Antibiotic prescribing during an outbreak of meningococcal disease.

During a prolonged outbreak of meningococcal disease caused by serogroup B serotype 15 sulphonamide-resistant strains in one British health district, there was considerable variation in attack rates by town. General practitioner (GP) antibiotic prescribing rates were compared in high and low incidence towns. The only significant difference found was that erythromycin prescribing was more frequent in the high incidence towns (rate ratio 4.0, 95% CI 3.2-4.8, in March 1987 and 3.0, 95% CI 2.4-3.7, in November 1987). This was probably due to increased GP consultation rates for upper respiratory tract infection (URTI), but higher erythromycin usage may have increased meningococcal acquisition rates or susceptibility to meningococcal disease. Antibiotic prescribing rates should be further investigated in defined areas of high and low incidence of meningococcal disease.     

Surveillance of invasive meningococcal disease in Queensland, 2002.

During 2002, 124 cases of invasive meningococcal disease were notified in Queensland. This was similar to the previous year (n = 128). Four (3.2%) of the cases died. Trends by age and serogroup were generally similar to previous years and were consistent with the overall patterns of this disease in Australia. However, an apparent increase in serogroup C, which infected 41 per cent of cases, needs continued monitoring. This report highlights the need for continued surveillance of morbidity and mortality patterns and management of this disease. Ongoing surveillance will monitor the impact of the National Meningococcal C Vaccination Programme, commenced in early 2003. This report also highlights the need for ongoing community education to ensure people seek medical attention early after onset of the illness. This report shows that when general practitioners considered meningococcal disease as a diagnosis, their patients were admitted to hospital sooner than patients in whom this diagnosis was not initially considered. Acknowledging that early disease may present diagnostic difficulties, further awareness raising amongst general practitioners is required to promote early recognition and referral.     

Variations in case fatality and fatality risk factors of meningococcal disease in Western Norway, 1985-2002

In a retrospective epidemiological study, 293 meningococcal disease patients hospitalized during 1985-2002, were examined for fatality and risk factors related to death. The overall case fatality rate (CFR) was 8.2%, but increased from 4% during 1985-1993 to 17% during 1994-2002. The latter 9-year period was characterized by more serogroup C infections and more patients with thrombocytopenia on admission to hospital. All patients categorized as meningitis on admission survived. Of the 24 patients who died, 21 had meningococcal skin rash on admission, 23 had an onset to admission time of < or =24 h, and 16 had severe septicaemia with hypotension and/or ecchymoses without meningitis on admission. By multivariate analyses, a short onset to admission time, >50 petechiae, thrombocytopenia and severe septicaemia on admission were associated with fatality. More lives could be saved through earlier admission to hospital. This can be achieved through more information to the public about the early signs of meningococcal septicaemia, with the recommendation to look for skin rash in patients with acute fever during the first day and night.     

Epidemiology of invasive meningococcal infections of children in Slovenia during 1993-1999

Invasive strains of Neisseria meningitidis isolated from sterile body fluids of children aged 0-14 years were intentionally collected in nine Slovenian laboratories, and sent to the laboratory of the National Institute of Public Health, Ljubljana for final evaluation. From 1993-1999 we collected 53 invasive strains from children presented in this study. The incidence rate of invasive diseases in children shows that there is a rapid fall from 4.74/100,000 in 1993 to 0.90/100,000 in 1999. Invasive diseases predominated in children in the age group 0-1 year (19.6 cases per 100,000 children); followed by the age groups 2-4 years, 5-9 years and 10-14 years. The results of serogrouping indicate that the largest proportion of meningococci isolated (90%) were group B, while 8% of isolates were group C and only 2% group Y. The serotype/serosubtype distribution shows that the most frequent serotype (excluding 19 non-typable NT strains) was serotype 22, which was expressed in 9 strains and the most frequent serosubtype (excluding 11 NST strains) was P1.5,2 found in 7 strains. The most frequently isolated strains (excluding NT/NST strains) were B:22:P1.14; B:NT:P1.5 and B:NT:P1.16. Thirty-one strains collected during 1993-1995 were analysed by multilocus enzyme electrophoresis (MEE). There were 25 electrophoretic types (ETs) among 31 strains; the strains were very heterogeneous with only four ETs being represented by more than one strain. Study shows that meningococcal disease is still endemic in Slovenia.     

Epidemiology of invasive meningococcal disease in north Queensland, 1995 to 1999.

This study describes all episodes of invasive meningococcal disease (n=120) acquired in north Queensland over the 5 year period 1995 to 1999. Indigenous people had a 3-fold greater risk than others of acquiring invasive meningococcal disease. There were 7 deaths, six in non-indigenous people. The majority (72.4%) of identified isolates were serogroup B. We found no evidence of significant resistance to the antibiotics recommended for treatment or chemoprophylaxis. Two outbreaks of disease were identified, one serogroup B and one serogroup C. Compared to the previous 5 years (1990 to 1994) there were far fewer cases of serogroup C disease and a lower incidence and risk of invasive meningococcal disease among indigenous people.     

Risk factors for pediatric invasive pneumococcal disease in the Intermountain West, 1996-2002

PURPOSE: In response to concerns that the epidemiology of pediatric invasive pneumococcal disease (IPD) in the Intermountain West (i.e., Utah, Idaho, Wyoming, Montana, and parts of Arizona and Nevada) was poorly understood and might differ from elsewhere in the United States, a case-control study was undertaken to determine factors associated with IPD during 1996-2002. METHODS: A telephone questionnaire was administered to parents of children comprising 120 cases identified through hospital records and to parents of 156 age-matched controls located by random-digit dialing. The unit of analysis was each matched case-control set. RESULTS: Underlying chronic illness was reported for 32 (27%) of the cases. For previously healthy children, breastfeeding had a protective benefit (adjusted odds ratio: 0.2; 95% confidence interval [CI], 0.1-0.6), while a history of tympanostomy tube surgery was a risk factor (adjusted odds ratio: 12.6; 95% CI, 1.5-107.3). CONCLUSIONS: The presence of an underlying chronic illness was the strongest risk factor for IPD. Except for a history of tympanostomy tube surgery, the factors associated with IPD in this investigation were similar to those reported from other geographic regions. Tympanostomy surgery might serve as a surrogate indicator for predisposition to recurrent otitis media or decreased ability to clear pneumococcal infection, raising risk for invasive disease. Pediatric clinicians should continue to encourage breastfeeding, and continued emphasis on pneumococcal vaccination should help prevent IPD.     

Meningococcal disease in South Africa, 1999-2002

We describe the epidemiology of invasive meningococcal disease in South Africa from August 1999 through July 2002, as reported to a laboratory-based surveillance system. Neisseria meningitidis isolates were further characterized. In total, 854 cases of laboratory-confirmed disease were reported, with an annual incidence rate of 0.64/100,000 population. Incidence was highest in infants < 1 year of age. Serogroup B caused 41% of cases; serogroup A, 23%; serogroup Y, 21%; serogroup C, 8%; and serogroup W135, 5%. Serogroup B was the predominant serogroup in Western Cape Province, and disease rates remained stable. Serogroup A was most prevalent in Gauteng Province and increased over the 3 years. On pulsed-field gel electrophoresis analysis, serogroup A strains showed clonality, and serogroup B demonstrated considerable diversity. Selected isolates of serogroup A belonged to sequence type (ST)-1 (subgroup I/II) complex, serogroup B to ST-32/electrophoretic type (ET)-5 complex, and serogroup W135 to ST-11/ET-37 complex.     

Surveillance for invasive meningococcal disease in children, US-Mexico border, 2005-2008

We reviewed confirmed cases of pediatric invasive meningococcal disease in Tijuana, Mexico, and San Diego County, California, USA, during 2005-2008. The overall incidence and fatality rate observed in Tijuana were similar to those found in the US, and serogroup distribution suggests that most cases in Tijuana are vaccine preventable.     

Mumps vaccine effectiveness and risk factors for disease in households during an outbreak in New York City

Background and objectives

Mumps outbreaks have been reported among vaccinated populations, and declining mumps vaccine effectiveness (VE) has been suggested as one possible cause. During a large mumps outbreak in New York City, we assessed: (1) VE of measles-mumps-rubella vaccine (MMR) against mumps and (2) risk factors for acquiring mumps in households.

Methods

Cases of mumps were investigated using standard methods. Additional information on disease and vaccination status of household contacts was collected. Case households completed follow-up phone interviews 78–198 days after initial investigation to ascertain additional cases. Mumps cases meeting the study case definition were included in the analysis. Risk factors for mumps were assessed, and VE was calculated using secondary household attack rates.

Results

Three hundred and eleven households with 2176 residents were included in the analysis. The median age of residents was 13 years (range <1–85), and 462 (21.2%) residents met the study mumps case definition. Among 7–17 year olds, 89.7% received one or more doses of MMR vaccine, with 76.7% receiving two doses. Young adults aged 10–14 years (OR = 2.4, CI = 1.3–4.7) and 15–19 years (OR = 2.5, CI = 1.3–5.0) were at highest risk of mumps. The overall 2-dose VE for secondary contacts aged five and older was 86.3% (CI 63.3–94.9).

Conclusions

The two-dose effectiveness of MMR vaccine against mumps was 86.3%, consistent with other published mumps VE estimates. Many factors likely contributed to this outbreak. Suboptimal MMR coverage in the affected population combined with VE may not have conferred adequate immunity to prevent transmission and may have contributed to this outbreak. Achieving high MMR coverage remains the best available strategy for prevention of mumps outbreaks.     

International Circumpolar Surveillance System for invasive pneumococcal disease, 1999-2005

The International Circumpolar Surveillance System is a population-based surveillance network for invasive bacterial disease in the Arctic. The 7-valent pneumococcal conjugate vaccine (PCV7) was introduced for routine infant vaccination in Alaska (2001), northern Canada (2002-2006), and Norway (2006). Data for invasive pneumococcal disease (IPD) were analyzed to identify clinical findings, disease rates, serotype distribution, and antimicrobial drug susceptibility; 11,244 IPD cases were reported. Pneumonia and bacteremia were common clinical findings. Rates of IPD among indigenous persons in Alaska and northern Canada were 43 and 38 cases per 100,000 population, respectively. Rates in children <2 years of age ranged from 21 to 153 cases per 100,000 population. In Alaska and northern Canada, IPD rates in children <2 years of age caused by PCV7 serotypes decreased by >80% after routine vaccination. IPD rates are high among indigenous persons and children in Arctic countries. After vaccine introduction, IPD caused by non-PCV7 serotypes increased in Alaska.     

Meningococcal C conjugate vaccine effectiveness before and during an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C/cc11, Tuscany,Italy

IntroductionIn Tuscany, Italy, where a universal immunization program with monovalent meningococcal C conjugate vaccine (MCC) was introduced in 2005, an outbreak of invasive meningococcal disease (IMD) due to the hypervirulent strain of Neisseria meningitidis C/cc11 occurred in 2015–2016, leading to an immunization reactive campaign using either the tetravalent (ACWY) meningococcal conjugate or the MCC vaccine. During the outbreak, IMD serogroup C (MenC) cases were also reported among vaccinated individuals. This study aimed to characterize meningococcal C conjugate vaccines (MenC-vaccines) failures and to estimate their effectiveness since the introduction (2005–2016) and during the outbreak (2015–2016).MethodsMenC cases and related vaccine-failures were drawn from the National Surveillance System of Invasive Bacterial Disease (IBD) for the period 2006–2016. A retrospective cohort-study, including the Tuscany' population of the birth-cohorts 1994–2014, was carried out. Based on annual reports of vaccination, person-years of MenC-vaccines exposed and unexposed individuals were calculated by calendar-year, birth-cohort, and local health unit. Adjusted (by birth-cohort, local health unit, and calendar-year) risk-ratios (ARR) of MenC invasive disease for vaccinated vs unvaccinated were estimated by the Poisson model. Vaccine-effectiveness (VE) was estimated as: VE = 1-ARR.ResultsIn the period 2006–2016, 85 MenC-invasive disease cases were reported; 61 (71.8%) from 2015 to 2016. Twelve vaccine failures occurred, all of them during the outbreak. The time-interval from immunization to IMD onset was 20 days in one case, from 9 months to 3 years in six cases, and ≥7 years in five cases. VE was, 100% (95%CI not estimable, p = 0.03) before the outbreak (2006–2014) and 77% (95%CI 36–92, p < 0.01) during the outbreak; VE was 80% (95%CI 54–92, p < 0.01) during the overall period.ConclusionsIn Tuscany, MenC-vaccine failures occurred exclusively during the 2015–2016 outbreak. Most of them occurred several years after vaccination. VE during the outbreak-period was rather high supporting an effective protection induced by MenC-vaccines.     

Serogroup C meningococcal disease outbreak associated with discotheque attendance during carnival

In the week following a carnival during 19-24 February 1998, an outbreak of meningococcal disease occurred in a rural German county. The available isolates belonged to phenotype C:2a:P1.2,5 and were clonally related by pulsed-field gel electrophoresis. A case-control study was done to identify risk factors for the outbreak and to define possible vaccination target groups. Five persons aged 13-16 years who fell ill during 24-27 February were included in the study. Four of 5 cases and 10 of 32 controls visited local discotheques (OR = 8.8; P = 0.06). Cases also visited discotheques more frequently than controls (chi2 for trend, P = 0.0002). Multiple discotheques during the carnival may have been predominant locations of transmission in this outbreak. Because this risk factor was limited in time, a mass community vaccination campaign was not initiated.     

Spatiotemporal analysis of invasive meningococcal disease, Germany

Meningococci can cause clusters of disease. Specimens from 1,616 patients in Germany obtained over 42 months were typed by serogrouping and sequence typing of PorA and FetA and yielded a highly diverse dataset (Simpson's index 0.963). A retrospective spatiotemporal scan statistic (SaTScan) was applied in an automated fashion to identify clusters for each finetype defined by serogroup variable region (VR) VR1 and VR2 of the PorA and VR of the FetA. A total of 26 significant clusters (p< or =0.05) were detected. On average, a cluster consisted of 2.6 patients. The median population in the geographic area of a cluster was 475,011, the median cluster duration was 4.0 days, and the proportion of cases in spatiotemporal clusters was 4.2%. The study exemplifies how the combination of molecular finetyping and spatiotemporal analysis can be used to assess an infectious disease in a large European country.     

Accelerated measles control--Cambodia, 1999-2002

Cambodia is recovering from approximately 30 years of civil war that resulted in the breakdown of the country's public health infrastructure. In 1999, the Ministry of Health initiated a measles-control program with the goal of reducing the annual incidence of measles to <10,000 cases in 2005 by strengthening measles surveillance, improving routine vaccination coverage, implementing supplementary measles immunization activities (SIAs), and providing vitamin A during outbreak investigations and SIAs. This report summarizes measles-vaccination activities and their impact in reducing reported measles cases from 13,827 in 1999 to 1,234 in 2002 and suggests options for future measles-control efforts in postconflict situations.     

Enhanced surveillance for meningococcal disease in Queensland in 1999

Enhanced surveillance of invasive meningococcal disease commenced in Queensland in 1999. There were 93 cases, an incidence of 2.8/100,000 population. Most (87%) cases were laboratory confirmed, but 12 per cent were probable cases without laboratory confirmation. The highest age-specific attack rates were in the under 1, 1 to 4 and 15 to 24 year age groups. Most of the serologically characterised isolates were group B (70%), followed by group C (24%). There were 12 deaths, resulting in a case fatality rate of 13 per cent. Those who died were more likely to have group C than group B disease (OR 5.04, CI 1.05-25.14). Only 14 per cent of cases that saw a general practitioner (GP) prior to hospitalization received parenteral antibiotics, 23 per cent of the 35 cases referred to hospital by a GP received pre-hospital parenteral antibiotics and 33 per cent of cases were notified to health authorities within 24 hours of hospital admission. Thirty per cent were notified two or more days after hospitalization, delaying the start of public health action. Enhanced surveillance has demonstrated a need to promote the use of pre-hospital parenteral antibiotics by GPs and a need to encourage more timely reporting of cases to health authorities.     

云南省宣威市1999-2012年鼠疫监测结果及流行危险因素分析

目的掌握宣威市家鼠鼠情、蚤情、蚤分布、密度等情况,分析宣威市发生鼠疫流行的危险因素。方法按照《云南省鼠疫监测方案》,于1999-2012年对不同乡（镇、街道）的家鼠进行监测,并将监测结果进行分析。结果1999-2012年共捕鼠1757只,平均鼠密度为5.98%,最高年份达11.36%,优势鼠种为褐家鼠（占51.05%）和黄胸鼠（占37.05%）,黄胸鼠平均密度为2.22%,高于国家黄胸鼠控制标准（1%）;平均染蚤率为33.18%,总蚤指数为0.84,未发现印鼠客蚤,优势蚤为不等单蚤（占66.46%）;共获得鼠血清1560份,用间接血凝试验检测F1抗体,未发现阳性标本。结论宣威市未发现鼠间鼠疫流行线索,但从环境、历史、鼠疫研究成果、鼠密度、染蚤率、优势鼠种、优势蚤等因素综合分析,存在着鼠疫发生和流行的可能性。     

Modifiable health risk factors and medical expenditures - The case of Taiwan

To contain escalating healthcare spending has become a great challenge for many countries around the world. Among all factors influencing medical costs, extensive studies have shown that adoption of healthy lifestyles such as not smoking, moderate drinking, eating healthy food, and exercising regularly can contribute to good health and lower the odds of having diseases that result in higher medical spending. The goal of this paper is to explore the relationship between modifiable risk factors and healthcare costs in Taiwan. A two-part model is employed to estimate the association between modifiable risk factors and medical expenditures. A logit model is used in the first stage of estimation and a generalized linear model is used in the second stage of estimation. Linking the 2001 National Health Interview Survey (NHIS) and the claims data in the National Health Insurance Research Database (NHIRD) in Taiwan, I find some significant associations between several lifestyle variables and medical expenditures. Former smokers are found to have higher probability of using medical care and incur higher medical expenses. People with exercise habits are less likely to use inpatient care services, and they incur lower inpatient expenses. Therefore, healthcare policies promoting non-smoking and physical activities should be used in Taiwan to curb rising expenditures and to achieve better care for people with chronic diseases.     

Modifiable cardiovascular risk factors among adults in Aleppo,Syria

Objectives  

This report provides the first comprehensive and standardized assessment of the distribution of cardiovascular disease (CVD) risk factors in Syria, where such data are still scarce.