Multiple modes of hepatitis A virus transmission among methamphetamine users

Methamphetamine users are at increased risk of hepatitis A, but modes of transmission are unclear. The authors conducted a case-control study among methamphetamine users during an outbreak in Iowa in 1997. Twenty-eight reported, laboratory-confirmed, hepatitis A cases did not differ from 18 susceptible controls with respect to age, sex, or number of doses used. When compared with controls in multivariate analysis, case-patients were more likely to have injected methamphetamine (odds ratio (OR) = 5.5, 95% confidence interval (CI): 1.1, 27), to have used methamphetamine with another case-patient (OR = 6.2, 95% CI: 0.95, 41), and to have used brown methamphetamine (OR = 5.5, 95% CI: 0.51, 59). Receptive needle sharing was reported by 10 of the 20 case-patients who injected. Methamphetamine use with another case-patient was also associated with hepatitis A in an analysis restricted to noninjectors (OR = 17, 95% CI: 1.0, 630). During this outbreak, hepatitis A may have been transmitted from person to person among methamphetamine users through the fecal-oral and the percutaneous routes. Methamphetamine users should be vaccinated against hepatitis A and should be given immune globulin if they used methamphetamine with a case-patient in the last 2 weeks. Persons who intend to continue using methamphetamine should be advised about safer practices.     

Increased Patient Cost-Sharing,Weak US Economy,and Poor Health Habits: Implications for Employers and Insurers

Many healthcare stakeholders, including insurers and employers, agree that growth in healthcare costs is inevitable. But the current trend toward further cost-shifting to employees and other health plan members is unsustainable. In 2008, the Zitter Group conducted a large national study on the relationship between insurers and employers, to understand how these 2 healthcare stakeholders interact in the creation of health benefit design. The survey results were previously summarized and discussed in the February/March 2009 issue of this journal. The present article aims to assess the implications of those results in the context of the growing tendency to increase patient cost-sharing, a weak US economy, and poor health habits. Increasing cost-sharing is a blunt instrument: although it may reduce utilization of frivolous services, it may also result in individuals forgoing medically necessary care. Increases in deductibles will lead to an overall decrease in optimal care-seeking behavior as families juggle healthcare costs with a weak economy and stagnating wages.In the spring of 2008, the Zitter Group conducted a large national study of the insurer—employer relationship to understand how these 2 stakeholders interact in the creation of healthcare benefit design. The 2-arm study consisted of concurrent web-based quantitative surveys with commercial managed care executives, large employers, and major employer benefits consultants.1 It was designed to provide a richly detailed snapshot of trends in employer-sponsored healthcare coverage. Despite having varying ideas on specific healthcare benefit design strategies, employers and insurers assign similar weights to the importance of cost, quality, and access when making benefit design decisions.1,2 For both groups, the importance assigned to cost is 1.5 times higher in value than healthcare access or healthcare quality.1 Throughout the survey, both groups cited access and quality concerns, but in the current environment of steadily rising cost growth, the importance assigned to cost takes on an even greater significance. The survey results were summarized in the February/March issue of this journal.1 The present article is a follow-up to that article, and its goal is to place those survey results in the context of increased patient cost-sharing, a weak US economy, and the poor health habits that are characteristic of many segments of the American population.According to the data from the Benefit Design Index, in the absence of clear alternatives to traditional benefit designs, cost-shifting to patients through increases in copayments, deductibles, and premiums remains the primary cost-containment strategy used by employers and insurers. More than half of employers and three quarters of insurers have increased their premiums and deductibles between June 2007 and June 2008.1 Furthermore, two thirds of insurers and half of employers do not believe that the recent slowing growth rate of premiums is sustainable and, as a result, expect to increase all forms of patient cost-sharing.1 However, employers remain aware of the dangers of passing too many costs to employees; high out-of-pocket costs can translate into reduced adherence to medical treatments and, ultimately, deteriorating employee health and productivity.1,2In 2003, 30% of employees reported having a chronic health condition.3 That rate was likely to be even higher in 2008.4 The American Hospital Association reported that approximately 69 million workers took 1 or more sick days in 2003, totaling 407 million lost work days.3 In addition, 50% of employees reported being distracted at work by health concerns, reducing their productivity.3 Although absenteeism and lost productivity cost estimates vary widely, it is likely that they cost US businesses several million dollars a year.5,6 Combine the burdens of high employer healthcare costs, deteriorating employee health, and a weak US economy, and you have the ingredients for a “perfect storm”—one that is likely to lead to an insurance “death spiral,” from which we may not be able to recover.     

Person-to-Person Household and Nosocomial Transmission of Andes Hantavirus,Southern Chile, 2011

Andes hantavirus (ANDV) causes hantavirus cardiopulmonary syndrome in Chile and is the only hantavirus for which person-to-person transmission has been proven. We describe an outbreak of 5 human cases of ANDV infection in which symptoms developed in 2 household contacts and 2 health care workers after exposure to the index case-patient. Results of an epidemiologic investigation and sequence analysis of the virus isolates support person-to-person transmission of ANDV for the 4 secondary case-patients, including nosocomial transmission for the 2 health care workers. Health care personnel who have direct contact with ANDV case-patients or their body fluids should take precautions to prevent transmission of the virus. In addition, because the incubation period of ANDV after environmental exposure is longer than that for person-to-person exposure, all persons exposed to a confirmed ANDV case-patient or with possible environmental exposure to the virus should be monitored for 42 days for clinical symptoms.     

PUBLIC AND ORAL HEALTH

The Affordable Care Act (ACA) expanded health insurance coverage and strengthened incentives for health care organizations to engage in community-wide health improvement initiatives. These incentives include enhanced community benefit requirements for tax-exempt hospitals, adjusted medical loss ratio requirements for health insurers, tax incentives for employers, and competitive federal funding through the Prevention and Public Health Fund. Reduced uncompensated care costs and cost-shifting may allow hospitals and other institutions to increase investments in community health, particularly when coupled with incentives to do so. Prior research is inconsistent regarding how health care organizations have responded to these reforms, due in part to data limitations. This study uses novel longitudinal data from a national cohort of U.S. communities to estimate whether changes in coverage and uncompensated care have led to changes in the implementation of community health activities by hospitals, physicians, insurers, and employers. The National Longitudinal Survey of Public Health Systems (NALSYS) follows a national cohort of approximately 600 communities between 2012 and 2018 to measure the implementation of guideline-recommended community health improvement activities in each community and the network of organizations contributing to each activity. Importantly, these data are reported by local public health officials rather than by hospitals and health care institutions who may inflate reported contributions. Survey data are linked with county-level coverage estimates, demographic and socioeconomic characteristics, health care market structure data, and CMS hospital cost report data on uncompensated care costs. Fixed-effects regression models with instrumental variables (IV) are used to estimate the causal effects of changes in coverage and uncompensated care on implementation of community health activities by hospitals, physicians, insurers, and employers while controlling for unmeasured confounding. Stratified random sample of 600 U.S. counties observed between 2012 and 2018. Coverage increased and uncompensated care costs declined after 2014 in 87% and 73% of communities, respectively, but by widely varying magnitudes. IV estimates indicate that a 10% reduction in uncompensated care costs resulted in a 14% increase in implementation of community health activities by hospitals (P < 0.01), along with an 8% increase in implementation by insurers (P < 0.05). Results for physicians and employers were not statistically significant. The estimated hospital and insurer effects were concentrated in states that expanded Medicaid eligibility under ACA (P < 0.01). Hospitals and insurers have expanded their involvement in community-wide health activities proportionate with the level of decline in demand for uncompensated care in their communities. Incentives for health care institutions to engage in community-wide health improvement initiatives appear effective in communities where gains in coverage lead to savings that can be redeployed for community benefit. This response may be an important but unrecognized pathway through which coverage gains improve population health, but recent erosion in coverage may dampen this effect. The Robert Wood Johnson Foundation.     

Patterns of Virus Exposure and Presumed Household Transmission among Persons with Coronavirus Disease,United States,January–April 2020

We characterized common exposures reported by a convenience sample of 202 US patients with coronavirus disease during January–April 2020 and identified factors associated with presumed household transmission. The most commonly reported settings of known exposure were households and healthcare facilities; among case-patients who had known contact with a confirmed case-patient compared with those who did not, healthcare occupations were more common. Among case-patients without known contact, use of public transportation was more common. Within the household, presumed transmission was highest from older (>65 years) index case-patients and from children to parents, independent of index case-patient age. These findings may inform guidance for limiting transmission and emphasize the value of testing to identify community-acquired infections.     

Epidemiologic Evidence for Airborne Transmission of SARS-CoV-2 during Church Singing,Australia, 2020

An outbreak of severe acute respiratory syndrome coronavirus 2 infection occurred among church attendees after an infectious chorister sang at multiple services. We detected 12 secondary case-patients. Video recordings of the services showed that case-patients were seated in the same section, up to 15 m from the primary case-patient, without close physical contact, suggesting airborne transmission.     

Escherichia coli O157:H7 outbreak associated with consumption of ground beef, June-July 2002

OBJECTIVE: A case-control and environmental study tested the hypothesis that purchasing and eating ground beef from a specific source was the cause of a cluster of cases of hemolytic uremic syndrome (HUS) and Escherichia coli (E. coli) O157:H7 gastroenteritis. METHODS: A case-control study comparing risk factors was conducted over the telephone on nine case-patients with 23 selected controls. An environmental investigation was conducted that consisted of reviewing beef handling practices at a specific local supermarket and obtaining ground beef samples from the store and two households with case-patients. RESULTS: The analysis of the case-control study showed that eight case-patients (89%) purchased ground beef at Grocery Chain A compared with four controls who did not develop illness (17%) (matched odds ratio=undefined; 95% confidence interval 2.8, infinity; p=0.006). The environmental investigation showed that Grocery Chain A received meat from Meatpacker A. Laboratory analysis of meat samples from Meatpacker A and Grocery Chain A and stool samples from some patients recovered an identical strain of E. coli O157:H7 according to pulse-field gel electrophoresis. CONCLUSIONS: Both the case-control and environmental studies showed that purchasing ground beef at Grocery Chain A, which received ground beef from Meatpacker A, was the major risk factor for illness in eight case-patients; the ninth case-patient was found to be unrelated to the outbreak. Furthermore, meat from Meatpacker A was associated with a nationwide outbreak of E. coli O157:H7 illness that resulted in the second largest recall of beef in U.S. history at the time.     

Economic impact of a hepatitis A epidemic in a mid-sized urban community: the case of Spokane,Washington

Data reported here represent an effort to build on previous work regarding the costs of hepatitis A. We expand this work to include an estimation of the costs of hepatitis A on a community wide basis. In addition to calculating the costs of disease management and health care delivery, we include an analysis of additional child care costs, lost productivity, costs associated with outbreak management, and the impact on affected restaurants that required public notification and the administration of Immune Globulin to patrons. The work reported here is specific to Spokane county, Washington. The objective is to enable the Spokane Regional Health District to communicate to the community costs of managing an outbreak of hepatitis A and to inform implementation of a hepatitis A vaccination program on a community wide basis. The average cost (direct and indirect) per case for the entire sample is $2,683. The estimated total cost for the sample (145 cases) is approximately $370,193. Inpatient hospital care is the largest direct medical expense and lost productivity is a major indirect cost to the community. Lessons learned from undertaking this task include: (1) costs incurred are not immediately obvious, (2) without infrastructure in place, tracking costs is difficult, if not impossible, (3) potential for large expenditures is apparent, (4) estimates are consistent with those generated in previous studies, and (5) previous findings of vaccination of certain high-risk populations as a cost-efficient approach is corroborated.     

A large nosocomial outbreak of hepatitis C virus infections at a hemodialysis center.

OBJECTIVE: To identify modes of HCV transmission during an outbreak of HCV infection in a hemodialysis unit. DESIGN: An epidemiologic study, virologic analysis, assessment of infection control practices and procedures, and technical examination of products and dialysis machines. SETTING: A private hemodialysis unit treating approximately 70 patients. PATIENTS: Detection of HCV RNA by PCR was performed among patients receiving dialysis in 2001. Case-patients were patients who had a first positive result for HCV RNA between January 2001 and January 2002 and either acute hepatitis, a seroconversion for HCV antibodies, or a previous negative result. Three control-patients were randomly selected per case-patient. RESULTS: Of the 61 patients treated in the unit in 2001 and not infected with HCV, 22 (36.1%) became case-patients with onset from May 2001 to January 2002 for an incidence density rate of 70 per 100 patient-years. Phylogenic analysis identified four distinct HCV groups and an index case-patient for each with a similar virus among patients already known to be infected. No multidose medication vials or material was shared between patients. Connection to a dialysis machine by a nurse who had connected an HCV-infected patient "just before" or "one patient before" increased the risk of HCV infection, whereas using the same dialysis machine after a patient infected with HCV did not. Understaffing, lack of training, and breaches in infection control were documented. Direct observation of practices revealed frequent flooding of blood into the double filter on the arterial pressure tubing set. CONCLUSIONS: During this outbreak, HCV transmission was mainly patient to patient via healthcare workers' hands. However, transmission via dialysis machines because of possible contamination of internal components could not be excluded.     

Spinach-associated Escherichia coli O157:H7 outbreak, Utah and New Mexico, 2006

In 2006, Utah and New Mexico health departments investigated a multistate cluster of Escherichia coli O157:H7. A case-control study of 22 case-patients found that consuming bagged spinach was significantly associated with illness (p<0.01). The outbreak strain was isolated from 3 bags of 1 brand of spinach. Nationally, 205 persons were ill with the outbreak strain.     

Contact Tracing Activities during the Ebola Virus Disease Epidemic in Kindia and Faranah,Guinea, 2014

The largest recorded Ebola virus disease epidemic began in March 2014; as of July 2015, it continued in 3 principally affected countries: Guinea, Liberia, and Sierra Leone. Control efforts include contact tracing to expedite identification of the virus in suspect case-patients. We examined contact tracing activities during September 20–December 31, 2014, in 2 prefectures of Guinea using national and local data about case-patients and their contacts. Results show less than one third of case-patients (28.3% and 31.1%) were registered as contacts before case identification; approximately two thirds (61.1% and 67.7%) had no registered contacts. Time to isolation of suspected case-patients was not immediate (median 5 and 3 days for Kindia and Faranah, respectively), and secondary attack rates varied by relationships of persons who had contact with the source case-patient and the type of case-patient to which a contact was exposed. More complete contact tracing efforts are needed to augment control of this epidemic.     

Two nosocomial pertussis outbreaks and their associated costs - King County, Washington, 2004.

OBJECTIVE: Pertussis outbreaks in healthcare settings result in resource-intensive control activities, but studies have rarely evaluated the associated costs. We describe and estimate costs associated with 2 nosocomial pertussis outbreaks in King County, Washington, during the period from July 25 to September 15, 2004. One outbreak occurred at a 500-bed tertiary care hospital (hospital A), and the other occurred at a 250-bed pediatric hospital (hospital B). METHODS: We estimated the costs of each outbreak from the hospitals' perspective through standardized interviews with hospital staff and review of contact tracing logs. Direct costs included personnel time and laboratory and medication costs, whereas indirect costs were those resulting from hospital staff furloughs. RESULTS: Hospital A incurred direct costs of $195,342 and indirect costs of $68,015; hospital B incurred direct costs of $71,130 and indirect costs of $50,000. Cost differences resulted primarily from higher personnel costs at hospital A ($134,536), compared with hospital B ($21,645). Total cost per pertussis case was $43,893 for hospital A (6 cases) and $30,282 for hospital B (4 cases). Total cost per person exposed to a pertussis patient were $357 for hospital A (738 exposures) and $164 for hospital B (737 exposures). CONCLUSIONS: Nosocomial pertussis outbreaks result in substantial costs to hospitals, even when the number of pertussis cases is low. The cost-effectiveness of strategies to prevent nosocomial pertussis outbreaks, including vaccination of healthcare workers, should be evaluated.     

Impact of Bipolar Disorder on Employers

Among the typical employer’s workforce, there are employees with various physical and psychological conditions that may affect their healthcare costs and productivity. One such condition, bipolar disorder, is especially costly. Despite many available treatments, a large portion of bipolar disorder-related costs are not related to direct healthcare expenditures, but rather are indirect expenditures related to lost productivity. Thus, ensuring that employees who exhibit symptoms of bipolar disorder receive a timely and correct diagnosis followed by appropriate treatment may prove cost effective. To accomplish this, employer-sponsored health plans should have adequate resources to provide treatment to employees and dependents with bipolar disorder and use evidence-based guidelines to treat the disorder. Increasing awareness of bipolar disorder through education and training in the workplace or the establishment of employee assistance programs may help link those with the disorder to treatment. The provision of reasonable workplace accommodations to employees with bipolar disorder may increase productivity, resulting in additional savings. The coordination of all health plan programs and related services provided to employees is an important consideration. By becoming knowledgeable about bipolar disorder and its treatments, employers can better work with insurers, health management vendors, and intermediary organizations to provide worksite and health plan programs to assist their affected employees.     

An outbreak of hepatitis A in Gloucester, UK.

During an outbreak of hepatitis A that occurred in Gloucester, UK between September 1989 and January 1991, 162 clinical cases were identified through notifications and laboratory reports, a monthly attack rate of 1.05 per 10,000 residents. The highest attack rate was seen in 5-14-year-olds. There were significant correlations between hepatitis A attack rates in the electoral wards of Gloucester and with the Jarman UPA 8 scores for the wards and with overcrowding, unemployment, under 5-year-olds and ethnic minority. The use of human normal immune globulin prophylaxis (HNIG) for household contacts was unsuccessful in ending the outbreak, partly because only one third of cases reported a household contact with recent hepatitis A. Our experience does not support the use of HNIG in stopping community-wide outbreaks of hepatitis A. Two public health campaigns were mounted during the outbreak; both were followed by a fall in the number of cases. Greater priority should be given to the implementation and evaluation of public health campaigns in future community-wide outbreaks of hepatitis A.     

Hepatitis B vaccination for injection drug users--Pierce County, Washington, 2000

Hepatitis B vaccination has been recommended for injection drug users (IDUs) since 1982, but vaccination coverage of IDUs remains low (1), and outbreaks of hepatitis B among IDUs continue to occur. An outbreak of hepatitis B primarily among IDUs in Pierce County, Washington, detected in April 2000, included 60 cases and resulted in three deaths among IDUs co-infected with hepatitis delta virus. A program to administer hepatitis B vaccine to IDUs was implemented to control the outbreak, and the number of cases identified decreased from 13 per month in May to two cases since November. This report describes a vaccination program during which IDUs accepted hepatitis B vaccination provided free of charge in community-based settings and illustrates how effective hepatitis B vaccination programs targeted at IDUs can be implemented through collaborations between departments of health and corrections and community organizations.     

Review: Offering Domestic Partnership Health Benefits: An Economic Concern?

In the United States, employers are an important source of health insurance for citizens less than 65 years of age. Yet despite the country's increasing number of unmarried partner households, fewer than 1 in 4 workers are employed by firms that offer healthcare benefits to same-sex and/or opposite-sex domestic partners. This paper presents the main arguments, from societal and employer perspectives, for offering domestic partnership benefits. As the number of companies offering such benefits has grown, data on the direct costs of insurance have become available. The experience of insurers and employers suggests that adverse selection is not a substantial problem. Domestic partners usually account for only a small percentage of an employer's risk pool, which also limits the potential effect on total insurance costs. Although low enrollment attenuates their potential economic impact on national healthcare, domestic partnership health benefits remain important from a sociopolitical standpoint—acknowledging the value of equity and diversity in the workplace.     

Outbreak of hepatitis C virus infection in a hemodialysis unit: potential transmission by the hemodialysis machine?

OBJECTIVE: To identify the routes of transmission during an outbreak of infection with hepatitis C virus (HCV) genotype 2a/2c in a hemodialysis unit. DESIGN: A matched case-control study was conducted to identify risk factors for HCV seroconversion. Direct observation and staff interviews were conducted to assess infection control practices. Molecular methods were used in a comparison of HCV infecting isolates from the case-patients and from patients infected with the 2a/2c genotype before admission to the unit. SETTING: A hemodialysis unit treating an average of 90 patients. PATIENTS: A case-patient was defined as a patient receiving hemodialysis with a seroconversion for HCV genotype 2a/2c between January 1994 and July 1997 who had received dialysis in the unit during the 3 months before the onset of disease. For each case-patient, 3 control-patients were randomly selected among all susceptible patients treated in the unit during the presumed contamination period of the case-patient. RESULTS: HCV seroconversion was associated with the number of hemodialysis sessions undergone on a machine shared with (odds ratio [OR] per additional session, 1.3; 95% confidence interval [CI95], 0.9 to 1.8) or in the same room as (OR per additional session, 1.1; CI95, 1.0 to 1.2) a patient who was anti-HCV (genotype 2a/2c) positive. We observed several breaches in infection control procedures. Wetting of transducer protectors in the external pressure tubing sets with patient blood reflux was observed, leading to a potential contamination by blood of the pressure-sensing port of the machine, which is not accessible to routine disinfection. The molecular analysis of HCV infecting isolates identified among the case-patients revealed two groups of identical isolates similar to those of two patients infected before admission to the unit. CONCLUSIONS: The results suggest patient-to-patient transmission of HCV by breaches in infection control practices and possible contamination of the machine. No additional cases have occurred since the reinforcement of infection control procedures and the use of a second transducer protector.     

Severe acute respiratory syndrome, Beijing, 2003

The largest outbreak of severe acute respiratory syndrome (SARS) struck Beijing in spring 2003. Multiple importations of SARS to Beijing initiated transmission in several healthcare facilities. Beijing's outbreak began March 5; by late April, daily hospital admissions for SARS exceeded 100 for several days; 2,521 cases of probable SARS occurred. Attack rates were highest in those 20-39 years of age; 1% of cases occurred in children <10 years. The case-fatality rate was highest among patients >65 years (27.7% vs. 4.8% for those 20-64 years, p < 0.001). Healthcare workers accounted for 16% of probable cases. The proportion of case-patients without known contact to a SARS patient increased significantly in May. Implementation of early detection, isolation, contact tracing, quarantine, triage of case-patients to designated SARS hospitals, and community mobilization ended the outbreak.     

Major outbreak of hepatitis A associated with orange juice among tourists, Egypt, 2004

In 2004, a major outbreak of hepatitis A among tourists returning from Egypt involved 351 case-patients from 9 European countries who were infected with a single strain (genotype 1 b). The case-control study identified orange juice as the most likely infection vehicle. Vaccination against hepatitis A virus is strongly recommended before travel to disease-endemic areas.