An outbreak of scabies in a teaching hospital: lessons learned.

OBJECTIVE: To investigate an outbreak of scabies in an inner-city teaching hospital, identify pathways of transmission, institute effective control measures to end the outbreak, and prevent future occurrences. DESIGN: Outbreak investigation, case-control study, and chart review. SETTING: Large tertiary acute-care hospital. RESULTS: A patient with unrecognized Norwegian (crusted) scabies was admitted to the acquired immunodeficiency syndrome (AIDS) service of a 940-bed acute-care hospital. Over 4 months, 773 healthcare workers (HCWs) and 204 patients were exposed to scabies. Of the exposed HCWs, 147 (19%) worked on the AIDS service. Risk factors for being infested with scabies among HCWs included working on the AIDS service (odds ratio [OR], 5.3; 95% confidence interval [CI95], 2.17-13.15) and being a nurse, physical therapist, or HCW with extensive physical contact with infected patients (OR, 4.5; CI95, 1.26-17.45). Aggressive infection control precautions beyond Centers for Disease Control and Prevention barrier and isolation recommendations were instituted, including the following: (1) early identification of infected patients; (2) prophylactic treatment with topical applications for all exposed HCWs; (3) use of two treatments 1 week apart for all cases of Norwegian scabies; (4) maintaining isolation for 8 days and barrier precautions for 24 hours after completing second treatment for a diagnosis of Norwegian scabies; and (5) oral ivermectin for treatment of patients who failed conventional therapy. CONCLUSIONS: HCWs with the most patient contact are at highest risk of acquiring scabies. Because HCWs who used traditionally accepted barriers while caring for patients with Norwegian scabies continued to develop scabies, we found additional measures were required in the acute-care hospital. HCWs with skin exposure to patients with scabies should receive prophylactic treatment. We recommend (1) using heightened barrier precautions for care of patients with scabies and (2) extending the isolation period for 8 days or 24 hours after the second treatment with a scabicide for those patients with Norwegian scabies. Oral ivermectin was well tolerated for treating patients and HCWs who failed conventional treatment. Finally, we developed a surveillance system that provides a "barometric measure" of the infection rate in the community. If scabies increases in the community, a tiered triage system is activated to protect against transmission among HCWs or hospital patients.     

Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions.

BACKGROUND: Modified contact precautions (MCP), defined as routine donning of isolation gowns (along with routine gloving) on entry into the rooms of patients under contact precautions, regardless of the likelihood of direct exposure to the patient or their immediate environment, were instituted at our medical center to reduce nosocomial transmission of common hospital pathogens. OBJECTIVES: To study compliance with MCP policy regarding routine gowning in intensive care units (ICUs) and general wards and to determine the relationship between gown and glove use in the care of patients under MCP in ICUs. DESIGN: Prospective observational study from February 20, 2004, through January 8, 2005, involving 2,110 persons (1,504 healthcare workers [HCWs] and 606 non-HCW visitors). SETTING: A 900-bed tertiary care teaching community hospital. RESULTS: Overall compliance with routine gown use was observed for 1,542 persons (73%), including 1,150 HCWs (76%) and 392 visitors (65%) (odds ratio [OR], 1.8 [95% confidence interval {CI}, 1.4-2.2]; P<.001). Visitors in the ICUs (186 [91%] of 204) were more likely than visitors in the general wards (202 [51%] of 398) to comply with gown use (OR, 10 [95% CI, 6.0-17.0]; P<.001). In logistic regression analysis, independent predictors of gown compliance among HCWs were female sex (OR, 2.3 [95% CI, 1.8-3.0]; P<.001) and ICU setting (OR, 2.2 [95% CI, 1.7-2.9]; P<.001). In the ICUs, gown use was highly predictive of glove use among HCWs (positive predictive value, 95%). CONCLUSION: Improvement in compliance with gown use at our medical center will require more-intensive educational efforts targeted at male HCWs and at HCWs and visitors on general wards. In the care of ICU patients under MCP, HCW compliance with gown use may be used as a proxy for their compliance with glove use.     

Cluster of cases of severe acute respiratory syndrome among Toronto healthcare workers after implementation of infection control precautions: a case series.

OBJECTIVE: To review the severe acute respiratory syndrome (SARS) infection control practices, the types of exposure to patients with SARS, and the activities associated with treatment of such patients among healthcare workers (HCWs) who developed SARS in Toronto, Canada, after SARS-specific infection control precautions had been implemented. METHODS: A retrospective review of work logs and patient assignments, detailed review of medical records of patients with SARS, and comprehensive telephone-based interviews of HCWs who met the case definition for SARS after implementation of infection control precautions. RESULTS: Seventeen HCWs from 6 hospitals developed disease that met the case definition for SARS after implementation of infection control precautions. These HCWs had a mean age (+/-SD) of 39+/-2.3 years. Two HCWs were not interviewed because of illness. Of the remaining 15, only 9 (60%) reported that they had received formal infection control training. Thirteen HCWs (87%) were unsure of proper order in which personal protective equipment should be donned and doffed. Six HCWs (40%) reused items (eg, stethoscopes, goggles, and cleaning equipment) elsewhere on the ward after initial use in a room in which a patient with SARS was staying. Use of masks, gowns, gloves, and eyewear was inconsistent among HCWs. Eight (54%) reported that they were aware of a breach in infection control precautions. HCWs reported fatigue due to an increased number and length of shifts; participants worked a median of 10 shifts during the 10 days before onset of symptoms. Seven HCWs were involved in the intubation of a patient with SARS. One HCW died, and the remaining 16 recovered. CONCLUSION: Multiple factors were likely responsible for SARS in these HCWs, including the performance of high-risk patient care procedures, inconsistent use of personal protective equipment, fatigue, and lack of adequate infection control training.     

An evidence-based review of patient-centered behavioral interventions for hypertension

INTRODUCTION: While behavioral interventions may be viewed as important strategies to improve blood pressure (BP), an evidence-based review of studies evaluating these interventions may help to guide clinical practice. METHODS: We employed systematic review and meta-analysis of the literature (1970-1999) to assess the independent and additive effects of three behavioral interventions on BP control (counseling, self-monitoring of BP, and structured training courses). RESULTS: Of 232 articles assessing behavioral interventions, 15 (4072 subjects) evaluated the effectiveness of patient-centered counseling, patient self-monitoring of BP, and structured training courses. Pooled results revealed that counseling was favored over usual care (3.2 mmHg [95% CI, 1.2-5.3] improvement in diastolic blood pressure [DBP] and 11.1 mmHg [95% CI, 4.1-18.1] improvement in systolic blood pressure [SBP]) and training courses (10 mmHg improvement in DBP [95% CI, 4.8-15.6]). Counseling plus training was favored over counseling (4.7 mmHg improvement in SBP [95% CI, 1.2-8.2]) and afforded more subjects hypertension control (95% [95% CI, 87-99]) than those receiving counseling (51% [95% CI, 34-66]) or training alone (64% [95% CI, 48-77]). CONCLUSIONS: Evidence suggests that counseling offers BP improvement over usual care, and that adding structured training courses to counseling may further improve BP. However, there is not enough evidence to conclude whether self-monitoring of BP or training courses alone offer consistent improvement in BP over counseling or usual care. The magnitude of BP reduction offered by counseling indicates this may be an important adjunct to pharmacologic therapy.     

Risk perception and attitudes towards HIV in Serbian health care workers

BACKGROUND: Health care workers (HCWs) are at risk of occupational exposure to human immunodeficiency virus (HIV). AIM: To investigate the perception of professional risk from, and the knowledge, attitudes and practice of HCWs to HIV and AIDS in Serbia. METHODS: Cross-sectional study of 1,559 Serbian HCWs using self-administered anonymous questionnaires. Chi-square testing and multiple logistic regression analysis were applied. RESULTS: Eighty-nine per cent of HCWs believed that they were at risk of acquiring HIV through occupational exposure. The perception of professional risk was higher among HCWs frequently exposed to patients' blood and body fluids (OR 7.9, 95% CI 4.4-14.5), who used additional personal protection if the HIV status of patient was known (OR 2.6, 95% CI 1.5-4.6), who had experienced sharp injuries within the last year (OR 1.9, 95% CI 1.0-3.8) or who had been tested for HIV (OR 2.1, 95% CI 1.2-3.5), and among HCWs who had treated HIV-positive patients (OR 1.7, 95% CI 1.1-2.8). The majority of respondents had deficient knowledge about modes of HIV transmission. Attitudes towards HIV-positive patients were significantly different by occupation. Seventy per cent of HCWs used appropriate protection during their daily work with patients. CONCLUSIONS: HCWs require specific educational programmes and training protocols to ensure that they are adequately protected when carrying out high quality care.     

Characteristics of road accident victims with positive blood alcohol levels.

Objective: To identify the differential features of positive blood alcohol level (BAL) in people injured in road crashes who were attended an acute care service. Methods: Cross-sectional study of persons aged 18 years old or older injured in motor vehicle crashes who were attended in the Traumatology Emergency Department of Vall d'Hebron Hospital (Spain) between July 2001 and February 2002. Results: The study sample included 431 patients. A positive alcohol test was found in 13.7% of the sample. A statistically significant and independent association was found between positive BAL and male sex (odds ratio [OR] = 2.5 [95% CI, 1.3-5.4]), hospital admission (OR = 2.7 [95% CI, 1.3-5.4]), being attended on a weekend (OR = 3.7 [95% CI, 2.0-6.9]) and being attended during the night and early morning (OR = 4.6 [95% CI, 2.0-10.3]) or in the morning (OR = 3.6 [95% CI, 1.5-8.4]). Conclusions: The present study identifies a subgroup of people injured in motor vehicle crashes with a greater likelihood of positive BAL, in whom more active screening and secondary prevention activities should be implemented within traumatology and acute care settings.     

我市医务人员严重急性呼吸综合征医院感染流行原因调查与对策

目的 调查某市医务人员感染严重急性呼吸综合征(severe acute respiratory syndrome，SARS)的途径及危险因素。方法 对直接参加过抢救和间接接触SARS患而被感染的医务人员采取统一填表、座谈、走访、电话采访等方式进行调查。结果 调查三所医院感染SARS的医务人员共88人，占全市发病医务人员总人数的87．13％。导致医务人员易感的原因是：对疾病缺乏认识，防范意识不强；管理网络不健全；患隐瞒流行病史；隔离环境及防护用品达不到要求等。结论 重视医院感染管理及对医务人员的医院感染知识培训，强化消毒隔离和自我保护意识，是控制医院感染流行及保护医务人员的有力措施。     

Medical procedures and the risk of iatrogenic hepatitis C infection: case-controlled study in north-eastern Poland

Many hepatitis C virus (HCV)-infected individuals do not have any obvious risk factors and one of the putative sources of infection may be inadvertent exposure to infected blood or body fluids in the clinical setting. The aim of this study was to assess the role of medical procedures in transmission of hepatitis C in north-eastern Poland. In total, 194 patients with chronic hepatitis C were eligible for the study. The control group consisted of 275 age- and sex-matched individuals. Patients with a history of intravenous drug use were excluded. On multivariate analysis, transfusions [odds ratio (OR) = 3.7, 95% confidence interval (CI) 2.2-6.3], minor surgery (OR = 3.2, 95% CI 1.5-6.7) and dental care (OR = 2.3, 95% CI = 1.4-4.0) were independently associated with HCV infection. We conclude that apart from transfusion, minor medical procedures and dental care may carry a significant risk of hepatitis C infection. Improvements in basic hygiene routines and strict adherence to universal precautions may be essential to prevent iatrogenic transmission of the infection.     

Severe acute respiratory syndrome (SARS) and healthcare workers

The recent outbreak of severe acute respiratory synt drome (SARS) was spread by international air travel, a direct result of globalization. The disease is caused by a novel coronavirus, transmitted from human to human by droplets or by direct contact. Healthcare workers (HCWs) were at high risk and accounted for a fifth of all cases globally. Risk factors for infection in HCWs included lack of awareness and preparedness when the disease first struck, poor institutional infection control measures, lack of training in infection control procedures, poor compliance with the use of personal protection equipment (PPE), exposure to high-risk procedures such as intubation and nebulization, and exposure to unsuspected SARS patients. Measures to prevent nosocomial infection included establishing isolation wards for triage, SARS patients, and step-down; training and monitoring hospital staff in infection-control procedures; active and passive screening of HCWs; enforcement of droplet and contact precautions; and compliance with the use of PPE.     

医护人员预防SARS医院内感染的个人防护措施效果评价

目的 评价医务人员预防SARS医院内感染个人防护措施的效果,验证SARS的传播途径。方法 在广东省10家收治SARS患者的主要医院进行了成组设计的病例对照研究,对象为常规参加SARS诊治工作且直接抢救重患者的医护人员,共257人,其中病例组77例,对照组180人。采用统一调查表了解调查对象接触SARS患者程度、个人防护情况、卫生习惯、预防服药等方面情况。单因素分析采用X2检验、多因素分析利用非条件logistic回归分析。并用趋势X2检验分析个人防护措施的剂量反应关系和联合使用效果。结果 单因素分析结果显示,一直戴12层及以上口罩、穿隔离衣、用鞋套、戴手套、必要时戴眼罩、消毒洗手、漱口液漱口、用滴鼻滴眼液保护鼻眼黏膜、及时洗澡换衣、“不在病区吃饭/饮水/抽烟”、服oseltamivir phosphate等均有保护作用(P<0.05)。非条件logistic多因素回归分析有显著意义的有戴口罩(OR=0.78,95％CI:0.60～0.99)、戴眼罩(OR=0.20,95％CI:0.10～0.41)和穿鞋套(OR=0.58,95％CI:0.39～0.86)。并且趋势分析显示口罩及口罩类型、穿隔离衣、用鞋套、戴手套、必要时戴眼罩、漱口液漱口、用滴鼻滴眼液保护鼻眼黏膜和及时洗澡换衣等措施存在剂量效应关系。无防护参与SARS患者抢救的医护人员的罹患率高达61.5％(16/26),保护率随防     

Eradication of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit by active surveillance and aggressive infection control measures.

OBJECTIVES: To describe an outbreak of hospital-acquired MRSA in a NICU and to identify the risk factors for, outcomes of, and interventions that eliminated it. SETTING: An 18-bed, level III-IV NICU in a community hospital. METHODS: Interventions to control MRSA included active surveillance, aggressive contact isolation, and cohorting and de-colonization of infants and HCWs with MRSA. A case-control study was performed to compare infants with and without MRSA. RESULTS: A cluster of 6 cases of MRSA infection between September and October 2001 represented an increased attack rate of 21.2% compared with 5.3% in the previous months. Active surveillance identified unsuspected MRSA colonization in 6 (21.4%) of 28 patients and 6 (5.5%) of 110 HCWs screened. They were all successfully decolonized. There was an increased risk of MRSA colonization and infection among infants with low birth weight or younger gestational age. Multiple gestation was associated with an increased risk of colonization (OR, 37.5; CI95, 3.9-363.1) and infection (OR, 5.36; CI95, 1.37-20.96). Gavage feeding (OR, 10.33; CI95, 1.28-83.37) and intubation (OR, 5.97; CI95, 1.22-29.31) were associated with increased risk of infection. Infants with MRSA infection had a significantly longer hospital stay than infants without MRSA (51.83 vs 21.46 days; P = .003). Rep-PCR with mec typing and PVL analysis confirmed the presence of a single common strain of hospital-acquired MRSA. CONCLUSION: Active surveillance, aggressive implementation of contact isolation, cohorting, and decolonization effectively eradicated MRSA from the NICU for 2 1/2 years following the outbreak.     

一起医院内集聚性诺如病毒胃肠炎的调查

目的 调查分析一起在上海市徐汇区某社区卫生服务中心内科病房内发生的集聚性诺如病毒GⅡ型胃肠炎疫情的特征及其原因.方法 采用统一的集体性腹泻个案调查表进行现场流行病学调查,使用病例对照研究方法分析相关危险因素,采用RT-PCR方法检测病毒核酸.结果 该起疫情共报告病例22例,发病率为31.0％,以呕吐腹泻为主要临床表现,疫情流行持续8d,引入率为30.3％;时间分布呈单峰,空间分布有集聚性;通过实验室检测确定有两名护工隐性感染,在11份粪便、肛拭标本中检出9份诺如病毒GⅡ型核酸阳性,6份环节标本呈核酸阴性;由隐性感染护工护理的患者发病率高于非感染护工护理的患者(x2 =4.98,P=0.026),OR值为11.2(95％ CI=1.80～116.80);空间分布的集聚性与隐性感染护工护理的床位高发病率有较好的一致性.结论 该次疫情是一起发生在医疗机构内由诺如病毒GⅡ型引起的集聚性胃肠炎疫情,隐性感染的护工是传染源之一,接触传播是重要的传播途径;该次疫情在对手卫生、标准防护执行力进行干预及落实各项消毒隔离措施后得到有效控制.     

Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails.

BACKGROUND: From April to June 2001, an outbreak of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae infections was investigated in our neonatal intensive care unit. METHODS: Cultures of the gastrointestinal tracts of patients, the hands of healthcare workers (HCWs), and the environment were performed to detect potential reservoirs for ESBL-producing K. pneumoniae. Strains of K. pneumoniae were typed by pulsed-field gel electrophoresis using XbaI. A case-control study was performed to determine risk factors for acquisition of the outbreak clone (clone A); cases were infants infected or colonized with clone A and controls (3 per case) were infants with negative surveillance cultures. RESULTS: During the study period, 19 case-infants, of whom 13 were detected by surveillance cultures, harbored clone A. The overall attack rate for the outbreak strain was 45%; 9 of 19 infants presented with invasive disease (n = 6) or developed invasive disease (n = 3) after colonization was detected. Clone A was found on the hands of 2 HCWs, 1 of whom wore artificial nails, and on the designated stethoscope of a case-infant. Multiple logistic regression analysis revealed that length of stay per day (odds ratio [OR], 1.05; 95% confidence interval [CI95], 1.02 to 1.09) and exposure to the HCW wearing artificial fingernails (OR, 7.87; CI95, 1.75 to 35.36) were associated with infection or colonization with clone A. CONCLUSION: Short, well-groomed, natural nails should be mandatory for HCWs with direct patient contact     

Why is it that internists do not follow guidelines for preventing intravascular catheter infections?

BACKGROUND AND OBJECTIVE: High morbidity of CVC-related infections has led to national guidelines for their prevention. Despite recommendations for the use of maximal barrier precautions (mask, sterile gloves, gown, and large drape) and skin antisepsis with 2% chlorhexidine gluconate during CVC insertion, internists in the United States are not implementing these practices frequently. This study sought to identify and characterize the obstacles to and potential opportunities for improving adherence. DESIGN: Cross-sectional survey. PARTICIPANTS: One thousand randomly selected physician-members of the American College of Physicians-American Society of Internal Medicine. METHODS: Several potential determinants of adherence to maximal barrier precautions were assessed, including awareness of, agreement with, and ability to implement the recommendation, as well as the practice and training characteristics of the respondents. Factors influencing antiseptic selection were also recorded. RESULTS: Of 526 respondents, 178 (34%) had recently inserted CVCs. Clinician experience and subspecialty, awareness of CDC guidelines, and external influences (eg, time to collect equipment) did not affect maximal barrier precautions adherence. The only independent predictor of adherence was high outcome expectancy for the use of large sterile drapes (OR, 5.3; CI95, 2.2-12.6). Availability had the greatest influence on internists' selection of specific antiseptic agents, whereas cost was the least important determinant. CONCLUSIONS: Despite established efficacy, use of maximal barrier precautions and chlorhexidine gluconate is low among internists. Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.     

A randomized controlled trial of group intervention based on social cognitive theory for smoking cessation in China

BACKGROUND: New training programs need to be developed to help Chinese smokers achieve quitting. The objective of this study was to assess the effectiveness of a group smoking cessation intervention based on social cognitive theory among Chinese smokers. METHOD: A total of 225 smokers were eligible for the study and were randomly assigned to an intervention group (n=118) and a control group (n=107). The intervention group received the course soon after a baseline survey, whereas the control group received routine training in the first 6 months, and then took the same course. Effectiveness was evaluated at 6-month and 1-year follow-up from baseline. RESULTS: After 6 months, 40.5% (47/116) in the intervention group and 5.0% (5/101) in the control group quit smoking (absolute risk reduction: 35.5% [95% confidence interval (CI): 24.2-46.8%]). The 6-month continuous abstinence rate was 28.4% (33/116) in the intervention group and 3.0% (3/101) in the control group (absolute risk reduction 25.4% [95% CI: 15.6-35.2%]). At 1-year follow-up, the proportion of quitting and the 6-month abstinence rate in the intervention group were 35.8% and 22.0%, respectively. The factors associated with smoking cessation during the 6 month period were intervention (adjusted odds ratio [OR]=6.42 [95% CI: 2.46-13.28]), as well as anticipation of quitting (adjusted OR=1.46 [95% CI: 1.12-1.91]) and skill self-efficacy score in the baseline (adjusted OR=1.04 [95% CI: 1.01-1.07]). The same intervention was conducted in the control group after the 6-month study, in which a similar intervention effect was observed. CONCLUSION: A smoking cessation intervention based on social cognitive theory among Chinese smokers is highly effective.     

An outbreak of mumps among young adults in Vancouver, British Columbia, associated with 'rave' parties.

In early 1997 an unexpectedly high number of cases of mumps was reported in Vancouver, British Columbia. METHODS: A case control study was conducted to address four objectives: 1) Describe the outbreak and the population at risk, 2) examine the impact of mumps on this population, 3) identify personal risk factors for infection, and 4) test the hypothesis that social gatherings, 'rave' parties in particular, were a risk factor in this outbreak. RESULTS: Mumps infection was associated with: attending a rave party [OR = 17; 95% CI: 2.7-710], residing in Vancouver [OR = 3.7; 95% CI: 1.4-10], and contact with a person with mumps [OR = 13; 95% CI: 2-552], during the 'exposure' period. Vaccine effectiveness, ascertained by self-reported immunization status, was 80% [95% CI: 29%-96%]. CONCLUSIONS: Attendance at rave parties was associated with mumps infection during this outbreak. Many persons aged 17-40 may remain susceptible to mumps; in BC these persons are eligible for one dose of MMR and should be encouraged to be vaccinated.     

Risk factors of catheter-related bloodstream infections in parenteral nutrition catheterization

BACKGROUND: Intravascular catheters are integral to the practice of modern medicine. Potential risk factors for catheter-related bloodstream infection (CRBSI) include underlying disease, method of catheter insertion, and duration and purpose of catheterization. The administration of parenteral nutrition (PN) through intravascular catheters increases CRBSI risks. The purpose of this study was to evaluate the risk factors of CRBSI in patients with PN administration. METHODS: This study was conducted at the Karadeniz Technical University Hospital between October 2003 and November 2004. All the patients to whom PN was administered through intravascular catheters were prospectively monitored for the presence of CRBSI and risk factors. RESULTS: During the study period, 111 intravascular catheters through which PN was administered were monitored for a total of 1646 catheter-days. CRBSI was determined in 31 cases, a CRBSI rate of 18.8 per 1,000 catheter-days. When risk factors affecting CRBSI were investigated using logistic regression, an increase in APACHE II score (OR, 1.10; 95% CI, 1.01-1.21; p = .012), prolongation of catheterization (OR, 1.08; 95% CI, 1.02-1.14; p = .004), catheterization in emergent conditions (OR, 5.45; 95% CI, 1.20-24.82; p = .016), and poor patient hygiene (OR, 4.38; 95% CI, 1.39-13.78; p = .019) were all determined to be independent risk factors. Proper implementation of hand hygiene and maximal barrier precautions during the insertion of catheters reduced CRBSI levels (OR, 0.28; 95% CI, 0.09-0.88; p = .003 and OR, 0.26; 95% CI, 0.08-0.93; p = .017, respectively). CONCLUSIONS: It was concluded that the duration of catheterization should be shortened; that the intravascular catheter, which is inserted in urgent situations, should be removed as soon as possible; and that maximal sterile barrier precautions should be taken and due attention should be paid to hand hygiene.     

Influence of meteorological factors and air pollution on the outbreak of severe acute respiratory syndrome

OBJECTIVES: To understand the association between the outbreak of severe acute respiratory syndrome (SARS) and meteorological factors and air pollution. STUDY DESIGN: An ecological study was conducted. METHODS: Three hundred and fifty primary probable SARS cases diagnosed in mainland China between 1 January and 31 May 2003, and their 6727 close contacts during the period of their clinical symptoms before admission, were included in this study. Of the 6727 close contacts, 135 (2.0%) later developed clinical symptoms and were diagnosed as probable SARS cases. The daily meteorological data and daily air pollution data during the same SARS outbreak period in mainland China were used in the data analysis. Logistic regression analyses were conducted to explore the association between the secondary attack rate of SARS and meteorological factors and air pollution. RESULTS: In univariate analyses, daily average temperature (DAT), daily average air pressure (DAAP), and daily average relative humidity (DARH) were inversely associated with secondary attack rate (P<0.001); a significant positive association was found for daily hours of sunshine (DHS) (P<0.001). In multivariate analyses, factors associated with secondary attack rate were DAAP (odds ratio (OR)=0.53, 95% confidence interval (CI): 0.42, 0.66), DARH (OR=0.73, 95% CI: 0.53, 1.00), and daily average wind velocity (DAWV; OR=0.81, 95% CI: 0.68, 0.96). Adjustment for the onset time of a primary case led to little change in the results. In addition, in Hebei Province, a major affected area in China, only DAWV (OR=0.38, 95% CI: 0.20, 0.72) was a significant predictor of secondary attack rate with adjustment for the onset time of primary case. In Inner Mongolia, another major affected area in China, DAWV (OR=0.50, 95% CI: 0.26, 0.94) and DHS (OR=0.27, 95% CI: 0.09, 0.81) were significant predictors of secondary attack rate with adjustment for the onset time of primary case. CONCLUSIONS: Our results suggest that the SARS outbreak was significantly associated with DAWV, and that DAAP, DARH and DHS may also have influenced the SARS outbreak to some extent. However, because of ecological fallacy and uncontrolled confounding effects that may have biased the results, the association between the SARS outbreak and these meteorological factors and air pollution deserve further investigation.     

Influenza vaccination of healthcare workers in the United States, 1989-2002.

OBJECTIVES: We sought to estimate influenza vaccination coverage among healthcare workers (HCWs) in the United States during 1989-2002 and to identify factors associated with vaccination in this group. The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for HCWs to reduce transmission of influenza to patients at high risk for serious complications of influenza. DESIGN: Analysis of cross-sectional data from 1989-2002 surveys conducted by the National Health Interview Survey (NHIS). The outcome measure was self-reported influenza vaccination in the past 12 months. Bivariate and multivariate analysis of 2002 NHIS data. SETTING: Household interviews conducted during 1989-2002, weighted to reflect the noninstitutionalized, civilian US population. PARTICIPANTS: Adults aged 18 years or older participated in the study. A total of 2,089 were employed in healthcare occupations or settings in 2002, and 17,160 were employed in nonhealthcare occupations or settings. RESULTS: The influenza vaccination rate among US HCWs increased from 10.0% in 1989 to 38.4% in 2002, with no significant change since 1997. In a multivariate model that included data from the 2002 NHIS, factors associated with a higher rate of influenza vaccination among HCWs aged 18-64 years included age of 50 years or older (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.1), hospital employee status (OR, 1.5; 95% CI, 1.2-1.9), 1 or more visits to the office of a healthcare professional in the past 12 months (OR, 1.5; 95% CI, 1.1-2.2), receipt of employer-provided health insurance (OR, 1.5; 95% CI, 1.1-2.1), a history of pneumococcal vaccination (OR, 3.9; 95% CI, 2.5-6.1), and history of hepatitis B vaccination (OR, 1.9; 95% CI, 1.4-2.4). Non-Hispanic black persons were less likely to be vaccinated (OR, 0.6; 95% CI, 0.5-0.9) than non-Hispanic white persons. There were no significant differences in vaccination levels according to HCW occupation category. CONCLUSIONS: Influenza immunization among HCWs reached a plateau during 1997-2002. New strategies are needed to encourage US HCWs to receive influenza vaccination to prevent influenza illness in themselves and transmission of influenza to vulnerable patients.     

Outbreak of vancomycin-resistant enterococci in a burn unit.

OBJECTIVE: To investigate and control an outbreak of colonization and infection caused by vancomycin-resistant enterococci (VRE) in a burn intensive care unit (BICU). DESIGN: Epidemiological investigation, including multiple point-prevalence culture surveys of patients and environment, cultures from hands of healthcare workers (HCWs), pulsed-field gel electrophoresis (PFGE) typing of patient and environmental isolates, case-control study, and institution and monitoring of control measures. SETTING: BICU in an 800-bed university medical center in Galveston, Texas. RESULTS: Between June 6, 1996, and July 14, 1997, 21 patients were colonized by VRE, and 4 of these patients developed bacteremia. Of 2,844 environmental cultures, 338 (11.9%) were positive, but all hand cultures from HCWs were negative. PFGE typing indicated that the outbreak was clonal, with VRE isolates from patients differing by < or =4 bands from the index case. Thirteen of 14 environmental isolates varied by < or =4 bands from the pattern of the index case. A case-control study analyzed by exact logistic regression identified diarrhea (odds ratio [OR], 43.9; 95% confidence interval [CI95], 5.5-infinity; P=.0001) and administration of an antacid (OR, 24.2; CI95, 2.9-infinity; P=.002) as independent risk factors for acquisition of VRE. During a 5-week period in October and November 1996, all patient and 317 environmental cultures were negative for VRE. The outbreak recurred from a contaminated electrocardiogram lead that had not been identified during the prior 5 weeks. VRE were finally eradicated from the BICU in July 1997, using barrier isolation and a very aggressive environmental decontamination program. CONCLUSIONS: A VRE outbreak in a BICU over 13 months was caused by a single clone. After apparent eradication of VRE from a BICU, recrudescence of the outbreak occurred, evidently from a small inapparent source of environmental contamination. Changes in gastrointestinal (GI) tract function (motility) and administration of medications, other than antibiotics, that have an effect on the GI tract may increase the risk of GI tract colonization by VRE in burn patients. Application of barrier isolation and an aggressive environmental decontamination program can eradicate VRE from a burn population.