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Escherichia coli O157:H7 remains a public health problem in the United States despite a dramatic increase in the awareness of, and concern about, foodborne infections since the 1993 multistate E. coli O157:H7 epidemic. Although surveillance data can be difficult to interpret, the incidence of endemic disease caused by this organism is probably not increasing, and might be decreasing, at least in selected populations. With increased recognition of E. coli O157:H7 infection has come the investigation of increasing number of outbreaks, leading to the recognition of many "new" vehicles, including some foods not traditionally associated with enteric infections, such as dry-cured salami and lettuce. Molecular fingerprinting techniques are being used to track the transmission of E. coli O157:H7 through human populations. Analysis of DNA encoding virulence factors and surface antigens suggests that diarrheagenic E. coli have evolved by acquiring large DNA fragments, with subsequent chromosomal recombination. Some Shiga toxin-producing E. coli other than E. coli O157:H7 are no doubt pathogens, but the majority of these toxigenic strains found in food are probably not virulent. More research is needed to define the characteristics that render selected Shiga toxin-producing organisms harmful to humans.

Objective. Human papillomavirus (HPV) causes almost all cervical cancer in women and contributes to vaginal, anal, oropharyngeal, and penile cancer morbidity and mortality. Although vaccines effective in preventing up to nine types of HPV are available, vaccination rates are low nationally. We assessed HPV vaccination coverage by age, sex, and county using Washington State Immunization Information System data. Methods. We calculated on-time dose coverage by county and statewide among adolescents aged 11–12 years and assessed coverage by age 18 years. We calculated missed opportunities as the number of visits at which doses of other adolescent vaccines were administered without administration of the first dose of HPV vaccine (HPV1). Results. In 2013, HPV vaccination coverage estimates with one, two, and three doses (HPV1-3) for adolescents aged 11–12 years were 48.5%, 32.4%, and 18.3% among girls and 31.2%, 17.1%, and 8.1% among boys. The three-dose HPV vaccine coverage estimate increased to 40.1% among girls by age 18 but was unchanged for boys. Coverage estimates varied by age, sex, and county. One-third of eligible unvaccinated girls and two of five eligible boys aged 11–17 years had at least one missed opportunity to receive HPV1. Conclusion. Despite a recommendation to vaccinate adolescents aged 11–12 years, HPV vaccination is often delayed and coverage levels among all age groups are below national target levels. Improved understanding of the variability of HPV vaccination coverage rates by age, sex, and county can inform targeted interventions statewide.

Clinical, laboratory, and epidemiologic evidence suggest that 3 individuals with acute coccidioidomycosis were exposed in Washington State, significantly beyond previously identified endemic areas. Given the patients' lack of recent travel, coccidioidomycosis was not suspected, leading to delays in diagnosis and appropriate therapy. Clinicians should be aware of this possibility and consider the diagnosis.

Background. Cryptococcus gattii (Cg) has caused increasing infections in the US Pacific Northwest (PNW) since 2004. We describe this outbreak and compare clinical aspects of infection in the United States among patients infected with different Cg genotypes. Methods. Beginning in 2005, PNW state health departments conducted retrospective and prospective passive surveillance for Cg infections, including patient interviews and chart reviews; clinical isolates were genotyped at the US Centers for Disease Control and Prevention (CDC). We examined symptom frequency and underlying conditions in US patients with Cg infection and modeled factors associated with death. Results. From 1 December 2004 to July 2011, 96Cg infections were reported to the CDC. Eighty-three were in patients in or travelers to the PNW, 78 of which were genotypes VGIIa, VGIIb, or VGIIc (outbreak strains). Eighteen patients in and outside the PNW had other molecular type Cg infections (nonoutbreak strains). Patients with outbreak strain infections were more likely than those with nonoutbreak-strain infections to have preexisting conditions (86% vs 31%, respectively; P , .0001) and respiratory symptoms (75% vs 36%, respectively; P 5 .03) and less likely to have central nervous system (CNS) symptoms (37% vs 90%, respectively; P 5 .008). Preexisting conditions were associated with increased pneumonia risk and decreased risk of meningitis and CNS symptoms. Nineteen (33%) of 57 patients died. Past-year oral steroid use increased odds of death in multivariate analysis (P 5 .05). Conclusions. Clinical differences may exist between outbreak-strain (VGIIa, VGIIb, and VGIIc) and nonoutbreak-strain Cg infections in the United States. Clinicians should have a low threshold for testing for Cg, particularly among patients with recent travel to the PNW.

Background: Rabies is a zoonotic viral disease that can affect all mammals. In the United States, the majority of human rabies cases are caused by bats, which are the only known reservoirs for rabies virus (RABV) in Washington State. We sought to characterize bat RABV epidemiology in Washington among bats submitted by the public for RABV testing. Methods: We examined temporal and spatial trends in RABV positivity (% positive) for taxonomically identified bats submitted to diagnostic laboratories during 2006–2017. For a subset of Myotis species, we evaluated sensitivity and predictive value positive (PPV) of morphological identification keys, using mitochondrial markers (cytochrome b) as a reference. For bats tested during 2000–2016, we analyzed RABV positivity by circumstances of encounters with humans, cats, and dogs. Results: During 2006–2017, RABV positivity for all bat species was 6.0% (176/2,928). Among species with ≥100 submissions, RABV positivity was 2.0%–11.7% and highest among big brown bats (Eptesicus fuscus). An increasing trend in annual positivity was significant only for big brown bats (P = 0.02), and was circumstantially linked to a geographic cluster. Sensitivity and PPV of morphological identification keys was high for M. evotis but varied for M. lucifugus, M. californicus, M. yumanensis, and M. septentrionalis. A positive RABV result was significantly associated with nonsynanthropic species, abnormal behavior, abnormal hiding, injury, biting, found in a body of water, found alive, found outdoors, and caught by a dog. Conclusion: Monitoring passive RABV surveillance trends enables public health authorities to perform more accurate risk assessments. Differences in temporal and spatial trends in RABV positivity by bat species indicate the importance of collecting taxonomic data, although morphological identification can be unreliable for certain Myotis species. Current public health practices for RABV exposures should be maintained as RABV infection in bats can never be excluded without diagnostic testing.

CONTEXT Health care providers are required to report newly diagnosed notifiable conditions including the case's vital status according to state regulations, but it is uncertain how many cases remain unreported. Death certificates could potentially serve as a data source for detecting unreported deaths due to notifiable conditions. OBJECTIVE We sought to evaluate the usefulness of electronic death records to augment notifiable conditions reporting in Washington State. DESIGN Cross-sectional study. SETTING All residents of Washington State. PARTICIPANTS Decedents from 2010-2012. MAIN OUTCOME MEASURES Total number of fatal cases of acute infectious notifiable conditions in Washington residents estimated by capture-recapture analysis, proportion of estimated fatal cases reported to Washington's notifiable conditions database (Public Health Issue Management System [PHIMS]), and the proportion of estimated fatal cases identified solely from the death records. Information was obtained by searching multiple cause-of death fields on 2010-2012 death records for keywords for acute infectious notifiable conditions. RESULTS Capture-recapture analysis estimated 317 fatal cases of these conditions could be expected over the 3 years studied (95% CI: 276,358). Public Health Issue Management System alone identified 38% of total estimated cases; using PHIMS and death record data increased identification to 71%. Electronic filing of death records was very timely, with a median of 4 days to visibility. Death record data were highly complete. CONCLUSIONS Use of death records will augment the notifiable condition reporting system and potentially improve mortality estimates and disease control.

We used real-time polymerase chain reaction and culture to demonstrate persistent colonization of soils by Coccidioides immitis, an agent of valley fever, in Washington State linked to recent human infections and located outside the endemic range. Whole-genome sequencing confirmed genetic identity between isolates from soil and one of the case-patients.

Coccidioidomycosis ("valley fever") is caused by inhaling spores of the soil-dwelling fungi Coccidioides immitis or Coccidioides posadasii. Most infections are subclinical. When clinical manifestations do occur (typically 1-4 weeks after exposure), they are similar to those associated with influenza or community-acquired pneumonia. Disseminated disease is rare. Residual pulmonary nodules can lead to chronic lung disease. Fluconazole or other triazoles often are used for treatment, but mild cases often resolve without specific therapy. A total of 17,802 cases were reported in the United States in 2012.

Reactive arthritis and Reiter's syndrome have been reported following gastroenteritis. Prevalence studies for these conditions are uncommon, and the prevalence of Reiter's syndrome after Salmonella enteritidis infection has not been previously reported. After a large outbreak of S. enteritidis gastroenteritis, a survey of persons exposed to the implicated food source was conducted, and those with reactive arthritis were evaluated for possible risk factors. Among 481 persons responding to the questionnaire, 217 cases of S. enteritidis gastroenteritis were identified (31 confirmed and 186 clinical cases; attack rate, 45%). Twenty-nine percent of the cases had symptoms of reactive arthritis, 3% had symptoms of Reiter's syndrome, and 10% had reactive arthritis with oral ulcers. Markers for severe illness (diarrhea > or =7 days, emergency room visit or hospitalization, and antibiotic treatment) were statistically significant but colinear factors associated with reactive arthritis. Increased awareness of postdysenteric reactive arthritis and Reiter's syndrome is recommended.

We examined the incidence of non-Hodgkin's lymphoma (NHL) in Chinese, Japanese, and Filipino residents of the United States to obtain further clues about the etiology of the disease. The age, race, and birthplace of residents of Hawaii, San Francisco/Oakland (California), and western Washington who had received a diagnosis of NHL during the period 1973-86 were obtained from population-based cancer registries, and a special tabulation from the 1980 Census was used to estimate the number of person-years at risk for each category of resident. The incidence of NHL in each of the Asian groups examined was 35 to 85 percent that of US-born Whites. However, there was no consistent trend of increasing incidence with increasing generation of residence in any of the groups. In Asian-Americans, the risk of small cell lymphocytic and plasmacytoid lymphoma was 10 to 85 percent that of Whites, although no clear trends of risk with generation of residence in the US were observed. They also were at a reduced risk of follicular lymphoma, and in Chinese and Japanese persons, the risk was lower in first generation than in later generation migrants (Chinese: Asian-born relative risk [RR] = 0.11, US-born, RR = 0.84; Japanese: Asian-born, RR = 0.15, US-born, RR = 0.36). The risk of diffuse lymphoma was similar in Chinese- and Japanese-Americans and US-born Whites. We conclude that, with the exception of follicular lymphoma, the basis for the relatively low incidence of NHL in Asian-Americans does not lie in exposures or characteristics that differ between the migrants themselves and their descendants.

In 2000, shigellosis traced to a commercially prepared dip developed in 406 persons nationwide. An ill employee may have inadvertently contaminated processing equipment. This outbreak demonstrates the vulnerability of the food supply and how infectious organisms can rapidly disseminate through point-source contamination of a widely distributed food item.

Childhood drowning rates vary substantially among demographic groups with higher rates among toddlers than children aged 5–14, higher rates among nonwhites than whites, and higher rates among males than females. To assess swimming frequency, ability, and site as possible causes of these differences, questions were added about these items to a survey administered on-site to families using New Jersey's public beaches. Responses describing 6,366 children indicated that swimming competence increased markedly at about age 5, was greater among whites than nonwhites, and was similar for males and females. Swimming frequency was greatest among children aged 5–9 and did not differ substantially by race or sex. Few families swam at unguarded sites. Subject to limitations related to the sampling procedure, we conclude that differences in swimming exposure are not likely to explain age, race, and sex differences in childhood drowning rates. Differences in swimming competence may explain age and race (but not sex) differences in childhood drowning rates, but additional work is needed to determine whether they actually do so.

Chromite ore processing residue occurs at over 130 sites in Hudson County, New Jersey. Many of these sites are in urban residential areas. This waste is a result of 70 years of chromate and bichromate chemical manufacturing. At least 15% of the sites contain total chromium concentrations greater than 10,000 mg/kg, with hexavalent content ranging from about 1 to 50%. Continuing leaching of this waste results in yellow-colored surface water runoff and yellow deposits on the soil surface and inside basement walls. The chemistry, environmental fate, health effects, and human exposure potentials for this waste are described. Images FIGURE 1.

In 2002, the Northwest Center for Public Health Practice (NWCPHP) at the University of Washington initiated the Epidemiology Competencies Project, with the goal of developing competency-based epidemiology training for non-epidemiologist public health practitioners in the northwestern United States. An advisory committee consisting of epidemiology faculty and experienced public health practitioners developed the epidemiology competencies. NWCPHP used the competencies to guide the development of in-person trainings, a series of online epidemiology modules, and a Web-based repository of epidemiology teaching materials. The epidemiology competencies provided a framework for collaborative work between NWCPHP and local and regional public health partners to develop trainings that best met the needs of a particular public health organization. Evaluation surveys indicated a high level of satisfaction with the online epidemiology modules developed from the epidemiology competencies. However, measuring the effectiveness of competency-based epidemiology training for expanding epidemiology knowledge and skills of the public health workforce remains a challenge.

We studied the molecular epidemiology of the recent fast-food restaurant chain-associated Escherichia coli O157:H7 outbreak in Washington State. Genomic DNAs prepared from strains isolated from 433 patients were probed with radiolabelled Shiga-like toxin (SLT) I and SLT II genes and bacteriophage lambda DNA and were subsequently analyzed for their restriction fragment length polymorphism (RFLP) patterns. The SLT RFLP and lambda RFLP profiles of an E. coli O157:H7 strain isolated from the incriminated beef and prototype patient were compared with those of the patient isolates for determination of the concordance between patterns. Of the 377 patients with primary and secondary cases of infection epidemiologically linked to the outbreak, isolates from 367 (97.3%) of the patients displayed SLT RFLP and lambda RFLP profiles identical to those of the outbreak strains. Isolates from 10 of the 377 (2.6%) patients possessed SLT RFLP and lambda RFLP profiles different from those of the outbreak strains, and the patients from whom those isolates were obtained were subsequently characterized as having non-outbreak-related infections. The E. coli O157:H7 strains isolated from 31 of 44 (70.4%) patients who were epidemiologically excluded from the outbreak were linked to the outbreak by RFLP typing. Our results indicate that SLT RFLP and lambda RFLP analyses are stable and sensitive methods, and when they are used in conjunction with an epidemiological investigation they could result in an earlier recognition of outbreaks and their sources, hence prompting measures to prevent the continued transmission of E. coli O157:H7.

In men, genital exposure to ultraviolet radiation (UVR) has been hypothesized to increase the risk of non-melanotic skin tumors at that site. However, during the period 1973-86, no change in the incidence of penile or scrotal skin tumors occurred in the United States, despite a likely increase in the population's level of genital exposure to UVR through the use of sunlamps and sunbeds. While UVR in conjunction with use of 8-methoxypsoralen by men with psoriasis is clearly related to an increase in the incidence of male genital skin tumors, our data provide no support for the hypothesis that, among men in general, UVR alone has this same effect.

ContextMultidrug-resistant Salmonella Typhimurium DT104 has recently emerged as a cause of human and animal illness in Europe and North America. In early 1997, health officials in Yakima County, Washington, noted a 5-fold increase in salmonellosis among the county's Hispanic population.ObjectivesTo characterize bacterial strains and identify risk factors for infection with Salmonella Typhimurium in Yakima County.DesignLaboratory, case-control, and environmental investigations.Setting and ParticipantsPatients with culture-confirmed Salmonella Typhimurium infection living in Yakima County and age- and neighborhood-matched control subjects.Main Outcome MeasuresFood vehicle implication based on case-control study and outbreak control.ResultsBetween January 1 and May 5, 1997, 54 culture-confirmed cases of Salmonella Typhimurium were reported. The median age of patients was 4 years and 91% were Hispanic. Patients reported diarrhea (100%), abdominal cramps (93%), fever (93%), bloody stools (72%), and vomiting (53%); 5 patients (9%) were hospitalized. Twenty-two patients and 61 control subjects were enrolled in the case-control study. Seventeen case patients (77%) reported eating unpasteurized Mexican-style soft cheese in the 7 days before onset of illness compared with 17 control subjects (28%) (matched odds ratio, 32.3; 95% confidence interval, 3.0-874.6). All case-patient isolates were phage definitive type 104 (DT104) (n=10) or DT104b (n=12), and 20 (91%) were resistant to ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, and tetracycline. The cheese produced and eaten by 2 unrelated patients was made with raw milk traced to the same local farm. Milk samples from nearby dairies yielded Salmonella Typhimurium DT104. The incidence of Salmonella Typhimurium infections in Yakima County returned to pre-1992 levels following interventions based on these findings.ConclusionsMultidrug-resistant Salmonella Typhimurium DT104 emerged as a cause of salmonellosis in Yakima County, and Mexican-style soft cheese made with unpasteurized milk is an important vehicle for Salmonella Typhimurium DT104 transmission. We postulate that recent increases in human salmonellosis reflect the emergence of Salmonella Typhimurium DT104 among dairy cows in the region. Continued efforts are needed to discourage consumption of raw milk products, promote healthier alternatives, and study the ecology of multidrug-resistant Salmonella Typhimurium.

Objective. —To determine the source of and describe a large outbreak of Escherichia coli O157:H7 infections in Washington State. Design. —Case-control study; environmental investigation; provider-based surveillance for E coli O157:H7 infections. Setting. —Chain of fast-food restaurants, hospitals, physician offices, local laboratories, and local health departments. Participants. —Patients with diarrhea and neighborhood controls. A case was defined as diarrhea with culture-confirmed E coli O157:H7 infection or postdiarrheal hemolytic uremic syndrome (HUS) occurring from December 1, 1992, through February 28, 1993, in a Washington State resident. Controls were age- and neighborhood-matched friends of the first 16 case patients. Interventions. —Announcement to the public; recall of implicated hamburger lots. Main Outcome Measure. —Abatement of outbreak due to E coli O157:H7. Results. —Infection was associated with eating at a fast-food chain (chain A) in the 10 days before symptoms began. Twelve (75%) of 16 case patients but no controls had eaten at chain A (matched odds ratio undefined; lower 95% confidence interval, 3.5; P E coli O157:H7 strains isolated from all regular hamburger lots of a single production date shipped to Washington was identical to that of the strains isolated from patients. Ten (63%) of 16 regular hamburgers cooked according to chain A policy had internal temperatures below 60°C. Public health action removed more than 250 000 potentially contaminated hamburgers, preventing an estimated 800 cases. Conclusions. —This E coli O157:H7 outbreak, the largest reported, resulted from errors in meat processing and cooking. Public health surveillance through state-mandated reporting of E coli O157:H7 infection as is carried out in Washington State was critical for prompt outbreak recognition and control. Measures should be developed to reduce meat contamination. Consumers and food service workers should be educated about cooking hamburger meat thoroughly. ( JAMA . 1994;272:1349-1353)