aeruginosa during the various stages of preparation. No P. aeruginosa organisms were recovered from the finished product at 1 min after the addition of iodine-iodide. However, we found P. aeruginosa in PxI 48 h after adding sterile PxI to the inside of a naturally contaminated polyvinyl chloride water distribution pipe. These organisms (10(4) CFU/ml) survived for as long as 98 days in contaminated stock PxI after it was removed from the polyvinyl chloride pipe. Both decreasing the free iodine level through addition of potassium iodide and increasing the free iodine level through dilution of the product resulted in an increased length of survival of P. aeruginosa in contaminated PxI solution. Comparative survival studies with pipes of different composition revealed that other materials may exert an effect similar to polyvinyl chloride. We concluded that polyvinyl chloride and perhaps other materials may play an important role in the survival of P. aeruginosa in iodophors and may be one source of resistant microbial populations when used in manufacturing plants which produce these antimicrobial solutions.

Pseudomonas cepacia was recovered from the blood cultures of 52 patients in four hospitals in New York over 6 months from April through October 1980. Epidemiologic investigation in one hospital indicated that the positive results of blood culture represented pseudobacteremias and implicated a 10% povidone-iodine solution used as an antiseptic and disinfectant (Pharmadine; Sherwood Pharmaceutical Company, Mahwah, New Jersey) as the source of contamination. Physicians who drew blood cultures positive for P. cepacia were more likely to have left povidone-iodine on the skin before venipuncture (p = 0.026) and were more likely to have applied povidone-iodine to the blood culture bottle tops and to have left it there while inoculating the blood culture media (p = 0.007) than those who drew cultures negative for P. cepacia. Direct inoculation of Pharmadine into brain-heart infusion broth yielded P. cepacia; however, 2 weeks after the first cultures, the same Pharmadine bottles were culture negative. The iodine concentrations of the contaminated Pharmadine solutions were similar to those of 10% povidone-iodine solutions distributed by other manufacturers.

Objectives. We surveyed U.S. immunization program managers (IPMs) as part of a project to improve public health preparedness against future emergencies by leveraging the immunization system. We examined immunization program policy and Immunization Information System (IIS) functionality changes as a result of the Haemophilus influenzae type B (Hib) vaccine shortage and pandemic influenza A(H1N1) (pH1N1). Evaluating changes in immunization program functionalities and policies following emergency response situations will assist in planning for future vaccine-related emergencies. Methods. We administered three consecutive surveys to IPMs from 64 state, city, and territorial jurisdictions in 2009, 2010, and 2012. We compared IPMs' responses across either two or three years (e.g., changes in response or consistent responses across years) using McNemar's test. Results. Immunization programs maintained increases in functionality related to communication systems with health-care providers during this period. Immunization programs often did not maintain changes to IIS functionalities made from 2009 to 2010 (e.g., identifying high-risk and priority populations, tracking adverse events, and mapping disease risk) in the post-pandemic period (2010–2012). About half of IPMs reporting additional IIS functionality in identifying high-risk populations from 2009 to 2010 reported no longer having this function in 2012. There was an 18% decline in respondents reporting geographic information systems risk-mapping capability in IIS from 2010 to 2012. Conclusions. Because of the Hib vaccine shortage and pH1N1, immunization program needs and efforts changed to address evolving situations. The lack of sustained increases in resources or system functions after the pandemic highlights the need for comprehensive, sustainable public health emergency preparedness systems and related resources.

To determine the risk of hepatitis B virus infection for rural hospital employees, we obtained serum and a completed questionnaire from each of 2,064 employees of 11 rural hospitals. Only 96 (4.7%) employees had hepatitis B virus markers. Increased marker prevalence was significantly associated with prior residence in a city with a population of greater than 100,000 (odds ratio, 2.9; 95% confidence interval, 1.6 to 5.2) and increasing blood contact (odds ratio, 1.6; confidence interval, 1.2 to 2.3); however, the association with blood contact was not significant when we limited analysis to the 836 employees who had never lived in a city. We conclude that the risk of hepatitis B virus infection for these rural hospital employees is low, probably because the incidence of hepatitis B in rural areas is low. ( JAMA 1984;252:3270-3272)

To the Editor.— Dr Kubin 1 questions the relevance of many articles on acquired immunodeficiency syndrome (AIDS) for the practicing physician. This is understandable, because most patients visit their physician because of other problems, and the physician's primary responsibility is to address those needs. However, Dr Kubin understates both the magnitude of the human immunodeficiency virus (HIV)/AIDS epidemic and the role that physicians can play in stopping it. Dr Kubin predicted that 72 000 patients would be diagnosed with AIDS by 1990, but this was already exceeded by more than 10 000 at the end of 1988. He estimated that by 1990 the number afflicted will be less than 1 in 2000, but current estimates are that 1 in 200 may already be infected 2 . Furthermore, in some areas 3% of children are born to HIV-infected mothers 3 ; the epidemic will not end in 1990. We suspect that Dr Kubin

Improved public health surveillance can lead to earlier implementation of prevention and control measures. Better surveillance data lead to a more rational establishment of priorities. More timely and accurate data facilitate earlier epidemic detection and control. With better surveillance data, the impact of intervention activities and other public health programs can be evaluated more accurately. In this paper we describe how to improve the science of surveillance in terms of data collection, analysis, and dissemination and its application to public health practice. We then discuss the potential benefits and costs of such efforts and suggest methods for evaluating alternative approaches. The argument for science in surveillance, on the other hand, may be subject to excess. Surveillance is not an end unto itself, but rather a tool. This tool should be refined and modified to adapt to the goals of a particular public health program. It is the development of methods to apply creative ideas to surveillance, and the rigorous assessment of the process, that will benefit from the application of scientific principles.

In Reply.— Dr Poma is correct in his assumption that nurse A voluntarily agreed to the cultures that were obtained. Throat cultures were also obtained from other family members; these did not yield group A Streptococcus . However, six months later, when nurse A was discovered to be carrying and disseminating group A Streptococcus of a different serotype, repeated family cultures disclosed that her 5-year-old daughter carried group A Streptococcus of a similar serotype. The daughter had been symptomatic with fever and a sore throat and may have been the source of her mother's reaquisition of group A Streptococcus . The mother and daughter were both treated. Microbiological testing is important to confirm epidemiologic findings, to determine when to allow a person suspected to be a disseminator of infection to resume patient-care duties, and for the advancement of knowledge that might be useful in preventing similar outbreaks or in limiting their extent.

Reporting of cases of communicable disease is important in the planning and evaluation of disease prevention and control programs, in the assurance of appropriate medical therapy, and in the detection of common-source outbreaks. In the United States, the authority to require notification of cases of disease resides in the respective state legislatures. We examined the laws and regulations of health departments of all US jurisdictions to ascertain diseases and conditions currently required to be reported in each state or territory. We present herein the state reporting requirements for infectious diseases and infectious disease—related conditions. To obtain additional information regarding time frames for reporting, agencies to which reports are required, persons required to report, and specific conditions under which reports are required, the reader is referred to the statutes and health department regulations of the respective states. (JAMA. 1989;262:3018-3026)

During a 3-month period, Pseudomonas cepacia was recovered from the peritoneal fluid of 10 patients having chronic dialysis therapy at a peritoneal dialysis center. Six patients developed clinical evidence of peritonitis; one patient developed septicemia. Epidemiologic studies showed that dialysis on specific peritoneal dialysis machines was associated with an increased risk of infection. Laboratory investigation showed contamination of two machines with P. cepacia. Inadequacies in the cleaning and disinfection practices of the automatic peritoneal dialysis machines were identified. Cross-contamination between machines probably occurred through the peritoneal fluid discharge from infected patients during dialysis. Also, the intermittent 2-hour exposure of the machine to 2% formaldehyde may have been inadequate. P. cepacia has not been isolated from the peritoneal fluid of any peritoneal dialysis patient after machine cleaning and disinfection practices were altered.

Why should physicians know how to complete death certificates? What diseases must be reported to health departments? While these questions may not titillate all readers ofThe Journal, the fact is that mortality and morbidity data provided by clinical practitioners serve as the foundation of essential databases used for planning, implementing, and evaluating health programs at all levels in the United States. As such, the role played by the practitioner in reporting health data has far-reaching effects on our nation's health programs. The medical literature has increasingly focused attention on the implications for accuracy in completing death certificates and other forms that are essential to meet the health information needs of the United States. For example, articles inThe Journaland other publications have recently addressed topics such as uses of multiple-cause-of-death data, reporting of congenital malformations, the imperative of documenting tobacco use—related mortality, surveillance for infectious diseases, and the

Excerpt To the editor: Although penicillin is one of the commoner causes of anaphylactic reactions, fatal reactions to oral penicillin are rare, with only a few reports in the medical literature (1...

Physicians and other health care providers have reported more than 110 000 cases of the acquired immunodeficiency syndrome (AIDS) to local and state health departments in the United States since 1981, including 34 000 in the past 12 months alone. Surveillance of AIDS in the United States accounts for nearly 60% of cases reported to the World Health Organization by 152 nations, 1 reflecting both the extent of the human immunodeficiency virus (HIV) epidemic in this country and the completeness of our reporting compared with that of other nations. Earlier in this decade, reports of AIDS cases in homosexual men, intravenous drug users, their heterosexual partners, transfusion recipients, and infants defined the principal modes of HIV transmission, well in advance of the discovery of HIV. More recently, AIDS surveillance has documented the spread of the epidemic beyond the major coastal centers, the striking disparity in the AIDS burden among blacks

During a four-month period, ten cases of group A streptococcal (GAS) postoperative wound infection occurred among patients in a community hospital. Bacteremia developed in two patients, and one patient died. Group A streptococcal surgical wound infections were associated with exposure to a circulating nurse and duration of surgery. Prophylactic antibiotics reduced the risk of infection. Vaginal, perineal, and anal cultures from nurse A yielded GAS, serotype M-4, T-4, as did the blood of two infected patients. Penicillin eradicated GAS colonization of nurse A, and she returned to work. Five months later, two additional cases of GAS postoperative wound infections occurred and were associated with recolonization of the same nurse with GAS, serotype M-nontypeable, T-12. She was relieved of patient-care duties, and no further cases have occurred. (JAMA1982;247:2680-2682)