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OBJECTIVE. School-based influenza vaccination programs are a potentially important method of protecting the community against influenza. We evaluated the feasibility and success of a large, school-based influenza vaccination campaign. METHODS. On-site administration of intranasally administered, live attenuated influenza vaccine was offered to all students and staff members in a large, metropolitan public school system in October to December 2005. We evaluated vaccine coverage levels, resources expended, and physician and parent attitudes and knowledge. RESULTS. Of 53 420 public school students, 24 198 were vaccinated with live attenuated influenza vaccine. Of 5841 school staff members, 3626 were vaccinated with live attenuated influenza vaccine or inactivated influenza vaccine. The proportions of students vaccinated were 56% among elementary schools, 45% among middle schools, and 30% among high schools. Schools with larger proportions of black or low-income families had lower vaccine coverage levels. The health department and school system expended 6900 person-hours during the campaign, and various health department clinics were closed for a total of 84 half-days. Community physicians were supportive of the campaign and frequently advised participation for eligible patients. Some physicians had misunderstandings about live attenuated influenza vaccine contraindications. Concern about adverse effects, having asthma, negative physician advice, and nonparticipation in any vaccination program were common reasons for students not participating. CONCLUSIONS. This influenza vaccination campaign in a large public school system achieved relatively high vaccine coverage levels bill required a substantial resource commitment from the local health department. This evaluation has critical implications for the ongoing debate regarding immunization policies for school-aged children and preparedness plans for pandemic influenza. KEYWORDS. influenza, immunizations, live attenuated influenza vaccine vaccine, herd immunity.

We describe an investigation into a Heartland virus (HRTV)-associated death in Tennessee with novel clinical and pathologic findings. HRTV can cause rapidly fatal, widely disseminated infection with multisystem organ failure in patients without substantial comorbidities. We identified viral antigen in multiple organ tissues where it was not detected previously. [ABSTRACT FROM AUTHOR]

Despite considerable scientific evidence about the health risks of drinking unpasteurized (raw) milk, advocates continue to lobby for the reduction of state regulatory restrictions on the sale of unpasteurized milk. Multivariate analyses were performed on 1998-1999, 2002-2003 and 2006-2007 FoodNet Population Survey data to determine char-acteristics of unpasteurized milk consumers. Across all years of the survey, 3.4% of respondents reported consuming unpasteurized milk at some point in the previous seven days. Our findings indicate that unpasteurized milk drinkers in the states covered by the analysis are more likely to be Hispanic, less educated and of lower income than non-drinkers and they are more likely to report drinking unpasteurized juice. [ABSTRACT FROM AUTHOR]

Background. Foodborne diseases are typically mild and self-limiting but can cause severe illness and death. We describe the epidemiology of deaths associated with bacterial pathogens using data from the Foodborne Diseases Active Surveillance Network (FoodNet) in the United States.Methods. We analyzed FoodNet data from 1996–2005 to determine the numbers and rates of deaths occurring within 7-days of laboratory-confirmation.Results. During 1996–2005, FoodNet ascertained 121,536 cases of laboratory-confirmed bacterial infections, including 552 (.5%) deaths, of which 215 (39%) and 168 (30%) were among persons infected with Salmonella and Listeria, respectively. The highest age-specific average annual population mortality rates were in older adults (≥65 years) for all pathogens except Shigella, for which the highest age-specific average annual population mortality rate was in children <5 years (.2/1 million population). Overall, most deaths (58%; 318) occurred in persons ≥65 years old. Listeria had the highest case fatality rate overall (16.9%), followed by Vibrio (5.8%), Shiga toxin–producing Escherichia coli O157 (0.8%), Salmonella (0.5%), Campylobacter (0.1%), and Shigella (0.1%).Conclusions. Salmonella and Listeria remain the leading causes of death in the United States due to bacterial pathogens transmitted commonly through food. Most such deaths occurred in persons ≥65 years old, indicating that this age group could benefit from effective food safety interventions. [ABSTRACT FROM PUBLISHER]

In 2009, the Tennessee Department of Health received reports of 5 tuberculin skin test (TST) conversions among employees of an elephant refuge and isolation of Mycobacterium tuberculosis from a resident elephant. To determine the extent of the outbreak and identify risk factors for TST conversion, we conducted a cohort study and onsite assessment. Risk for conversion was increased for elephant caregivers and administrative employees working in the barn housing the M. tuberculosis--infected elephant or in offices connected to the barn (risk ratio 20.3, 95% confidence interval 2.8--146.7). Indirect exposure to aerosolized M. tuberculosis and delayed or inadequate infection control practices likely contributed to transmission. The following factors are needed to reduce risk for M. tuberculosis transmission in the captive elephant industry: increased knowledge about M. tuberculosis infection in elephants, improved infection control practices, and specific occupational health programs. [ABSTRACT FROM AUTHOR]

Trypanosoma cruzi , the etiologic agent of Chagas' disease, is enzootic in animal populations of the southeastern United States. In the United States, T. cruzi prevalence has been reported for over 20 different wildlife species, and 7 autochthonous human cases have been documented since 1955. Previous canine (Canis familiaris) serosurveys have been limited either by small sample size or confined geographic reporting areas. In this study, we report a seroprevalence of 6.4% among 860 canines from 31 counties and 5 ecoregions throughout Tennessee, using an indirect immunofluorescent assay (IFA). Statistically significant associations between seropositivity and age, weight, and outdoor living were noted. Differences in seropositivity were not seen based on American Kennel Club (AKC) group, sex, habitat, land cover, and ecoregion. Greater attention should be given to possible T. cruzi transmission in Tennessee and veterinarians should consider Chagas' disease as a differential diagnosis with compatible signs. [ABSTRACT FROM AUTHOR]

Background: In September 2007, the Tennessee Department of Health was notified of a cluster of late-onset group B streptococcal (GBS) infections in a neonatal intensive care unit (NICU). Outbreaks of late-onset GBS are rare. Methods: A case was defined as culture-confirmed invasive GBS infection in a neonate aged ≥7 days, identified in hospital A during August 23 to September 6, 2007. We reviewed medical records; examined NICU microbiology reports; and performed serotyping, pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST) on invasive isolates. Maternal GBS screening, prophylaxis, and infection control policies were reviewed and staff practices observed. Results: Five cases of late-onset GBS were identified. None of the mothers of the infants received optimal GBS prophylaxis. Patient isolates were of 2 serotypes, 3 PFGE patterns, and 2 MLST patterns. Three isolates were indistinguishable on subtyping. These 3 cases were clustered in time. No common health care providers were identified. Infection control deviations in the NICU were observed. Conclusion: We identified a multiclonal cluster of 5 late-onset GBS cases. Multiple factors likely contributed to the outbreak, including nosocomial transmission of GBS. Further efforts to prevent late-onset GBS disease are necessary. [Copyright &y& Elsevier]

Trypanosoma cruzi is the etiologic agent of Chagas' disease. Autochthonous human and canine transmission of T. cruzi has been documented in Tennessee, but little is known about its ecology, including the prevalence of T. cruzi among wildlife in Tennessee. Serum samples from 706 raccoons (Procyon lotor) from 10 counties in the Ridge and Valley and Blue Ridge Mountains ecoregions of eastern Tennessee were tested for antibodies reactive with T. cruzi using the indirect fluorescent antibody assay. Two hundred six (29.2%) samples were seropositive, with 9 counties yielding positive samples (range 14.6-63.6%). Significantly more raccoons from rural habitats (35.1%) were found positive for T. cruzi exposure than were those from suburban habitats (23.1%, P < 0.001). Land cover class was not associated with seropositivity status (P = 0.441), even though deciduous forest was the most common site from where raccoons were trapped and the most common site of positive raccoons in rural areas (42%). Interestingly, age was positively associated with seropositivity. Raccoons older than 1 yr (adults) were 40.1% seropositive compared to 12.2% of those less than 1 yr (juveniles; P < 0.001). Female adults were significantly more likely to be exposed to T. cruzi than were male adult raccoons (P < 0.001). No significant seroprevalence difference was seen among male and female juveniles. This study contributes to understanding the dynamics of T. cruzi exposure within raccoon populations in Tennessee. The importance of habitat (rural vs. suburban) and microhabitat (dens) in risk of exposure to these populations is also discussed. [ABSTRACT FROM AUTHOR]

To estimate the global burden of nontyphoidal Salmonella gastroenteritis, we synthesized existing data from laboratory-based surveillance and special studies, with a hierarchical preference to (1) prospective population-based studies, (2) "multiplier studies," (3) disease notifications, (4) returning traveler data, and (5) extrapolation. We applied incidence estimates to population projections for the 21 Global Burden of Disease regions to calculate regional numbers of cases, which were summed to provide a global number of cases. Uncertainty calculations were performed using Monte Carlo simulation. We estimated that 93.8 million cases (5th to 95th percentile, 61.8-131.6 million) of gastroenteritis due to Salmonella species occur globally each year, with 155,000 deaths (5th to 95th percentile, 39,000-303,000 deaths). Of these, we estimated 80.3 million cases were foodborne. Salmonella infection represents a considerable burden in both developing and developed countries. Efforts to reduce transmission of salmonellae by food and other routes must be implemented on a global scale. [ABSTRACT FROM AUTHOR]

Background. Hemolytic uremic syndrome (HUS) is a life-threatening illness usually caused by infection with Shiga toxin-producing Escherichia coli O157 (STEC O157). We evaluated the age-specific rate of HUS and death among persons with STEC O157 infection and the risk factors associated with developing HUS. Methods. STEC O157 infections and HUS cases were reported from 8 sites participating in the Foodborne Diseases Active Surveillance Network during 2000-2006. For each case of STEC O157 infection and HUS, demographic and clinical outcomes were reported. The proportion of STEC O157 infections resulting in HUS was determined. Results. A total of 3464 STEC O157 infections were ascertained; 218 persons (6.3%) developed HUS. The highest proportion of HUS cases (15.3%) occurred among children aged <5 years. Death occurred in 0.6% of all patients with STEC O157 infection and in 4.6% of those with HUS. With or without HUS, persons aged ⩾60 years had the highest rate of death due to STEC O157 infection. Twelve (3.1%) of 390 persons aged ⩾60 years died, including 5 (33.3%) of 15 persons with HUS and 7 (1.9%) of 375 without. Among children aged <5 years, death occurred in 4 (3.0%) of those with HUS and 2 (0.3%) of those without. Conclusions. Young children and females had an increased risk of HUS after STEC O157 infection. With or without HUS, elderly persons had the highest proportion of deaths associated with STEC O157 infection. These data support recommendations for aggressive supportive care of young children and the elderly early during illness due to STEC O157. [ABSTRACT FROM AUTHOR]

Background. Most human infections are caused by closely related serotypes within 1 species of Salmonella. Few data are available on differences in severity of disease among common serotypes. Methods. We examined data from all cases of Salmonella infection in FoodNet states during 1996-2006. Data included serotype, specimen source, hospitalization, and outcome. Results. Among 46,639 cases, 687 serotypes were identified. Overall, 41,624 isolates (89%) were from stool specimens, 2524 (5%) were from blood, and 1669 (4%) were from urine; 10,393 (22%) cases required hospitalization, and death occurred in 219 (0.5%). The case fatality rate for S. Newport (0.3%) was significantly lower than for Typhimurium (0.6%); Dublin (3.0%) was higher. With respect to invasive disease, 13 serotypes had a significantly higher proportion than Typhimurium (6%), including Enteritidis (7%), Heidelberg (13%), Choleraesuis (57%), and Dublin (64%); 13 serotypes were significantly less likely to be invasive. Twelve serotypes, including Enteritidis (21%) and Javiana (21%), were less likely to cause hospitalization than Typhimurium (24%); Choleraesuis (60%) was significantly more so. Conclusions. Salmonella serotypes are closely related genetically yet differ significantly in their pathogenic potentials. Understanding the mechanisms responsible for this may be key to a more general understanding of the invasiveness of intestinal bacterial infections. [ABSTRACT FROM AUTHOR]

Stool cultures can be important in guiding antimicrobial therapy for diarrhea. From among 11.64 million person-years of Tennessee Medicaid enrollment data collected from 1995 through 2004, 315,828 diarrheal episodes were identified. Stool cultures were performed for only 15,820 episodes (5.0%). Antimicrobials were prescribed for 32,949 episodes (10.4%), 89.4% of which were not accompanied by a stool culture. White race and urban residence were associated with higher rates of stool culture. Frequent use of antimicrobials for diarrhea without stool culture may indicate inappropriate antimicrobial use and has critical implications for public health. [ABSTRACT FROM AUTHOR]

Background. We present 2 case reports in the United States and investigations of diphtheria-like illness caused by toxigenic Corynebacteriurn ulcerans. A fatal case occurred in a 75-year-old male Washington resident who was treated with clindamycin but did not receive equine diphtheria antitoxin. A second, nonfatal case occurred in a 66-year-old female Tennessee resident who received erythromycin and diphtheria antitoxin. Methods. Both case patients and close human and animal contacts were investigated by their respective state health departments. Results. C. ulcerans isolated from the patient who died was resistant to erythromycin and clindamycin. For both isolates, conventional polymerase chain reaction results were positive for A and B subunits of diphtheria toxin gene tox, and modified Elek tests confirmed toxin production. The source of infection remained undetermined for both cases. Neither patient was up-to-date with diphtheria toxoid vaccination. Conclusion. These case reports highlight the importance of early treatment with diphtheria antitoxin, the selection of effective antimicrobial agents, and prevention through up-to-date vaccination. [ABSTRACT FROM AUTHOR]

Linezolid was approved in 2000 for treatment of gram-positive coccal infections. We performed a case-control study during a hospital outbreak of linezolid-resistant enterococci (LRE) infections, comparing cases of LRE infection (cases) with linezolid-sensitive enterococci infections (controls). Nasal and perirectal swab samples were obtained from all patients in a 1-day point-prevalence survey. We examined antimicrobial drug use and calculated the defined daily dose of linezolid per 1,000 patient-days. Fifteen LRE cases were identified (13 Enterococcus faecalis and 2 E. faecium); 7 were vancomycin-resistant. Compared with controls, case-patients had increased in-hospital mortality rates and lengths of stay. Multivariate analysis identified independent predictors of LRE infection: prior cultures positive for methicillin-resistant Staphylococcus aureus (adjusted odds ratio [AOR] 27), hospitalization duration before index culture (AOR 1.1 per day), and duration of preceding linezolid therapy (AOR 1.1 per day). Linezolid exposure and patient-to-patient transmission appear to be responsible for LRE infections, an important emeraina hospital problem. [ABSTRACT FROM AUTHOR]

Background. Nontyphoidal Salmonella is a leading cause of foodborne illness. Few studies have explored the health consequences of antimicrobial-resistant Salmonella. Methods. The National Antimicrobial Resistance Monitoring System (NARMS) performs susceptibility testing on nontyphoidal Salmonella isolates. The Foodborne Diseases Active Surveillance Network (FoodNet) ascertains outcomes for patients with culture-confirmed Salmonella infection, in 9 states, each of which participates in NARMS. We analyzed the frequency of bloodstream infection and hospitalization among patients with resistant infections. Isolates defined as resistant to a clinically important agent were resistant to 1 or more of the following agents: ampicillin, ceftriaxone, ciprofloxacin, gentamicin, and/or trimethoprim-sulfamethoxazole. Results. During 1996-2001, NARMS received 7370 serotyped, nontyphoidal Salmonella isolates from blood or stool. Bloodstream infection occurred more frequently among patients infected with an isolate resistant to 1 clinically important agent (adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.2-2.1), compared with patients with pansusceptible infection. During 1996-2001, Food Net staff ascertained outcomes for 1415 patients who had isolates tested in NARMS. Hospitalization with bloodstream infection occurred more frequently among patients infected with an isolate resistant to 1 clinically important agent (adjusted OR, 3.1; 95% CI, 1.4-6.6), compared with patients with pansusceptible infection. Conclusions. Patients with antimicrobial-resistant nontyphoidal Salmonella infection were more likely to have bloodstream infection and to be hospitalized than were patients with pansusceptible infection. Mitigation of antimicrobial resistance in Salmonella will likely benefit human health. [ABSTRACT FROM AUTHOR]

Provides information on the role and responsibilities of physicians in treating mass psychogenic illness or mass hysteria. Description of a typical case; Medical definition of mass psychogenic illness; Predominant symptoms of the illness; Characteristics.