Pregnancy-related mortality in New Jersey, 1975 to 1989.

OBJECTIVES. National data are thought to underestimate pregnancy-related mortality in the United States. A multisource surveillance system for pregnancy-associated deaths in New Jersey offers an opportunity to identify the magnitude of and the trends in pregnancy-related mortality at the state level. METHODS. Data from all reported pregnancy-related deaths in the state from 1975 to 1989 were studied, and pregnancy mortality ratios were calculated. RESULTS. The New Jersey pregnancy mortality ratio decreased from the late 1970s to the early 1980s but began to rise in the late 1980s. The pregnancy mortality ratio for non-Whites was 3.6 times that for Whites for the 15-year period. The causes of pregnancy-related deaths changed over the 15-year period, with direct obstetrical causes playing a decreasing role. AIDS has become the major cause of pregnancy-related mortality in New Jersey. Finally, approximately 44% of the pregnancy-related deaths were considered to be preventable by the physician or patient or both. CONCLUSIONS. New efforts must be made to combat the recent rise in pregnancy-related deaths, with special attention to preventing deaths among non-White women.     

Cross-jurisdictional transmission of Mycobacterium tuberculosis in Maryland and Washington,D C, 1996-2000, linked to the homeless

From 1996 to 2000, 23 Maryland and Washington, D.C., tuberculosis cases were identified in one six-band DNA cluster. Cases were clustered on the basis of their Mycobacterium tuberculosis isolates. Medical record reviews and interviews were conducted to identify epidemiologic linkages. Eighteen (78%) of the 23 case-patients with identical restriction fragment length polymorphism patterns were linked to another member; half the patients were associated with a Washington, D.C., homeless shelter. Molecular epidemiology defined the extent of this large, cross-jurisdictional outbreak.     

The contribution of recently acquired Mycobacterium tuberculosis infection to the New York City tuberculosis epidemic, 1989-1993

Current theory in the molecular epidemiology of tuberculosis holds that tuberculosis cases harboring Mycobacterium tuberculosis strains with a common deoxyribonucleic acid (DNA) fingerprint are the result of recent M. tuberculosis transmission. Here we propose a mathematical approach independent of DNA fingerprinting to estimating the percentage of recent transmissions responsible for current tuberculosis incidence. The "short-term reproductive number" of tuberculosis is defined as the average number of tuberculosis cases developing within 1 year of infection. Multiplying the short-term reproductive number by the number of tuberculosis cases in each year and dividing by the subsequent year's tuberculosis case burden equals the proportion of tuberculosis cases in the subsequent year that are due to recent transmission. We carried out separate calculations for human immunodeficiency virus (HIV)-negative and HIV-positive tuberculosis cases. We applied the model to pulmonary (infectious) tuberculosis cases diagnosed in New York City during 1989-1993, using tuberculosis and AIDS surveillance data. Model-based estimates of the proportion of tuberculosis due to recent transmission were lower than estimates based on DNA fingerprints. Reconciliation of these divergent estimates may require the re-estimation of model parameters from data collected de novo, additional model development, and further advances in DNA fingerprinting methods.     

Extrapulmonary tuberculosis among foreign-born patients, New York City, 1995 to 1996

In New York City both the proportion of total tuberculosis cases that are extrapulmonary and the proportion of total tuberculosis cases that are foreign-born have increased since 1992. We examined the association of region of birth and site of extrapulmonary tuberculosis among 3982 persons confirmed to have tuberculosis in 1995 or 1996, while controlling for age, gender, culture result, reporting facility, and HIV status. Patients born in the Middle East (odds ratio; 3.9, p = .0001), India (odds ratio = 2.5, p = .0007), other Asian countries (excluding China, Japan and countries of the former Soviet Union) (odds ratio = 2.7, p = .0001), sub-Saharan Africa (odds ratio = 2.6, p = .0001), and the Caribbean (odds ratio = 2.0, p = .0001) were more likely to have extrapulmonary disease than patients born in the United States. The proportion of total cases with extrapulmonary involvement is likely to increase in areas where the foreign-born comprise a growing proportion of all cases of tuberculosis. Although reasons for regional differences in tuberculosis disease site are not known, these findings should alert health care providers to maintain a high index of suspicion for extrapulmonary tuberculosis among some foreign-born groups.     

Surveillance of occupational lead exposure in New Jersey: 1986 to 1989.

Between January 1986 and June 1989, 1916 New Jersey workers were identified through a surveillance system for occupational lead exposure. The average annual proportion of workers with a blood lead level above 2.42 mumol/L was 12%. Industries with the highest proportion of workers with blood lead levels above 2.42 mumol/L were special trade construction (35%) and industries dealing with scrap and waste materials (27%).     

Taking the next step to privacy compliance for hospitals: implementing the OHA guidelines

The recently released "Guidelines for Managing Privacy, Data Protection and Security for Ontario Hospitals," prepared by the Ontario Hospital eHealth Council Privacy and Security Working Group (the "Guidelines") are useful in that they provide a comprehensive overview of the types of issues raised for hospitals by existing and pending privacy legislation, and a very high-level framework for addressing same. However, the Guidelines are, as stated high-level guidelines only,--leaving hospital management to grapple with the next big step towards privacy compliance: how to operationalize the Guidelines within their particular hospital.     

A conceptual model of the case-based payment scheme for New Jersey hospitals.

In this paper I propose a methodology for paying short-term general hospitals on the basis of prospective cost-based case-mix revenue budgets. A hospital's budget is divided into patient care--related components and other components. The patient care--related budget is based on the case mix of patients treated by the hospital. Diagnosis-related groupings of patients are developed and a revenue per case amount is calculated for each group, based on reasonable costs of treatment, with a profit incentive for cost reduction resulting from improvements in productivity, efficiency, or more rational delivery of hospital services. The institutional budget is calculated on the basis of interinstitutional comparisons using a peer grouping method. I discuss various fundamental issues related to payment including paying for bad debt and indigency, the effect of insurance coverage, and a regional approach to capital funding. Case-mix payment allow for closer integration of payer programs with the activities of Professional Standards Review Organizations and health planning agencies. Additionally, payment based on the treatment of patients encourages a clear-cut management relationship between physician activities and hospital programs.     

Distinct trends in tuberculosis morbidity among foreign-born and US-born persons in New Jersey, 1986 through 1995.

OBJECTIVES: This study evaluated tuberculosis (TB) morbidity trends among foreign-born and US-born persons. METHODS: TB surveillance data in New Jersey from 1986 to 1995 were analyzed. RESULTS: The overall TB incidence rate in New Jersey declined 15% from 1992 to 1995 after 7 years of increase. However, the incidence rate of TB in foreign-born persons increased 75% from 1986 through 1995. The proportion of foreign-born persons with TB increased from 20% in 1986 to 37% in 1995. CONCLUSIONS: TB morbidity among foreign-born persons has continued to increase, despite the decline in overall TB morbidity since 1992. Targeted TB prevention and control strategies should be developed to effectively reduce TB morbidity in foreign-born persons.     

Trends in AIDS among Hispanics in the United States, 1991-1996.

OBJECTIVES: This article describes recent trends in AIDS among US Hispanics. METHODS: Incidence rates were calculated from AIDS surveillance data for persons diagnosed from 1991 through 1996. Increases in the number of cases among Hispanics were calculated by linear regression. RESULTS: Of the 415,864 persons diagnosed with AIDS from 1991 through 1996, 19% were Hispanic. Among Hispanics with AIDS, 67% were born in the United States or Puerto Rico. The relative risk (RR) of AIDS for Hispanics compared with Whites was highest for women (RR = 7.0), followed by children (RR = 6.2) and men (RR = 2.8). Increases in the number of cases were higher among foreign-born Hispanics. CONCLUSIONS: An understanding of which Hispanic subgroups are at greatest risk for HIV infection is important for prevention efforts.     

Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues

The transmission of tuberculosis is a recognized risk in health-care settings. Several recent outbreaks of tuberculosis in health-care settings, including outbreaks involving multidrug-resistant strains of Mycobacterium tuberculosis, have heightened concern about nosocomial transmission. In addition, increases in tuberculosis cases in many areas are related to the high risk of tuberculosis among persons infected with the human immunodeficiency virus (HIV). Transmission of tuberculosis to persons with HIV infection is of particular concern because they are at high risk of developing active tuberculosis if infected. Health-care workers should be particularly alert to the need for preventing tuberculosis transmission in settings in which persons with HIV infection receive care, especially settings in which cough-inducing procedures (e.g., sputum induction and aerosolized pentamidine [AP] treatments) are being performed. Transmission is most likely to occur from patients with unrecognized pulmonary or laryngeal tuberculosis who are not on effective antituberculosis therapy and have not been placed in tuberculosis (acid-fast bacilli [AFB]) isolation. Health-care facilities in which persons at high risk for tuberculosis work or receive care should periodically review their tuberculosis policies and procedures, and determine the actions necessary to minimize the risk of tuberculosis transmission in their particular settings. The prevention of tuberculosis transmission in health-care settings requires that all of the following basic approaches be used: a) prevention of the generation of infectious airborne particles (droplet nuclei) by early identification and treatment of persons with tuberculous infection and active tuberculosis, b) prevention of the spread of infectious droplet nuclei into the general air circulation by applying source-control methods, c) reduction of the number of infectious droplet nuclei in air contaminated with them, and d) surveillance of health-care-facility personnel for tuberculosis and tuberculous infection. Experience has shown that when inadequate attention is given to any of these approaches, the probability of tuberculosis transmission is increased. Specific actions to reduce the risk of tuberculosis transmission should include a) screening patients for active tuberculosis and tuberculous infection, b) providing rapid diagnostic services, c) prescribing appropriate curative and preventive therapy, d) maintaining physical measures to reduce microbial contamination of the air, e) providing isolation rooms for persons with, or suspected of having, infectious tuberculosis, f) screening health-care-facility personnel for tuberculous infection and tuberculosis, and g) promptly investigating and controlling outbreaks. Although completely eliminating the risk of tuberculosis transmission in all health-care settings may be impossible, adhering to these guidelines should minimize the risk to persons in these settings.     

Changes in Contaminant Levels in New Jersey Osprey Eggs and Prey, 1989 to 1998

Ospreys are good indicators of the health of estuarine areas because they feed almost exclusively on fish with the balance on other aquatic biota. Through the 1980s, ospreys nesting on Delaware Bay in New Jersey had reduced reproductive success relative to those nesting on the Atlantic coast and the Maurice River, a tributary of Delaware Bay. Earlier research suggested that elevated levels of DDT and polychlorinated biphenyl (PCB) contaminants identified in addled osprey eggs contributed to this reduced productivity. We repeated egg and prey sampling initially conducted in 1989 to evaluate the trends of contaminants in the last decade. Most organochlorine contaminants declined in osprey eggs in 1998 relative to 1989. Across three study areas, PCBs decreased from 4.1–7.7 ppm in 1989 to 1.8–3.2 ppm in 1998; DDE decreased from 1.2–3.2 ppm in 1989 to 0.7–1.2 ppm in 1998. Lead in eggs increased from an average of 0.01 to 0.30 ppm wet weight, and mercury averaged 0.12 ppm and increased only in Atlantic coast eggs. Most of these contaminant changes were also found in typical prey fish: PCBs decreased from 0.18–1.2 ppm in 1989 to 0.06–0.43 ppm in 1998; DDE decreased from 0.05–0.69 ppm in 1989 to 0.03–0.13 ppm in 1998. Lead and mercury increased in most fish samples. The improvement in most organochlorine contaminants in osprey eggs and prey reflected improved nest success in the Delaware Bay study area, and the nesting populations in the Atlantic and Maurice River study areas increased approximately 200% since 1989. PCBs and DDE in osprey eggs were below levels considered to be toxic to egg development. This study documents significant improvements in organochlorine contaminants in southern New Jersey ospreys, but justifies continued monitoring of heavy metals, such as lead and mercury, in aquatic ecosystems. Received: 19 April 2000/Accepted: 7 August 2000     

Rethinking the socioeconomics and geography of tuberculosis among foreign-born residents of New Jersey, 1994-1999

OBJECTIVES: This study investigated the socioeconomic profile of foreign-born tuberculosis patients in New Jersey. METHODS: Foreign- and US-born tuberculosis patients in 1994-1999 were compared using various measures of socioeconomic status. RESULTS: Out of 4295 tuberculosis patients, 2005 (47%) were foreign-born. Foreign-born patients resided in more affluent, more educated, and less crowded areas than did US-born patients (P <.005). They were also more likely to have been employed during the 2 years before diagnosis (62% vs 41%, P <.001). Private physicians treated the majority of South Asian-born patients. CONCLUSIONS: Substantial numbers of employed foreign-born tuberculosis patients now reside in affluent New Jersey locations. Changes in tuberculosis control programs may be required when the socioeconomic status and place of residence of foreign-born populations diverge from traditional assumptions linking poverty with tuberculosis.     

Trends in cancer mortality rates,Bergen County,New Jersey, 1962-75.

Publication of the "Atlas of Cancer Mortality for U.S. Counties, 1950-1969" caused a great deal of concern in counties shown in the Atlas to have had high cancer mortality rates in relation to the United States as a whole. An analysis was made of temporal trends of cancer mortality in Bergen County, a "high-rate county" in northeastern New Jersey, by calculating age-adjusted cancer mortality rates by sex and site for Bergen County residents for the period 1962-75. Mortality rates and time rates of change in mortality rates were compared to those in the United States as a whole. Male and female rates for respiratory cancer and male rates for all sites combined increased significantly more quickly in the United States than in Bergen County during the study period. The authors discuss these trends and recommended that recent time-specific mortality rates be furnished to county health commissions on a regular basis.     

Trends in enteric disease as a cause of death in the United States, 1989-1996

The authors examined rates of and trends in enteric disease as a cause of death in the United States. The National Center for Health Statistics Multiple Cause of Death databases for 1989-1996 were analyzed for International Classification of Diseases, Ninth Revision, codes for gastroenteritis due to infectious agents and codes describing illness with other enteric pathogens. The highest rates of death related to enteric diseases were seen among people older than 75 years, followed by children under 1 year of age. Rates increased markedly over time in the 65- to 74-year age group for bacterial enteric pathogens and in the 35- to 44-year age group for viral enteric pathogens. Enteric diseases were the underlying cause of death for an average of 2,740 deaths during each year of this study, and the rate of death due to enteric-related disease is increasing.     

A determination of healthcare worker exposure to Mycobacterium tuberculosis in two Californian hospitals

The US Centers for Disease Control and Prevention (CDC) recommends the prompt and sustained placement of potentially infectious tuberculosis patients in to negative-pressure isolation rooms, to help prevent other patients and workers, who remain outside of the room, from exposure to potential aerosols of Mycobacterium tuberculosis. The purpose of this study was to assess the potential for healthcare worker exposure to such aerosols and, to study compliance with the CDC guidelines. All room locations of culture-positive pulmonary TB patients were identified retrospectively for a one-year period at two hospitals. Placement in a negative-pressure isolation room was delayed for >24h after admission in 30% of 54 patients at hospital 1, and for 56% of nine patients at hospital 2. The median delay in isolation was three days at hospital 1, and five days at hospital 2. At hospital 1, of the 16 patients with delayed or no isolation, 14 (88%) were AFB smear-positive, and 12 (75%) were admitted to the hospital during the winter months. At hospital 2, of five patients with delayed or no isolation, two (40%) were AFB smear-positive, and four (80%) were admitted to the hospital during the winter months. The main reason for non-isolation was failure to initiate and sustain isolation for all suspect tuberculosis patients during the winter. These delays may reflect an insufficient number of isolation rooms to accommodate an increased usage of isolation rooms during the winter months. Delays in suspecting tuberculosis also contributed to non isolation. For 33% of the non-isolated patients, recognition of the diagnosis was delayed for three or more days. Patients were hospitalized on most adult inpatient wards, and virtually every hospital location that had these patients also had, non-isolated sources of mycobacterial aerosol. All workers were at risk of exposure, although the risk varied by hospital location, and should be tuberculosis skin-tested, at least annually. Suspect and known tuberculosis patients should be isolated until they are demonstrated to be non-infectious.     

艾滋病母婴传播阻断抗病毒治疗依从性及影响因素

目的:探讨艾滋病母婴传播阻断抗病毒治疗的依从性水平与主要影响因素,为制定HIV阳性孕产妇及其所生婴儿抗病毒治疗规范用药的措施提供依据。方法:在云南省5个艾滋病高发县(市、区)及一家省级保健机构对艾滋病母婴传播阻断抗病毒治疗方案的依从性进行了现况调查。结果:抗病毒治疗依从性良好者占91.0%(111/122)。影响HIV阳性孕产妇及婴儿服药依从性的主要因素为医生对HIV阳性孕产妇的态度,医患间的沟通与合作程度,方案的复杂程度,家庭人均收入,家庭支持,是否在县级及以上助产机构住院分娩,以及患者对艾滋病抗病毒治疗方案的认识,对生育的态度。结论:HIV感染孕产妇艾滋病母婴传播阻断抗病毒治疗服药依从性较好,多个因素对HIV感染孕产妇服药依从性有影响。     

天津地区临床分离结核分枝杆菌分型的初步研究

目的探讨天津地区结核分枝杆菌临床分离株分子流行病学特征。方法连续收集天津市海河医院2005年8月16日11月25日就诊患者痰培养阳性的结核分枝杆菌100株，采用间隔区寡核苷酸分型（spoligotyping）和多位点可变串联重复序列（VNTR）两种方法进行基因分型，并运用软件对二者的结果进行分析。依据北京分化支的定义，运用多重和实时定量PCR方法将其区分为W菌／典型北京家族菌株和非典型北京菌株，Χ^2检验分析两种亚群与患者年龄和耐药性之间的联系。结果排除污染菌株，共对96株结核分枝杆菌临床分离株进行两种方法的基因分型，spoligotyping结果91．7％为北京基因型（含3株类北京基因型）结核分枝杆菌（88／96）。VNTR分型可将北京基因型分为60种基因型。在北京分化支结核分枝杆菌中，W菌／典型北京家族菌株占93．2％（82／88）。两种北京分化支亚群与患者年龄及耐药性之间差异无统计学意义（P〉0．05）。结论天津地区结核病患者临床分离的结核分枝杆菌中，北京基因型呈现较为明显的优势。VNTR的分辨率明显高于spoligotyping。北京分化支的两种亚群在天津地区临床结核病患者中均有流行，但以W菌／典型北京家族菌株为主。