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In the United States between 1970 and 1974 there was an increase each year both in the absolute number of foodborne diseases outbreaks of chemical etiology reported to the Center for Disease Control and in the proportion of these outbreaks in the total reported foodborne disease outbreaks. Nearly half (48.9%) of these foodborne disease outbreaks of chemical origin were caused by toxic fish or shellfish. Of the rest, 16.5% were caused by poisonous mushrooms, 10.9% by heavy metal poisoning, 7.2% by excessive use in food of monosodium glutamate (the etiologic agent of Chinese Restaurant Syndrome) and 16.5% by miscellaneous chemicals. Practices that contributed to the occurrence of these outbreaks included the inadvertent selection for consumption of toxic fish, shellfish, or mushrooms, storage of fish at improper temperatures, storage of acidic liquids in metal containers, and addition of excessive amounts of monosodium glutamate to foods. Commercially-processed foods were responsible for outbreaks of scombroid fish poisoning, shellfish poisoning, and heavy metal poisoning. Because outbreaks of chemical etiology due to contaminated commercial products do occur, prompt recognition and reporting of outbreaks to public health personnel are essential so that epidemiologic investigations can be conducted and effective control measures promptly initiated.

OBJECTIVES: This study sought to determine the specific processes required for obtaining religious and philosophical exemptions to school immunization laws. METHODS: State health department immunization program managers in the 48 states that offer nonmedical exemptions were surveyed. Categories were assigned to reflect the complexity of the procedure within a state for obtaining an exemption. RESULTS: Sixteen of the states delegated sole authority for processing exemptions to school officials. Nine states had written policies informing parents who seek an exemption of the risks of not immunizing. The complexity of the exemption process, in terms of paperwork or effort required, was inversely associated with the proportion of exemptions field. CONCLUSIONS: In many states, the process of claiming a nonmedical exemption requires less effort than fulfilling immunization requirements. [ABSTRACT FROM AUTHOR]

Context: All US states require proof of immunization for school entry. Exemptions are generally offered for medical, religious, or philosophical reasons, but the health consequences of claiming such exemptions are poorly documented.Objectives: To quantify the risk of contracting measles among individuals claiming religious and/or philosophical exemptions from immunization (exemptors) compared with vaccinated persons, and to examine the risk that exemptors pose to the nonexempt population.Design, Setting, and Participants: Population-based, retrospective cohort study of data from 1985 through 1992, collected by the Measles Surveillance System of the Centers for Disease Control and Prevention, as well as from annual state immunization program reports on prevalence of exemptors and vaccination coverage. The study group was restricted to individuals aged 5 to 19 years. To empirically determine and quantify community risk, a mathematical model was developed that examines the spread of measles through communities with varying proportions of exemptors and vaccinated children.Main Outcome Measures: Relative risk of contracting measles for exemptors vs vaccinated individuals based on cohort study data. Community risk of contracting measles derived from a mathematical model.Results: On average, exemptors were 35 times more likely to contract measles than were vaccinated persons (95% confidence interval, 34-37). Relative risk varied by age and year. Comparing the incidence among exemptors with that among vaccinated children and adolescents during the years 1985-1992 indicated that the 1989-1991 measles resurgence may have occurred 1 year earlier among exemptors. Mapping of exemptors by county in California indicated that exempt populations tended to be clustered in certain geographic regions. Depending on assumptions of the model about the degree of mixing between exemptors and nonexemptors, an increase or decrease in the number of exemptors would affect the incidence of measles in nonexempt populations. If the number of exemptors doubled, the incidence of measles infection in nonexempt individuals would increase by 5.5%, 18.6%, and 30.8%, respectively, for intergroup mixing ratios of 20%, 40%, and 60%.Conclusions: These data suggest the need for systematic review of vaccine-preventable incidents to examine the effect of exemptors, increased surveillance of the number of exemptors and cases among them, and research to determine the reasons why individuals claim exemptions. [ABSTRACT FROM AUTHOR]

We conducted a study in a squatter settlement in Karachi, Pakistan where residents report commonly washing their hands to determine if providing soap, encouraging hand washing, and improving wash-water quality would improve hand cleanliness. We allocated interventions to 75 mothers and collected hand-rinse samples on unannounced visits. In the final model compared with mothers who received no hand-washing intervention, mothers who received soap would be expected to have 65% fewer thermotolerant coliform bacteria on their hands (95% CI 40%, 79%) and mothers who received soap, a safe water storage vessel, hypochlorite for water treatment, and instructions to wash their hands with soap and chlorinated water would be expected to have 74% fewer (95% CI 57%, 84%). The difference between those who received soap alone, and those who received soap plus the safe water vessel was not significant (P = 0.26). Providing soap and promoting hand washing measurably improved mothers' hand cleanliness even when used with contaminated water.

Objectives: To examine trends in the hospitalizations of children for diarrheal disease in the U.S. and to provide estimates for the burden of disease associated with rotavirus diarrhea., Methods: Data for diarrheal hospitalizations among U.S. children ages 1 month through 4 years were compiled from the National Hospital Discharge Survey for the years 1979 through 1992. Between 1979 and 1992, 12% of all hospitalizations of U.S. children 1 month through 4 years of age had an International Classification of Diseases code for diarrhea listed in one of the top three positions on the discharge diagnosis., Results: The annual rate of diarrheal hospitalizations, 97 per 10 000 persons (average, 185 742 per year), did not change substantially during the 14-year study period and accounted annually for 724 394 inpatient days (3.9 days per hospitalization). For most diarrheal hospitalizations (75.9%) no causative agent was specified in the National Hospital Discharge Survey records; of the remaining 24.8%, viruses were most commonly reported (19.3%), followed by bacteria (5.1%) and parasites (0.7%). The proportion of hospitalizations associated with viral diarrheas rose from 13% to 27% during the 14-year study period, whereas the proportion of hospitalizations for noninfectious diarrhea declined from 79% to 60%. Every year the number of hospitalizations peaked from November through April, the "winter" months, among children ages 4 through 35 months; this peak began in the West during November and December and reached the Northeast by March., Conclusions: Diarrhea continues to be a common cause of hospitalization among children in the United States and the winter seasonality estimated to be caused in large part by rotavirus would be expected to decrease if rotavirus vaccines currently being developed were introduced. Our analysis of temporal trends in diarrheal hospitalizations provides a unique surrogate with which to estimate the disease burden associated with rotavirus diarrhea.

A period of high incidence of human Salmonella infections on the island of Guam saw the emergence of S. waycross as the most commonly isolated serotype as well as a concurrent decreasing proportion of isolates due to S. typhimurium. Predation of local rodents by an introduced snake is believed to account for the decreased prevalence of S. typhimurium infections, but reasons for the increased prevalence of S. waycross infections are unknown.

In September, 1973, diarrhoea caused by Salmonella typhimurium developed in 32 people in a Maine hospital. Both epidemiological and microbiological evidence indicated that raw egg beaten in milk ("egg-nog") was responsible for the infection. However, 6 patients and 8 employees had not had egg-nog, and their illness developed after the source of infection had been recognised and removed. Most of these people had had direct contact with an infected patient, and presumably acquired the infection by person-to-person spread. It is concluded that person-to-person spread of S. typhimurium can occur in hospitals and can be a hazard to patients and staff.

We conducted a prospective study of travelers' diarrhea on 73 physicians and 48 family members attending a medical congress in Mexico City, in October, 1974. Fecal and blood specimens were collected before, during and after their visit and examined for enteric bacterial pathogens, viruses and parasites. In 59 (49 per cent) participants travelers' diarrhea developed. Median duration of illness was five days. Onset occurred a median of six days after arrival. An etiologic agent was found in 63 per cent of ill participants. Enterotoxigenic Escherichia coli of different, non-"enteropathogenic" serotypes was the most common cause; other responsible pathogens included salmonellae, invasive Esch. coli., shigellae, Vibrio parahaemolyticus, Giardia lamblia and the human reovirus-like agent. Consumption of salads containing raw vegetables was associated with enterotoxigenic Esch. coli infection (P = 0.014). Travelers' diarrhea in Mexico is a syndrome caused by a variety of pathogens, the most common of which is enterotoxigenic Esch. col.

A chloramphenicol resistant strain of S. typhi which caused a very large epidemic of typhoid fever in Mexico in 1972-73 survived in opened bottles of one carbonated drink with a pH of 4.6 for two weeks and in another such drink with a pH of 5.1 for six months. Bottled beverages are potential sources of large outbreaks of enteric disease, and deserve the same type of standards sand monitoring as comparable fluids such as milk.

Diarrhea has been recognized as a frequent health problem among children enrolled in day-care centers. Thus, we evaluated the effect of a handwashing program in two day-care centers (HWC) on the incidence of diarrhea among children when compared to children in two control centers (CC). After the program was begun, the incidence of diarrhea at the HWC began to fall and after the second month of the study was consistently lower than that at the CC. The incidence of diarrhea in the HWC was approximately half that of the CC for the entire 35-week study period. Adenoviruses, rotavirus, Giardia lamblia, and enteropathogenic Escherichia coli were found in the stools of a small number of ill children, but not pathogen was identified in the stools of most children with diarrhea. These results suggest that a handwashing program will probably prevent at least some of the diarrhea in day-care centers.

In April-November 1974, Portugal had a cholera epidemic caused by Vibrio cholerae El Tor Inaba with 2467 bacteriologically confirmed hospitalized cases and 48 deaths. Most of the country was affected, with 17 of the 18 districts reporting cases. V. cholerae was isolated from 42 per cent of shellfish tested during the epidemic, and an epidemiologic study found that a history of consumption of raw or poorly cooked cockles was significantly more common among cholera patients than among paired controls. Water from a spring and a brand of commercially bottled water were also found to be vehicles of transmission of cholera. Although night soil was sometimes used on gardens, consumption of raw fruits and vegetables was not associated with illness.

In the 10 years 1964-1973, 105,832 isolations of shigellae were reported to the Center for Disease Control through a nationwide surveillance system. The number reported increased by approximately 13% annually, from 5852 in 1964, when only 17 centers reported all 4 quarters; to 16,797 in 1973, when 52 centers reported each quarter. The rate of reported isolations varied from 4.6 per 100,000 persons in 1965 to 9.1 per 100,000 in 1973. Shigella sonnei accounted for 64% of all these isolates and for more than 80% of isolates in 1973. The majority of reported cases of shigellosis occurred in young children and in women of childbearing age. During the 10-year surveillance period, 35 epidemics in 25 states were investigated. Two-thirds of these outbreaks were the result of person-to-person spread; investigations of common-source outbreaks showed the importance of both water and foodstuffs, especially salads, as potential vehicles of contamination. Indian reservations, custodial institutions, and day-care centers were identified as special high-risk settings for the transmission of shigellosis. The emergence of R-factor-mediated antimicrobial-resistance patterns in recent years has necessitated antibiotic sensitivity testing to determine the drug of choice for treatment of individual cases. Initial testing of oral vaccines suggests these vaccines will have only limited usefulness in protecting certain high-risk populations. Public health education coupled with improvements in water and sewerage systems remains the most satisfactory means of control.

In 1972 and 1973 a nationwide outbreak of typhoid fever occurred in Mexico. The responsible strain of Salmonella typhi had a characteristic pattern of phage lysis, resembling the type A pattern, referred to as degraded Vi(A), and was resistant to chloramphenicol and other antimicrobial agents in vitro and in vivo. Eighty cases of infection with strains of S. typhi that were related to the Mexican epidemic strain were reported in the United States. The epidemic in Mexico subsided in mid-1973, and no further cases of typhoid fever due to chloramphenicol-resistant organisms were reported in the United States. Infections with chloramphenicol-sensitive strains of S. typhi with the phage lysis pattern of degraded (Vi(A) occurred in association with travel in Mexico before and after the height of the epidemic in Mexico. Although typhoid fever due to chloramphenicol-resistant organisms has not been reported in the United States since the subsidence of the Mexican epidemic, testing of isolates of S. typhi for antibiotic sensitivity is recommended because of the continued existence of resistant strains elsewhere.

During a cholera epidemic, Vibrio cholerae was isolated from two springs which supplied mineral water to a spa and to a commercial water bottling plant. Epidemiologic investigation found that cholera attack rates were 10-fold greater among visitors to the spa than among non-visitors. A subsequent matched-pair case-control study which excluded persons who had visted the spa showed that a history of consumption of the bottled non-carbonated water was significantly more common among bacteriologically confirmed cholera cases than among paired controls.

Diarrheal diseases result from two different processes: toxin elaboration by pathogens such as Vibrio cholerae and some strains of Escherichia coli and invasion of tissue, eg, by shigellae and salmonellae. Intestinal motility serves as a normal cleansing mechanism of the intestine, and drugs that decrease this motility may facilitate replication of pathogens and their attachment to or invasion of the intestinal tissue. Therapy should not be aimed at suppressing the symptom of diarrhea. It is now known that the electrolytes lost in the course of diarrheal disease can be replaced orally if they are given in solution with glucose. Although commercial preparations are not readily available, an effective solution can be made from ingredients commonly found in the home. Oral rehydration has greatly simplified treatment and has significantly reduced the morbidity and mortality associated with diarrheal diseases.

Isolates of Salmonella typhi from 3661 persons in the United States were reported to the Center for Disease Control from 1967 to 1972. Available case reports and carrier lists for the patients from whom the isolates were recovered were reviewed. During this period the yearly number of travel-associated cases rose 270% and, in contrast to indigenous cases, the number of travel-associated ones increased each year. This increase was largely due to cases associated in some way with Mexico. Furthermore, residents of the United States with Hispanic surnames were at higher risk of contracting typhoid in this country than was the rest of the population. Most indigenous cases were in children or young adults and were not linked to recognized outbreaks. Most known typhoid carriers in the United States are elderly women.

Between January 1 and March 15, 1974, approximately 1200 cases of acute gastrointestinal illness occurred in Richmond Heights, Florida, a residential community of 6500 in south Dade County. Over one-third of all families in the area had at least one member affected. The findings of 10 culture-proven cases of shigellosis among those who became ill and clinical signs and symptoms in the others suggest that most of the other cases that were not cultured may have been shigellosis also. Epidemiologic investigation showed that consumption of tap water was associated with illness in the initial cases of affected families. Evaluation of the Richmond Heights public water supply disclosed numerous inadequacies in both design and operation. One of the wells providing water to the community was continuously contaminated with excessive levels of fecal coliforms from a nearby septic tank, and a breakdown in chlorination on January 14-15 caused approximately 1 million gallons of inadequately chlorinated water from the contaminated well to be distributed to the community 48 hours before the epidemic began. Correction of deficiencies in the water plant was undertaken by the utility company; the residents of Richmond Heights were instructed to boil their drinking water or to use commercially bottled water pending completion of corrective measures. A FUll scale study is planned for all similar public water supplies in Dade County.

In July and August 1976, an outbreak of acute gastrointestinal illness occurred among persons who had consumed a commercially marketed soy protein tunafish salad extender. After a public warning of a possible product contamination, representatives of 350 households reported 508 persons ill with an afebrile gastrointestinal syndrome that occurred usually within 1 h after the salad-extender was eaten. Interviews of randomly selected reported ill persons (cases) showed that the principal symptoms were nausea (91%), abdominal cramps (71%), diarrhea (53%), headache (42%), difficulty breathing (36%), and vomiting (22%). A survey of persons in the community who had eaten tuna extender revealed an illness attack rate (5.1%), which was significantly higher than the background incidence of gastrointestinal illness (1.1%) in persons who did not eat the tuna extender (p < .05). A case-control study showed that significantly more cases than controls had a history of "allergy" (p < .02). Tests of the product prepared by the manufacturer with volunteers implicated texturized soy protein as the cause of the illness. The findings in this study demonstrated that consumption of textured soy protein may elicit an adverse gastrointestinal response in a small but significant number of individuals, especially those with a history of "allergy."

Non-cholera vibrios are organisms that are biochemically indistinguishable from Vibrio cholerae but do not agglutinate in vibrio 0 group 1 antiserum. Since 1972 there has been a dramatic increase in the number of these organisms referred to the Center for Disease Control for identification. Clinical, epidemiologic, and laboratory data were analyzed for 26 of 28 patients with isolates identified between January 1972 and March 1975. Thirteen (50%) of the isolates were obtained from feces of patients who had an acute diarrheal illness; no other pathogens were isolated from their feces, and all patients survived. Four (15%) patients had non-cholera vibrios isolated from other gastrointestinal or biliary tract sites; none of these patients had acute illness definitely attributable to non-cholera vibrios. Nine (35%) patients had non-cholera vibrios isolated from other tissues and body fluids; four deaths occurred in this group. Patients with acute diarrhea frequently had a history of recent shellfish ingestion or foreign travel, whereas some patients with systemic non-cholera vibrio infection had a history of recent occupational or recreational exposure to salt water.

In June and July 1975, Gastrointestinal illness occurred in more than 200 staff members and 2000 visitors to an American national park. In was characterized by prolonged diarrhea, cramps, nausea, and vomiting, lasted a median duration of 8 days, and was significantly associated with consumption of park water (P less than 0.001), which had been contaminated by raw sewage. Enterotoxigenic Escherichia coli serotype 06:K15:H16 was isolated from 20 of 49 ill park residents and from the park's water supply, but not from 71 residents who had never been ill or had been well for at least 4 days. No other bacterial, viral, or parasitic pathogens were isolated from ill or well persons. This outbreak is the first waterborne epidemic of diarrheal illness shown to be due to enterotoxigenic. E. coli, and this study documents one mode of transmission of this pathogen. This investigation also suggests the relative insensitivity of current methods for identifying persons infected with this organism, either by the culturing of randomly selected isolates or by measuring serologic responses.

Between Dec. 4, 1973, and Feb. 15, 1974, 80 cases of infection due to Salmonella eastbourne, previously a rare isolated serotype in the United States, were reported from twenty-three States. An additional 39 cases were reported from seven Provinces in Canada during a similar period. A telephone case-control study implicated Christmas-wrapped chocolate balls manufactured by a Canadian company as the vehicle of transmission. S. eastbourne was subsequently isolated from several samples of leftover chocolate balls obtained from homes where cases occurred. Investigation of the factory revealed that the contaminated Christmas and Easter chocolates, and a few chocolate items for year-round sale, had been produced between May and October, 1973. Bacteriological testing of samples taken at the plant implicated cocoa beans as the probable source of the salmonella organisms which, in the low-moisture chocolate, were able to survive heating during production. This outbreak and the finding of salmonella of other serotypes in chocolates produced by another manufacturer suggest that chocolate-related salmonellosis may be a significant public-health problem.

Experience has shown that neither drugs nor vaccines can hope to solve the world's enteric disease problems. But oral-fluid therapy, which has sharply reduced cholera mortality, is proving effective in treating other enteric diseases as well. And most developing countries are making real progress in providing the safe water supplies and sanitary conditions that deny enteric pathogens an opportunity to flourish and spread.

Current evidence suggests that diarrheagenic E. coli are not important causes of disease in the sanitized urban centers of the United States at this time. However, enterotoxigenic E. coli are a leading cause of diarrhea among travelers who visit developing countries. The failure of diarrheagenic E. coli pathogens to gain a foothold in this country, despite problems with enteropathogenic E. coli in nurseries during the 1940s and 1950s and the more recent multiple introductions of enterotoxigenic E. coli by travelers returning from developing areas of the world, demonstrates the epidemiologic impotence of diarrheagenic E. coli in the relatively sanitized environment of the United States. Nondiarrheagenic E. coli seem to be major pathogens in community-acquired and nosocomial infections in extraintestinal sites.

An interstate common-source outbreak of salmonellosis was first detected in the United States in September and October, 1975, when a tenfold increase in Salmonella newport isolates was noted through routine salmonella surveillance by the Colorado Department of Health. Eighteen primary cases with a distinctive antibiotic resistance pattern (tetracycline, streptomycin, and sulfonamides) were evaluated in a case-control study, and illness was found to be associated with eating raw hamburger (p less than .001) from any store of one grocery chain (p less than .001). A Dallas, Texas, processing plant that supplied the Colorado markets also supplied other states, and these other states were alerted. Maryland discovered nine S. newport isolates with the same antibiogram and, as in the Colorado outbreak, illness was associated with eating raw or very rare ground beef from the same grocery chain (p less than .03). A third outbreak of S. newport with the same antibiogram occurred on a Florida military base. S. newport with the same antibiogram and a phage lysis pattern identical to those of the human epidemic isolates was cultured from frozen hamburger recovered in Colorado and Florida. The associated hamburger originated at the same Dallas, Texas, processing plant. A source of the epidemic strain was not identified, but the organism probably originated before delivery to the plant.

In this study we utilized the salt-tolerant characteristics of vibrios to develop a more selective medium by addition of NaCl to thiosulfate citrate bile salts sucrose (TCBS) agar. The effect of adding salt to TCBS agar varied greatly among brands of TCBS agar and between lots of the same brand. The addition of salt at concentrations as high as 1.5% (2.5% total NaCl) caused the inhibition of growth of three species of commonly encountered normal bowel flora and one strain of classical Vibrio cholerae but did not compromise the use of TCBS agar for isolation of V. cholerae biotype El Tor.

A double-blind controlled field trial of live, oral, streptomycin-dependent Shigella sonnei vaccine was begun in an institution with endemic S. sonnei disease. Considerable unexpected child-to-child transmission of the vaccine strains inadvertantly caused the field trial to resemble a mass vaccination campaign. Although S. sonnei accounted for 90% of shigella infections from 1968 to 1971 and three-fourths of the cases occurred in the seven study cottages, S. sonnei disease disappeared following vaccination; epidemiologic features suggest a causal relationship. Clinical S. sonnei disease did not occur despite the detection by bacteriologic surveillance of carriers of virulent S. sonnei. Levels of hygiene remained compatible with transmission of shigella since 43 cases of S. flexneri 6 were seen. If the interpretation is correct, the disappearance of S. sonnei disease resulted from inadvertent "mass vaccination" and oral shigella vaccines may prove useful for control of endemic shigellosis institutions. Nevertheless, a properly designed controlled field trial, taking into account transmissibility of vaccine, in an institutional setting similar to Sunland is necessary to substantiate the role of oral shigella vaccines in control of institutional shigellosis.

To identify risk factors associated with hospitalization for acute lower respiratory tract illness, 102 children less than 2 years of age admitted to four Atlanta metropolitan area hospitals between December 1984 and June 1985 with the diagnosis of lower respiratory tract illness were studied. The most common causative agent associated with illness was respiratory syncytial virus, followed by other respiratory viruses, Haemophilus influenzae, and Streptococcus pneumoniae. The 102 case-patients were compared with 199 age- and sex-matched controls. A parent or guardian for each patient and control was interviewed by telephone regarding demographic data, care outside the home, breast-feeding, previous medical history, allergies, and smoking and illness in household members. Five factors were associated with lower respiratory tract illness in both a univariate analysis and a multiple logistic regression model (P less than .05). These factors were the number of people sleeping in the same room with the child, a lack of immunization the month before the patient was hospitalized, prematurity, a history of allergy, and regular attendance in a day-care center (more than six children in attendance). Care received outside of the home in a day-care home (less than or equal to six children in attendance) was not associated with lower respiratory tract illness. The suggestion made by our study and other studies was that for children less than 2 years of age, care outside of the home is an important risk factor for acquiring lower respiratory tract illness, as well as other infectious diseases, and that this risk can be reduced by using a day-care home instead of a day-care center.