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Background and objectives Research on Legionnaires’ Disease (LD) suggests there may be long-term health complications, but data are limited. This study investigated whether Intensive Care Unit (ICU) admission during LD hospitalization may be associated with adverse health outcomes and characterized subsequent discharge diagnoses in patients with LD up to 5 years post-LD. Methods We conducted a retrospective case series study with follow up for 5 years among patients hospitalized at a Department of Veterans Affairs (VA) Medical Center between 2005 and 2010 with LD. Data were collected from medical records on health history, LD severity (including ICU admission), and discharge diagnoses for 5 years post-LD or until death. We used ordinal logistic regression to explore associations between ICU admission and hospitalizations post-LD. Frequency counts were used to determine the most prevalent discharge diagnoses in the 5 years post-LD. Results For the 292 patients with laboratory-confirmed LD, those admitted to the ICU during LD hospitalization were more likely to have a greater number of hospitalizations within 5 years compared to non-ICU patients (ORHosp 1.92 CI95% 1.25, 2.95). Fifty-five percent (161/292) had ≥ 1 hospitalization within 5 years post-LD. After accounting for pre-existing diagnosis codes in patients with at least one hospitalization in the 2 years prior to LD (n = 77/161 patients, 47.8%), three of the four most frequent new diagnoses in the 5 years post-LD were non-chronic conditions: acute renal failure (n = 22, 28.6%), acute respiratory failure (n = 17, 22.1%) and unspecified pneumonia (n = 15, 19.5%). Conclusions Our findings indicate that LD requiring ICU admission is associated with more subsequent hospitalizations, a factor that could contribute to poorer future health for people with severe LD. In addition to chronic conditions prevalent in this study population, we found new diagnoses in the 5-year post-LD period including acute renal failure. With LD incidence increasing, more research is needed to understand conditions and factors that influence long term health after LD.

Due to similarities in initial disease presentation, clinicians may be inclined to repeatedly test community-acquired pneumonia cases for COVID-19 before recognizing the need to test for Legionnaires’ disease. Legionnaires’ disease is an illness characterized by pneumonia that has a summer/early fall seasonality due to favorable conditions forLegionellagrowth and exposure.Legionellaproliferate in warm water environments and stagnant sections of indoor plumbing and cooling systems. During the ongoing pandemic crisis, exposures to aerosolized water from recently reopened office or retail buildings should be considered as an epidemiologic risk factor forLegionellaexposure and an indication to test. The majority of Legionnaires’ disease cases occurring each year are not diagnosed, and some experts recommend that all patients hospitalized with community-acquired pneumonia without a known etiology be tested forLegionellainfection. Proper diagnosis can increase the likelihood of appropriate and timely antibiotic treatment, identify potential clusters of disease, and facilitate source attribution.

Context: The incidence of legionellosis has sharply increased in the United States as a result of contaminated water systems. Jurisdictions across the country are considering whether to develop and implement regulations to protect individuals against Legionnaires' disease with its associated high morbidity and mortality. Objective: This article sheds light on the implementation and effectiveness of a 2005 citywide Legionella testing mandate of multifamily housing cooling towers in Garland, Texas. This ordinance has been in place for more than 10 years and represents the first of its kind in the United States to mandate routine testing of cooling towers for Legionella in multifamily housing. Design, Setting, and Population: We utilized a mix of both qualitative and quantitative methods to explore the development, adoption, and implementation of the ordinance. Phone interviews were conducted with individuals from the City of Garland Health Department and apartment managers. Quantitative data included public health surveillance data on legionellosis. Main Outcome Measures: Barriers and facilitators of implementation, number and percentage of cooling towers from multifamily housing units that tested positive for Legionella by year, and number of legionellosis cases by year in Garland, Texas. Results: Study outcomes highlight key themes that facilitated the successful implementation of the Legionella testing mandate, including the importance of timing, leadership support, stakeholder engagement, and education and outreach. The number of contaminated cooling towers was reduced over time. Conclusion: Mandatory monitoring for legionella in a local jurisdiction may result in reduced risk of legionellosis from cooling towers through raising awareness and education of building owners and managers about the need to prevent, detect, and remediate legionella contamination in their building water systems. Garland, Texas, broke new ground in the United States in moving toward primary prevention of legionellosis. The ordinance may be useful both in serving to educate and increase awareness about the need for Legionella prevention and to monitor effectiveness of maintenance procedures.

Objective: Understanding whether interventions designed to improve antenatal vaccine uptake also change women's knowledge about vaccination is critical for improving vaccine coverage. This exploratory study evaluates the effectiveness of a multi-component influenza and tetanus, diphtheria, and acellular pertussis (Tdap) vaccine promotion package on improving women's knowledge, attitudes and beliefs toward antenatal vaccination. Study Design: In 2012/2013 a cluster-randomized trial was conducted to test the effectiveness of a vaccine promotion package on improving antenatal vaccine coverage. Participants included 325 unvaccinated pregnant women from 11 obstetric practices in Georgia. Eleven health beliefs measures were assessed at baseline and 2–3 months post-partum. Outcomes were differences in proportions of women citing favorable responses to each measure between study groups at follow-up. Results: Women enrolled in their third trimester had a higher probability of asking family members to vaccinate to protect the infant if they were in the intervention group versus the control group (36% vs. 22%; risk ratio [RR] = 1.65, 95% confidence interval [CI]: 1.21, 2.26). A similar association was not observed among women enrolled before their third trimester (39% vs. 44%; RR = 0.93, 95% CI: 0.50, 1.73). There were no other significant differences at follow-up between study groups. Conclusions: While exposure to the intervention package may have raised awareness that vaccinating close contacts can protect an infant, there is little evidence that the package changed women's attitudes and beliefs toward antenatal vaccination. Future research should ensure adequate exposure to the intervention and consider study design aspects including power to assess changes in secondary outcomes, discriminatory power of response options, and social desirability bias. This study is registered with clinicaltrials.gov, study ID NCT01761799.

BackgroundConsiderable research has identified barriers to antenatal influenza vaccination, yet no research has explored temporal trends in reasons for non-receipt.PurposeTo examine trends in reasons for non-receipt of influenza vaccination during pregnancy.MethodsSerial cross-sectional analyses using 8 years of Georgia Pregnancy Risk Assessment Monitoring Survey (PRAMS) data were conducted. Weighted logistic regression was used to examine trends in the prevalence of citing reasons for non-receipt over time.ResultsBetween 2004 and 2011, 8300 women reported no influenza vaccination during or immediately before pregnancy. Proportions of women citing “doctor didn’t mention vaccination,” “in first trimester during influenza season,” and “not pregnant during influenza season” decreased significantly over time (Doctor didn’t mention: 48.0% vs. 27.1%, test for trend p

Alfred P. Sloan Foundation Microbiology of the Built Environmental Program This study was partially supported by the Alfred P. Sloan Foundation Microbiology of the Built Environmental Program.

In 2017, we surveyed 101 SHEA Research Network hospitals regarding Legionnaires’ disease (LD). Of 29 respondents, 94% have or are developing a water management plan with varying characteristics and personnel engaged. Most LD diagnostic testing is limited to urine antigen testing. Many opportunities to improve LD prevention and diagnosis exist.

Legionellosis is an important public health problem in the United States and other countries, and residents of long-term care facilities (LTCFs) are at higher risk for Legionnaires' disease than the general population. In this study, we reviewed published US and international guidelines for the primary prevention of legionellosis in LTCFs, including nursing homes, skilled nursing facilities, assisted living facilities, and aged care facilities. The results of this review indicate that most guidelines emphasize adequate design and maintenance of water systems and water temperatures; however, guidance regarding routine preventative environmental testing for Legionella bacteria is not uniform among various jurisdictions, and facilities are generally left without clear guidance on this issue. In the United States, the Centers for Disease Control and Prevention does not recommend such testing in LTCFs, in contrast to the Veterans Health Administration and Environmental Protection Agency. Internationally, the World Health Organization recommends routine environmental testing, as do Ireland; France; The Netherlands; South Africa; Vienna, Austria; and Queensland, Australia. Among domestic and international guidelines in favor of environmental testing, recommendations on the frequency of testing for Legionella in water systems vary. Further research to inform recommendations on the usefulness of routine environmental testing and other measures for the primary prevention of legionellosis in this setting is needed.

Background Evidence-based interventions to improve influenza vaccine coverage among pregnant women are needed, particularly among those who remain unvaccinated late into the influenza season. Improving rates of antenatal tetanus, diphtheria and acellular pertussis (Tdap) vaccination is also needed. Purpose To test the effectiveness of a practice-, provider-, and patient-focused influenza and Tdap vaccine promotion package on improving antenatal influenza and Tdap vaccination in the obstetric setting. Methods A cluster-randomized trial among 11 obstetric practices in Georgia was conducted in 2012–2013. Intervention practices adopted the intervention package that included identification of a vaccine champion, provider-to-patient talking points, educational brochures, posters, lapel buttons, and iPads loaded with a patient-centered tutorial. Participants were recruited from December 2012–April 2013 and included 325 unvaccinated pregnant women in Georgia. Random effects regression models were used to evaluate primary and secondary outcomes. Results Data on antenatal influenza and Tdap vaccine receipt were obtained for 300 (92.3%) and 291 (89.5%) women, respectively. Although antenatal influenza and Tdap vaccination rates were higher in the intervention group than the control group, improvements were not significant (For influenza: risk difference (RD) = 3.6%, 95% confidence interval (CI): −4.0%, 11.2%; for Tdap: RD = 1.3%, 95% CI: −10.7%, 13.2%). While the majority of intervention package components were positively associated with antenatal vaccine receipt, a provider's recommendation was the factor most strongly associated with actual receipt, regardless of study group or vaccine. Conclusions The intervention package did not significantly improve antenatal influenza or Tdap vaccine coverage. More research is needed to determine what motivates women remaining unvaccinated against influenza late into the influenza season to get vaccinated. Future research should quantify the extent to which clinical interventions can bolster a provider's recommendation for vaccination. This study is registered with clinicaltrials.gov, study ID NCT01761799.

This study describes policies and guidelines to prevent Legionella contamination in water systems in buildings in the United States., Context: Reported cases of legionellosis more than tripled between 2001 and 2012 in the United States. The disease results primarily from exposure to aerosolized water contaminated with Legionella. Objective: To identify and describe policies and guidelines for the primary prevention of legionellosis in the US. Design: An Internet search for Legionella prevention guidelines in the United States at the federal and state levels was conducted from March to June 2012. Local government agency guidelines and guidelines from professional organizations that were identified in the initial search were also included. Setting: Federal, state, and local governing bodies and professional organizations. Results: Guidelines and regulations for the primary prevention of legionellosis (ie, Legionnaires' disease and Pontiac fever) have been developed by various public health and other government agencies at the federal, state, and local levels as well as by professional organizations. These guidelines are similar in recommending maintenance of building water systems; federal and other guidelines differ in the population/institutions targeted, the extent of technical detail, and support of monitoring water systems for levels of Legionella contamination. Conclusions: Legionellosis deserves a higher public health priority for research and policy development. Guidance across public health agencies for the primary prevention of legionellosis requires strengthening as this disease escalates in importance as a cause of severe morbidity and mortality. We recommend a formal and comprehensive review of national public health guidelines for prevention of legionellosis.

Nipah virus (NiV) encephalitis is endemic in Bangladesh, with yearly seasonal outbreaks occurring since 2003. NiV has a notable case fatality rate, 75–100 per cent depending on the strain. In Bangladesh, primary transmission to humans is believed to be because of consumption of bat-contaminated date palm sap (DPS). Both the disease and the virus have been investigated extensively, however efforts to implement preventive strategies have met social and cultural challenges. Here we present a variety of community approaches to control the spread of Nipah encephalitis, along with advantages and disadvantages of each. This information may be useful to health workers and policymakers in potential NiV outbreak areas in Southeast Asia.

To identify factors associated with vaccine receipt among correctional facilities during the A(H1N1)pdm09 influenza pandemic, this study surveyed one third of U.S. correctional facilities. Analysis of the association of average daily population (ADP) on A(H1N1)pdm09 influenza vaccine receipt found that an ADP increase of 100 inmates resulted in a 32% increased likelihood of receiving influenza vaccine among smaller jails. Zero percent of large jails, 14% of federal prisons, 11% of nonfederal prisons, and 57% of small jails reported never receiving pandemic influenza vaccine. A qualitative assessment identified barriers to vaccine delivery, lessons learned from pandemic response, and recommendations for public health partners. Building stronger relationships between public health entities and correctional facilities to collaborate in influenza pandemic preparedness efforts may help protect correctional and community populations.

Opportunities for improved disease reporting are identified by describing physicians' reporting knowledge and practices as well as reporting knowledge and specimen referral patterns among clinical laboratories in the state of Georgia. In 2005, a sample of physicians(n = 177) and all Georgia clinical laboratories (n = 139) were surveyed about reporting knowledge and practices. Knowledge was greater among physicians who received their medical degree before 1980 (P = .04), accessed e-mail (P< .01), used the Internet to obtain public health information (P < .01), and reported frequently (P= .06). Increased knowledge was not associated with training in reporting (P = .14). Physicians were often unaware of reporting procedures and mechanisms and often did not report because they believed others would report (52%). Laboratory representatives (56%) more often received training on disease reporting than physicians (32%). All laboratories sent some specimens for diagnostic testing at reference laboratories and 35% sent the specimens outside of Georgia. Physicians'characteristics may affect reporting knowledge independent of training on disease reporting, and increased knowledge is associated with increased reporting. Investigation of physician characteristics that contribute to improved reporting, such as an active engagement with public health, could help to guide changes to reporting-related training and technology. Reporting by other health care providers and physicians' perceptions that others will report both indicate that studies of all reporting stakeholders and clear delineation of reporting responsibilities are needed. Extensive specimen referral by laboratories suggests the need for coordination of reporting regulations and responsibilities beyond local boundaries.

Concern over the adequacy of biosafety training and incident-reporting practices within biological laboratories in the United States has risen in recent years due to the increase in research on infectious diseases and the concomitant rise in the number of biocontainment laboratories. Reports of laboratory-acquired infections and delays in reporting such incidents have also contributed to the concern. Consequently, biosafety training and incident-reporting practices are being given considerable attention by both the executive branch and Congress. We conducted a 51-question survey of biosafety professionals in June 2008 to capture information on methods used to train new laboratory workers within biosafety level 2 (BSL-2) laboratories, animal biosafety level 2 (ABSL-2) laboratories, biosafety level 3 (BSL-3) laboratories, and animal biosafety level 3 (ABSL-3) laboratories. The survey results suggest nearly all senior scientists, faculty, staff, and students working in these biocontainment laboratories are required to have biosafety training, and three-quarters of respondents indicated a biosafety or environmental health and safety professional provides explicit instructions on reporting incidents to each new lab worker. Only half of the respondents with BSL-2/ABSL-2 laboratories at their institution and 59% of respondents from institutions with BSL-3/ABSL-3 laboratories indicated custodial or maintenance workers are required to receive biosafety training at the BSL-2/ABSL-2 and BSL-3/ABSL-3 levels, respectively. Opportunities for targeted improvement such as providing training to non-traditional laboratory workers (e.g., custodians, maintenance workers) and posting laboratory incident-reporting protocols on institutional environmental health and safety websites may exist. Variations in biosafety training requirements, incident-reporting practices, and attitudes towards laboratory safety revealed through this survey of biosafety professionals also support the development of core competencies in biosafety practice that could lead to more uniform practices and robust safety cultures.

As pandemic influenza becomes an increasing threat, partnerships between public health and correctional facilities are necessary to prepare criminal justice systems adequately. In September 2007, the Planning for Pandemic Influenza in Prison Settings Conference took place in Georgia. This article describes the collaboration and ongoing goals established between administrative leaders and medical staff in Georgia prison facilities and public health officials. Sessions covered topics such as nonpharmaceutical interventions, health care surge capacity, and prison-community interfaces. Interactive activities and tabletop scenarios were used to promote dynamic learning, and pretests and posttests were administered to evaluate the short-term impact of conference participation. The conference has been followed by subsequent meetings and an ongoing process to guide prisons' preparation for pandemic influenza.

With an increased number of newly constructed high-containment laboratories and staff working in these facilities, the risk for emergency situations has increased, as has the need for systematic tr...

Background. Little is known about the occurrence of Q fever among veterinarians in the United States. In this study, we sought to estimate the prevalence of Coxiella burnetii antibodies among veterinarians and to identify risk factors for exposure. Methods. We tested serum samples from 508 veterinarians who attended the 143rd American Veterinary Medical Association Annual Convention in 2006. Samples were screened using a Q fever IgG enzyme-linked immunosorbent assay (ELISA). Samples with positive or equivocal results of ELISA were confirmed using phase I and phase II IgG immunofluorescence antibody assays, and end point IgG titers were determined for samples with positive results. Results. Antibodies against C. burnetii were detected in 113 (22.2%) of 508 veterinarians. Risk factors associated with seropositivity included age 46 years, routine contact with ponds, and treatment of cattle, swine, or wildlife. Conclusions. Veterinarians have a high level of exposure to C. burnetii, the causative organism of Q fever, especially those veterinarians who treat livestock. In this study, risk of C. burnetii seropositivity was also independently associated with contact with ponds. The role of exposure to standing bodies of water in infection is not usually considered and should be investigated in future studies. Additionally, the evidence of past infection with C. burnetii in 120% of veterinarians also highlights the need for use of appropriate personal protective equipment when treating animals that are potentially infected with C. burnetii. Physicians should consider the risk of infection with C. burnetii when treating ill veterinarians and others with potential occupational exposures.

Background. An abrupt increase in the incidence of legionellosis in the United States has been noted since 2003. Whether the recent increase is associated with shifting epidemiologic trends has not been well characterized. Methods. We analyzed all cases of legionellosis reported to the Centers for Disease Control and Prevention through the National Notifiable Disease Surveillance System from 1990 through 2005. Results. A total of 23,076 cases of legionellosis were reported to the Centers for Disease Control and Prevention from 1990 through 2005. The number of reported cases increased by 70% from 1310 cases in 2002 to 2223 cases in 2003, with a sustained increase to 12000 cases per year from 2003 through 2005. The eastern United States showed most of the increases in age-adjusted incidence rates after 2002, with the mean rate in the Middle Atlantic states during 2003–2005 exceeding that during 1990–2002 by 96%. During 2000–2005, legionellosis cases were most commonly reported in persons aged 45–64 years. Persons aged !65 years comprised 63% of total cases in 2000–2005. Age-adjusted incidence rates in males exceeded those in females for all age groups and years. Legionellosis incidence showed marked seasonality in eastern states, with most cases reported in the summer or fall. Conclusions. Reported legionellosis cases have increased substantially in recent years, particularly in the eastern United States and among middle-aged adults. Legionella infection should be considered in the differential diagnosis of any patient with pneumonia. Public health professionals should focus increased attention on detection and prevention of this important and increasing public health problem.

As the number of individuals working in high biocontainment laboratories (BSL-3 and -4) increases over time, human error remains one of the most important factors in the origin of hazardous inciden...

To estimate the proportion of obstetric practice web sites in the United States providing information on antenatal influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination.Using www.healthgrades.com, a national random sample of 1,003 obstetric practice web sites was examined for provision of information on antenatal vaccination and other preventive prenatal health topics. Data were collected for this cross-sectional study between September 25, 2014, and November 12, 2014. χ tests and odds ratios were calculated to determine significance and magnitude of associations between provision of antenatal vaccination information and other practice characteristics.Of 1,003 web sites examined, 229 (22.8%) posted information pertaining to antenatal vaccinations. Only 105 web sites (10.5%) provided up-to-date information about both antenatal influenza and Tdap vaccination. Compared with the proportion posting on antenatal vaccination, significantly more web sites posted on safe foods (40.8%; P.001), safe medications (36.9%; P.001), and safe exercise (38.5%; P.001) during pregnancy. When compared with web sites not mentioning these other prenatal health topics, web sites mentioning these topics were more likely to also mention antenatal vaccination (safe foods: 45.7% compared with 7.1%; odds ratio [OR] 11.07, 95% confidence interval [CI] 7.65-16.01; safe medications: 45.4% compared with 9.6%; OR 7.8, CI 5.58-10.89; safe exercise: 45.9% compared with 8.4%; OR 9.2, CI 6.5-13.03).A majority of obstetric care practice web sites do not provide information on antenatal vaccinations. Obstetric practices should consider using their web sites to provide reliable information on antenatal vaccinations as many already do for other prenatal health topics.

BACKGROUND: Improving influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccine coverage among pregnant women is needed. PURPOSE: To assess factors associated with intention to receive influenza and/or Tdap vaccinations during pregnancy with a focus on perceptions of influenza and pertussis disease severity and influenza vaccine safety. METHODS: Participants were 325 pregnant women in Georgia recruited from December 2012 – April 2013 who had not yet received a 2012/2013 influenza vaccine or a Tdap vaccine while pregnant. Women completed a survey assessing influenza vaccination history, likelihood of receiving antenatal influenza and/or Tdap vaccines, and knowledge, attitudes and beliefs about influenza, pertussis, and their associated vaccines. RESULTS: Seventy-three percent and 81% of women believed influenza and pertussis, respectively, would be serious during pregnancy while 87% and 92% believed influenza and pertussis, respectively, would be serious to their infants. Perception of pertussis severity for their infant was strongly associated with an intention to receive a Tdap vaccine before delivery (p=0.004). Despite perceptions of disease severity for themselves and their infants, only 34% and 44% intended to receive antenatal influenza and Tdap vaccines, respectively. Forty-six percent had low perceptions of safety regarding the influenza vaccine during pregnancy, and compared to women who perceived the influenza vaccine as safe, women who perceived the vaccine as unsafe were less likely to intend to receive antenatal influenza (48% vs. 20%; p < 0.001) or Tdap (53% vs. 33%; p < 0.001) vaccinations. CONCLUSIONS: Results from this baseline survey suggest that while pregnant women who remain unvaccinated against influenza within the first three months of the putative influenza season may be aware of the risks influenza and pertussis pose to themselves and their infants, many remain reluctant to receive influenza and Tdap vaccines antenatally. To improve vaccine uptake in the obstetric setting, our findings support development of evidence-based vaccine promotion interventions which emphasize vaccine safety during pregnancy and mention disease severity in infancy.

In Georgia, most individuals reported with West Nile virus (WNV) disease have been diagnosed with West Nile neuroinvasive disease (WNND). Relatively few cases of West Nile Fever (WNF) are reported, and the burden of illness due to WNV is likely underestimated. From July through October 2003, WNV serologic testing was performed on enrolled patients>or=18 years of age with fever admitted to a large, urban hospital in Atlanta, Georgia through the emergency department (ED). Patients' history, clinical, and laboratory data were recorded. Residual blood drawn in the ED was tested to determine the presence of WNV IgG and IgM antibodies. Of 254 patients tested for WNV, four (1.6%) patients were positive for WNV IgM and IgG antibodies, and had a clinical illness compatible with WNV. None of the four positive patients were clinically suspected of having WNV infection; discharge diagnoses included pneumonia, migraine, stroke, and gout. These four patients accounted for 80% of all WNV diagnosed in this hospital, 44% of all cases in Fulton County, and 7% of all cases reported in Georgia in 2003. The occurrence of WNV disease may be substantially greater than currently reflected in disease statistics in Georgia and many other states. When indicators of WNV activity are present and patients are likely to have had intensive mosquito exposure, WNV should be considered in the differential diagnosis of seriously ill, febrile patients.

Notifiable disease surveillance systems provide essential data for infectious disease prevention and control programs at the local, state, and national levels. Given that reporting completeness is known to vary considerably, this review identifies methods that can reliably enhance completeness of reporting. These surveillance-related activities include initiating active surveillance when appropriate; implementing automated, electronic laboratory-based reporting; strengthening ties with clinicians and other key partners in notifiable disease reporting; and increasing the use of laboratory diagnostic tests in identifying new cases. Despite ample data in support of these strategies, notifiable disease surveillance continues to receive insufficient attention and resources. Recent attention to public health preparedness provides an opportunity to strengthen notifiable disease surveillance and enhance completeness of reporting.

Objective Emergency department (ED)-based syndromic surveillance systems are being used by public health departments to monitor for outbreaks of infectious diseases, including bioterrorism; however, few systems have been validated. The authors evaluated a "drop-in" syndromic surveillance system by comparing syndrome categorization in the ED with chief complaints and ED discharge diagnoses from medical record review. Methods A surveillance form was completed for each ED visit at 15 participating Arizona hospitals between October 27 and November 18, 2001. Each patient visit was assigned one of ten clinical syndromes or "none." For six of 15 EDs, kappa statistics were used to compare syndrome agreement between surveillance forms and syndrome categorization with chief complaint and ED discharge diagnosis from medical record review. Results Overall, agreement between surveillance forms and ED discharge diagnoses (kappa = 0.55; 95% confidence interval [CI] = 0.52 to 0.59) was significantly higher than between surveillance forms and chief complaints (kappa = 0.48; 95% CI = 0.44 to 0.52). Agreement between chief complaints and ED discharge diagnoses was poor for respiratory tract infection with fever (kappa = 0.33; 95% CI = 0.27 to 0.39). Furthermore, pediatric chief complaints showed lower agreement for respiratory tract infection with fever when compared with adults (kappa = 0.34 [95% CI = 0.20 to 0.47] vs. kappa = 0.44 [95% CI = 0.28 to 0.59], respectively). Conclusions In general, this syndromic surveillance system classified patients into appropriate syndrome categories with fair to good agreement compared with chief complaints and discharge diagnoses. The present findings suggest that use of ED discharge diagnoses, in addition to or instead of chief complaints, may increase surveillance validity for both automated and drop-in syndromic surveillance systems.

Veterinary vaccines are being used with increasing frequency in the United States to protect the health of animals. However, humans may be inadvertently exposed to these products by means of unintentional inoculation or other routes of exposure. The potential for both exposure and for adverse consequences secondary to exposure to veterinary vaccines may be growing. With the exception of brucellosis vaccines, there have been few reports of suspected or confirmed adverse events in humans associated with the use of animal vaccines, but it is unclear whether that is because few adverse events occur or because adverse events are not recognized and/or reported. Results of a search for relevant literature and of communications with health officials at governmental and private institutions suggest that enhanced efforts are needed to recognize and to prevent human illness associated with use of veterinary vaccines.

Respiratory syncytial virus immune globulin intravenous (RSV-IGIV) has been approved by the Food and Drug Administration for use in the prevention of severe RSV infections in infants and children younger than 24 months with bronchopulmonary dysplasia or a history of premature birth (≤35 weeks of gestation). RSV-IGIV administered monthly during the RSV season resulted in a 41% to 65% reduction in hospitalization rates in two clinical trials; however, RSV-IGIV is costly, and intravenous administration can be logistically demanding. RSV-IGIV should be considered for infants with bronchopulmonary dysplasia who are receiving or have received oxygen therapy in the past 6 months. Infants with gestational ages of 32 weeks or less may also benefit clinically from RSV-IGIV prophylaxis. Immunization with measles-containing vaccines should be delayed for 9 months after the last dose of RSV-IGIV, but no changes need to be made for all other routinely administered vaccines. RSV-IGIV has not been approved for use in children with congenital heart disease, and available data indicate that RSV-IGIV should not be administered to children with cyanotic congenital heart disease because of safety concerns.

In 1992, the Committee on Infectious Diseases and Committee on Fetus and Newborn of the American Academy of Pediatrics provided guidelines for prevention of early-onset group B streptococcal (GBS) disease through intrapartum chemoprophylaxis of selected maternal GBS carriers.1 The guidelines were based on demonstrated efficacy in randomized, controlled clinical trials and selected only women with GBS colonization who had an obstetric risk factor.2 The guidelines were controversial34and their implementation incomplete.5 Since 1992, additional data have become available, and experience with the guidelines has been gained in numerous medical centers. Recently, consensus guidelines were developed by obstetricians, pediatricians, family practitioners, and public health authorities and published by the Centers for Disease Control and Prevention.6 These recommendations are supported by the American College of Obstetricians and Gynecologists7 and the American Academy of Pediatrics. This statement reviews the selection of pregnant women for chemoprophylaxis and provides an algorithm for management of their newborns.

Three decades into the HIV/AIDS epidemic, HIV prevention programs have been only partially effective. New prevention tools are providing new reasons for optimism. Effective use of these new tools, including the 'test-and-treat' strategy, will require considerable effort to assure that their potential for prevention is fully realized. Challenges with the test-and-treat strategy are global ones, and include retention in care and adherence to treatment. Worldwide, those with HIV infection become less adherent to antiretroviral therapy over time. Many factors contributing to retention in care and adherence to therapy differ among countries and regions of the world. HIV-infected persons receiving treatment in sub-Saharan Africa have been reported to have higher adherence rates than those receiving treatment on the North American continent; higher health literacy and perception of treatment as a social obligation may enhance adherence to treatment and retention in care. The HIV test-and-treat strategy offers a major step forward when combined with other prevention efforts; we need to consider what additional steps are needed to deliver on the promise of prevention through treatment.

Objective Although clinical microbiology testing facilitates both public health surveillance of infectious diseases and patient care, research on testing patterns is scant. We surveyed hospital laboratories in Georgia to assess their diagnostic testing practices. Methods Using e-mail, all directors of hospital laboratories in Georgia were invited to participate. The survey focused on timing and location of diagnostic testing in 2006 for 6 reportable diseases: giardiasis, legionellosis, meningococcal disease, pertussis, Rocky Mountain spotted fever, and West Nile virus disease. Results Of 141 laboratories, 62 (44%) responded to the survey. Hospitals varied widely in their use of diagnostic testing in 2006, with 95.1% testing for meningococcal disease, but only 66.1% and 63.3% testing for legionellosis and West Nile virus disease, respectively. Most laboratories (91%) performed gram stain/culture to diagnose meningococcal disease in-house and 23% performed ova and parasite panels for giardiasis were conducted in-house. Fewer than 11% of laboratories performed in-house testing for the remaining diseases. Laboratories affiliated with small hospitals (≤100 beds) were more likely to send specimens for outside testing compared with laboratories associated with large hospitals (>250 beds). Median turnaround time for ova and parasite panel testing for giardiasis was significantly shorter for in-house testing (1.0 days) than within-system (2.25 days) or outside laboratory (3.0 days) testing (P = .0003). No laboratories reported in-house testing for meningococcal disease, pertussis, or Rocky Mountain spotted fever using polymerase chain reaction. Conclusion Many hospitals did not order diagnostic tests for important infectious diseases during 2006, even for relatively common diseases. In addition, hospital laboratories were unlikely to perform diagnostic testing in-house; sending specimens to an outside laboratory may result in substantial delays in receiving results. These unsettling findings have adverse implications for both patient care and public health surveillance; they indicate an immediate need to study nationally the use and timeliness of clinical microbiologic testing.

BACKGROUND In the United States, considerable geographic variation in the rates of culture-confirmed Campylobacter infection has been consistently observed among sites participating in the Foodborne Diseases Active Surveillance Network (FoodNet). METHODS We used data from the FoodNet Population Surveys and a FoodNet case-control study of sporadic infection to examine whether differences in medical care seeking, medical practices, or risk factors contributed to geographic variation in incidence. RESULTS We found differences across the FoodNet sites in the proportion of persons seeking medical care for an acute campylobacteriosis-like illness (range, 24.9%-43.5%) and in the proportion of ill persons who submitted a stool sample (range, 18.6%-40.7%), but these differences were not statistically significant. We found no evidence of geographic effect modification of previously identified risk factors for campylobacteriosis in the case-control study analysis. The prevalence of some exposures varied among control subjects in the FoodNet sites, including the proportion of controls reporting eating chicken at a commercial eating establishment (18.2%-46.1%); contact with animal stool (8.9%-30.9%); drinking water from a lake, river, or stream (0%-5.1%); and contact with a farm animal (2.1%-12.7%). However, these differences do not fully explain the geographic variation in campylobacteriosis. CONCLUSIONS Future studies that quantify Campylobacter contamination in poultry or variation in host immunity may be useful in identifying sources of this geographic variation in incidence.

In June and July 2010, we conducted a national internet-based survey of 64 city, state, and territorial immunization program managers (IPMs) to assess their experiences in managing the 2009-10 H1N1 influenza vaccination campaign. Fifty-four (84%) of the managers or individuals responsible for an immunization program responded to the survey. To manage the campaign, 76% indicated their health department activated an incident command system (ICS) and 49% used an emergency operations center (EOC). Forty percent indicated they shared the leadership of the campaign with their state-level emergency preparedness program. The managers' perceptions of the helpfulness of the emergency preparedness staff was higher when they had collaborated with the emergency preparedness program on actual or simulated mass vaccination events within the previous 2 years. Fifty-seven percent found their pandemic influenza plan helpful, and those programs that mandated that vaccine providers enter data into their jurisdiction's immunization information system (IIS) were more likely than those who did not mandate data entry to rate their IIS as valuable for facilitating registration of nontraditional providers (42% vs. 25%, p

Three outbreaks of disease in the United States in 1993 caused by Escherichia coli O157:H7, Cryptosporidium organisms, and a previously unrecognized hantavirus clearly illustrate the increasing challenges posed by emerging infectious diseases. The largest US outbreak of E. coli O157:H7 infection reported occurred as a result of contaminated hamburgers served at a fast-food restaurant chain. The largest recorded waterborne disease outbreak in US history was due to contamination of a municipal water supply with cryptosporidia. In the southwestern United States, hantavirus was first recognized as the cause of a pulmonary syndrome with a mortality rate exceeding 50%. The detection of and response to these outbreaks document the need for a strong partnership between the clinical and public health sectors to prevent and control diseases. Health care reform in the United States provides an opportunity to address critical needs, such as improved surveillance and diagnosis, to ensure timely detection of and rapid response to newly emerging infectious diseases.

Background Dengue viruses (DENVs) and Japanese encephalitis virus (JEV) have significant cross-reactivity in serological assays; the clinical implications of this remain undefined. An improved understanding of whether and how JEV immunity modulates the clinical outcome of DENV infection is important as large-scale DENV vaccine trials will commence in areas where JEV is co-endemic and/or JEV immunization is routine. Methods and Findings The association between preexisting JEV neutralizing antibodies (NAbs) and the clinical severity of DENV infection was evaluated in a prospective school-based cohort in Thailand that captured asymptomatic, non-hospitalized, and hospitalized DENV infections. Covariates considered included age, baseline DENV antibody status, school of attendance, epidemic year, and infecting DENV serotype. 942 children experienced at least one DENV infection between 1998 and 2002, out of 3,687 children who were enrolled for at least one full year. In crude analysis, the presence of JEV NAbs was associated with an increased occurrence of symptomatic versus asymptomatic infection (odds ratio [OR] = 1.55, 95% CI: 1.08–2.23) but not hospitalized illness or dengue hemorrhagic fever (DHF). The association was strongest in children with negative DENV serology (DENV-naive) (OR = 2.75, 95% CI: 1.12–6.72), for whom the presence of JEV NAbs was also associated with a symptomatic illness of longer duration (5.4 days for JEV NAb+ versus 2.6 days for JEV NAb-, p = 0.048). JEV NAbs were associated with increased DHF in younger children with multitypic DENV NAb profiles (OR = 4.05, 95% CI: 1.18 to 13.87). Among those with JEV NAbs, the association with symptomatic illness did not vary by antibody titer. Interpretation The prior existence of JEV NAbs was associated with an increased probability of symptomatic as compared to asymptomatic DENV illness. These findings are in contrast to previous studies suggesting an attenuating effect of heterologous flavivirus immunity on DENV disease severity., Author Summary Dengue viruses (DENVs) and Japanese encephalitis virus (JEV) have significant cross-reactivity in serological assays, but the possible clinical implications of this remain poorly understood. Interactions between these flaviviruses are potentially important for public health because wild-type JEV continues to co-circulate with DENV in Southeast Asia, the area with the highest burden of DENV illness, and JEV vaccination coverage in this region is high. In this study, we examined how preexisting JEV neutralizing antibodies (NAbs) influenced the clinical severity of subsequent DENV infection using data from a prospective school-based cohort study in Thailand that captured a wide range of clinical severities, including asymptomatic, non-hospitalized, and hospitalized DENV infections. We found that the prior existence of JEV NAbs was associated with an increased occurrence of symptomatic versus asymptomatic DENV infection. This association was most notable in DENV-naives, in whom the presence of JEV NAbs was also associated with an illness of longer duration. These findings suggest that the issue of heterologous flavivirus immunity and DENV infection merits renewed attention and interest and that DENV vaccine developers might incorporate detailed assessments of preexisting immunity to non-DENV flaviviruses and histories of vaccination against non-DENV flaviviruses in evaluating DENV vaccine safety and efficacy.

The following CDC staff members prepared this report: National Center for Infectious Diseases Division of HIV/AIDS Kenneth G. Castro, M.D. John W. Ward, M.D. Laurence Slutsker, M.D., M.P.H. James W. Buehler, M.D. Harold W. Jaffe, M.D. Ruth L. Berkelman, M.D. Office of the Director Associate Director for HIV/AIDS James W. Curran, M.D., M.P.H. 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults Summary CDC has revised the classification system for HIV infection to emphasize the clinical importance of the CD4+ T-lymphocyte count in the categorization of HIV-related clinical conditions. This classification system replaces the system published by CDC in 1986 (1) and is primarily intended for use in public health practice. Consistent with the 1993 revised classification system, CDC has also expanded the AIDS surveillance case definition to include all HIV-infected persons who have less than 200 CD4+ T-lymphocytes/uL, or a CD4+ T-lymphocyte percentage of total lymphocytes of less than 14. This expansion includes the addition of three clinical conditions

Background. Mammography is widely known to reduce morbidity and mortality from breast cancer, but a population-based assessment of mammography use and follow-up of mammography findings has not been reported previously. Methods. An observational, population-based, follow-up study was conducted of all women having mammograms in the Greater Lansing, Michigan, metropolitan area, between June 1987 and June 1988. A total of 17,811 Greater Lansing women participated. The adherence of women to mammography screening guidelines was estimated, and mammography's utility to detect breast cancer was assessed through follow-up review of breast biopsy results. Results. Thirty-seven percent of the expected number of women 35 years of age and older had mammograms. Adherence to screening guidelines declined with age, and less than 5% (302 of 6700) of women 55 years of age and older reporting having annual mammograms. Seventy-six percent of women reported that their physicians prompted the examination. The predictive value of a positive mammogram was 21.9% for women without symptoms and 32.4% for women with symptoms. Mammography's sensitivity and specificity for breast cancer detection were 71% and 98%, respectively. Conclusions. The study highlights the need to target mammography to women 50 years of age and older, underscores the importance of physicians in promoting mammography, and demonstrates the analytic value and limitation of mammography in clinical decision-making.

OBJECTIVE To describe the characteristics of individuals > or = 13 years of age with HIV wasting syndrome in the United States and US territories. DESIGN Retrospective review of national AIDS case surveillance data. METHODS Data for the 147,225 individuals with AIDS reported to the Centers for Disease Control from 1 September 1987 to 31 August 1991 were reviewed. The frequency of HIV wasting syndrome and its association with demographic and exposure category variables and with other AIDS-indicator diseases were assessed. RESULTS A total of 10,525 (7.1%) had wasting syndrome as the only AIDS-indicator condition, and 15,726 (10.7%) had wasting syndrome plus at least one other AIDS-indicator condition. Patients with wasting syndrome as the only AIDS diagnosis were more likely to be female, to be black or Hispanic, and to have a mode of HIV exposure reported as injecting drug use, heterosexual contact, or transfusion/hemophilia. The proportion of AIDS patients reported with wasting syndrome varied by geographic distribution, ranging from 11% in the northeastern United States to 47% in Puerto Rico. The association between HIV wasting syndrome and Hispanic ethnicity was due to the much higher prevalence of wasting syndrome reported in Puerto Rican AIDS patients. The other AIDS-indicator conditions most strongly associated with wasting syndrome were isosporiasis, pulmonary candidiasis, esophageal candidiasis, HIV encephalopathy, chronic mucocutaneous herpes simplex, and coccidioidomycosis. CONCLUSIONS The association between HIV wasting syndrome and injecting drug use, and the significant racial/ethnic and geographic differences in prevalence of this AIDS diagnosis may reflect differences in diagnostic and reporting practices and/or access to medical care.

1 Demographic Changes 2 International Travel and Commerce 3 Societal Changes 4 Changes in Technology 5 Land-Use Patterns and Ecological Change 6 Microbial Adaptation and Change 7 Breakdown of Public-Health Infrastructure 8 Intent to do Harm: Bioterrorism 9 Infectious Origins of Chronic Diseases 10 Summary Keywords: bacterial infectious diseases-emergence and resurgence; infectious diseases-leading cause of death in developing countries; dramatic increases in international travel and commerce and infectious disease emergence; technology changes and emerging newly recognized pathogens; diarrheal illness outbreaks in child-care centers; advent of highly active antiretroviral therapy (HAART)-major impact on opportunistic infections; ecological changes and tick-borne diseases; microbial adaptation and change