[Show abstract][Hide abstract] ABSTRACT: We diagnosed invasive meningococcal disease by using immunohistochemical staining of embalmed tissue and PCR of vitreous humor from 2 men in New York City. Because vitreous humor is less subject than other body fluids to putrefaction, it is a good material for postmortem analysis.
[Show abstract][Hide abstract] ABSTRACT: Objectives. We compared school nurse visit syndromic surveillance system data to emergency department (ED) visit data for monitoring illness in New York City schoolchildren. Methods. School nurse visit data recorded in an electronic health record system are used to conduct daily surveillance of influenza-like illness, fever-flu, allergy, asthma, diarrhea, and vomiting syndromes. We calculated correlation coefficients to compare the percentage of syndrome visits to the school nurse and ED for children aged 5 to 14 years, from September 2006 to June 2011. Results. Trends in influenza-like illness correlated significantly (correlation coefficient = 0.89; P < .001) and 72% of school signals occurred on days that ED signaled. Trends in allergy (correlation coefficient = 0.73; P < .001) and asthma (correlation coefficient = 0.56; P < .001) also correlated and school signals overlapped with ED signals on 95% and 51% of days, respectively. Substantial daily variation in diarrhea and vomiting visits limited our ability to make comparisons. Conclusions. Compared with ED syndromic surveillance, the school nurse system identified similar trends in influenza-like illness, allergy, and asthma syndromes. Public health practitioners without school-based surveillance may be able to use age-specific analyses of ED syndromic surveillance data to monitor illness in schoolchildren. (Am J Public Health. Published online ahead of print November 14, 2013: e1-e7. doi:10.2105/AJPH.2013.301411).
American Journal of Public Health 11/2013; · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We describe the first report of temporally-related cases of Bordetella holmesii bacteremia. Demographic and clinical data were collected through chart abstraction and case-patient interviews. Twenty-two cases were identified from six states. Symptom onset dates ranged from April, 2010 to January, 2011. Median age of cases was 17.1 years and 64% of cases had functional or anatomic asplenia. PFGE profiles of a sample of isolates were identical. These cases occurred during a peak in pertussis outbreaks with documented cases of B. holmesii/B.pertussis respiratory co-infection; whether there is a link between B. holmseii respiratory and bloodstream infection is unknown.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Hospitalizations with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection have increased in New York City, with substantial geographic variation across neighborhoods. While individual-level risk factors, such as age, sex, HIV infection, and diabetes have been described, the role of neighborhood-level factors (e.g., neighborhood HIV prevalence or income) has not been examined. METHODS: To explore plausible neighborhood-level factors associated with CA-MRSA-related hospitalizations, a retrospective analysis was conducted using New York City hospital discharges from 2006 and New York City-specific survey and health department surveillance data. CA-MRSA-related hospitalizations were identified using diagnosis codes and admission information. Associations were determined by using sex-specific multilevel logistic regression. RESULTS: The CA-MRSA hospitalization rate varied by more than six-fold across New York City neighborhoods. Females hospitalized with CA-MRSA had more than twice the odds of residing in neighborhoods in the highest quintile of HIV prevalence (adjusted odds ratio [AOR]Q5 vs. Q1 2.3, 95%CI: 1.2-2.7). Both males and females hospitalized with CA-MRSA had nearly twice the odds of residing in neighborhoods with moderately high proportion of men who have sex with men (MSM) residing in the neighborhood (males: AORQ4 vs. Q1 1.7, 95%CI: 1.1-2.7; females: AORQ4 vs. Q1 2.0, 95%CI: 1.1-3.6); but this association did not hold for neighborhoods in the highest quintile proportion of MSM (males: AORQ5 vs. Q1 1.2, 95%CI: 0.76-1.8; females: AORQ5 vs. Q1 1.5, 95%CI: 0.82-2.7). CONCLUSIONS: Neighborhood characteristics were associated with CA-MRSA hospitalization odds, independent of individual-level risk factors, and may contribute to the population-level burden of CA-MRSA infection.
[Show abstract][Hide abstract] ABSTRACT: Children are important transmitters of influenza in the community and a number of non-pharmaceutical interventions (NPIs), including hand washing and use of hand sanitizer, have been recommended to mitigate the transmission of influenza, but limited information is available regarding schools' ability to implement these NPIs during an influenza outbreak. We evaluated implementation of NPIs during fall 2009 in response to H1N1 pandemic influenza (pH1N1) by New York City (NYC) public schools.
From January 25 through February 9, 2010, an online survey was sent to all the 1,632 NYC public schools and principals were asked to participate in the survey or to designate a school nurse or other school official with knowledge of school policies and characteristics to do so.
Of 1,633 schools, 376(23%) accessed and completed the survey. Nearly all respondents (99%) implemented at least two NPIs. Schools that had a Flu Response Team (FRT) as a part of school emergency preparedness plan were more likely to implement the NPI guidelines recommended by NYC public health officials than schools that did not have a FRT. Designation of a room for isolating ill students, for example, was more common in schools with a FRT (72%) than those without (53%) (p<0.001).
Implementing an NPI program in a large school system to mitigate the effects of an influenza outbreak is feasible, but there is potential need for additional resources in some schools to increase capacity and adherence to all recommendations. Public health influenza-preparedness plans should include school preparedness planning and FRTs.
PLoS ONE 01/2013; 8(1):e50916. · 3.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In August 2010, the New York City Department of Health and Mental Hygiene (DOHMH) conducted an investigation to identify and provide antibiotic prophylaxis to close contacts of a patient who had died of invasive meningococcal disease. Traditional contact tracing, which relies on interviews with the patient's close associates, identified 3 persons meeting prophylaxis criteria. In addition, DOHMH learned of an Internet site used by the patient to arrange anonymous sexual encounters. By working with the Internet site administrator through a liaison, DOHMH sent notification to 15 additional persons potentially at risk for meningococcal disease; of those, at least 1 met prophylaxis criteria. The Internet has been used previously for partner notification by sexually transmitted disease control programs. This case report illustrates how the Internet can aid contact investigations for other communicable diseases, especially when identifying potential contacts is urgent, patients have died, or contacts are unknown to the patient's associates.
Journal of public health management and practice: JPHMP 07/2012; 18(4):379-81. · 0.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe trends in hospitalizations with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection in New York City over 10 years and to explore the demographics and comorbidities of patients hospitalized with CA-MRSA infections.
Retrospective analysis of hospital discharges from New York State's Statewide Planning and Research Cooperative System database from 1997 to 2006.
All patients greater than 1 year of age admitted to New York hospitals with diagnosis codes indicating MRSA who met the criteria for CA-MRSA on the basis of admission information and comorbidities.
We determined hospitalization rates and compared demographics and comorbidities of patients hospitalized with CA-MRSA versus those hospitalized with all other non-MRSA diagnoses by multivariable logistic regression.
Of 18,226 hospitalizations with an MRSA diagnosis over 10 years, 3,579 (20%) were classified as community-associated. The CA-MRSA hospitalization rate increased from 1.47 to 10.65 per 100,000 people overall from 1997 to 2006. Relative to non-MRSA hospitalizations, men, children, Bronx and Manhattan residents, the homeless, patients with human immunodeficiency virus (HIV) infection, and persons with diabetes had higher adjusted odds of CA-MRSA hospitalization.
The CA-MRSA hospitalization rate appeared to increase between 1997 and 2006 in New York City, with residents of the Bronx and Manhattan, men, and persons with HIV infection or diabetes at increased odds of hospitalization with CA-MRSA. Further studies are needed to explore how changes in MRSA incidence, access to care, and other factors may have impacted these rates.
Infection Control and Hospital Epidemiology 07/2012; 33(7):725-31. · 4.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In May 2001, The New York City Department of Health and Mental Hygiene was informed of a cluster of 4 patients treated at an outpatient gastroenterology center who developed acute hepatitis C virus infection. An investigation identified a total of 12 clinic-associated hepatitis C virus transmissions and the outbreak and was traced to unsafe handling of multidose anesthetic vials and possible re-use of contaminated needles. This report typifies the types of outbreaks that continue to occur despite safe injection guidelines.
American journal of infection control 05/2012; · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The effects of individual school dismissal on influenza transmission have not been well studied. During the spring 2009 novel H1N1 outbreak, New York City implemented an individual school dismissal policy intended to limit influenza transmission at schools with high rates of influenza-like illness (ILI).
Active disease surveillance data collected by the New York City Health Department on rates of ILI in schools were used to evaluate the impact. Sixty-four schools that met the Health Department's criteria for considering dismissal were included in the analysis. Twenty-four schools that met criteria subsequently dismissed all classes for approximately 1 school week. A regression model was fit to these data, estimating the effect of school dismissal on rates of in-school ILI following reconvening, adjusting for potential confounders.
The model estimated that, on average, school dismissal reduced the rate of ILI by 7.1% over the entire average outbreak period. However, a large proportion of in-school ILI occurred before dismissal criteria were met. A separate model estimated that school absenteeism rates were not significantly affected by dismissal.
Results suggest that individual school dismissal could be considered in situations where schools have a disproportionate number of high-risk students or may be unable to implement recommended preventive or infection control measures. Future work should focus on developing more sensitive indicators of early outbreak detection in schools and evaluating the impact of school dismissal on community transmission.
Journal of School Health 03/2012; 82(3):123-30. · 1.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To use laboratory data to assess the specificity of syndromes used by the New York City emergency department (ED) syndromic surveillance system to monitor influenza activity.
For the period from October 1, 2009 through March 31, 2010, we examined the correlation between citywide ED syndrome assignment and laboratory-confirmed influenza and respiratory syncytial virus (RSV). In addition, ED syndromic data from five select NYC hospitals were matched at the patient and visit level to corresponding laboratory reports of influenza and RSV. The matched dataset was used to evaluate syndrome assignment by disease and to calculate the sensitivity and specificity of the influenza-like illness (ILI) syndrome.
Citywide ED visits for ILI correlated well with influenza laboratory diagnoses (R=0.92). From October 1, 2009, through March 31, 2010, there were 264,532 ED visits at the five select hospitals, from which the NYC Department of Health and Mental Hygiene (DOHMH) received confirmatory laboratory reports of 655 unique cases of influenza and 1348 cases of RSV. The ED visit of most (56%) influenza cases had been categorized in the fever/flu syndrome; only 15% were labeled ILI. Compared to other influenza-related syndromes, ILI had the lowest sensitivity (15%) but the highest specificity (90%) for laboratory-confirmed influenza. Sensitivity and specificity varied by age group and influenza activity level.
The ILI syndrome in the NYC ED syndromic surveillance system served as a specific but not sensitive indicator for influenza during the 2009-2010 influenza season. Despite its limited sensitivity, the ILI syndrome can be more informative for tracking influenza trends than the fever/flu or respiratory syndromes because it is less likely to capture cases of other respiratory viruses. However, ED ILI among specific age groups should be interpreted alongside laboratory surveillance data. ILI remains a valuable tool for monitoring influenza activity and trends as it facilitates comparisons nationally and across jurisdictions and is easily communicated to the public.
[Show abstract][Hide abstract] ABSTRACT: Academic literature has recorded increased microbial resistance in the United States and recent news media has adversely portrayed men who have sex with men (MSM) at increased risk for community associated methicillin resistant Staphylococcus aureus (CA-MRSA) transmission. CA-MRSA is a specific type of bacteria resistant to certain antibiotics, which limits treatment options for those needing clinical care. Infection can manifest as painful abscesses and can cause severe illness. With increased CA-MRSA infections overall, and attention given to MSM populations regarding CA-MRSA, as well as the fact that limited data on sociocultural factors that may facilitate transmission, we undertook a qualitative study to explore contextual influences that may fuel infection among MSM in New York City so that public health professionals can better recognize, and respond appropriately to, potential future outbreaks. In-depth interviews were used to qualitatively investigate perceptions and beliefs regarding transmission, as well as community understandings of treatment options. Participants included thirteen MSM who reported a previous CA-MRSA infection and nine community practitioners. A thematic content analysis of these interviews was conducted and data suggests that behaviors and exposures associated with transmission of CA-MRSA are common in certain MSM networks. Specifically, sociocultural influences and methamphetamine use activities were found to contribute to CA-MRSA transmission. We underscore the role of public health and health services practitioners in providing appropriate CA-MRSA awareness and education to MSM populations.
Journal of Community Health 08/2011; 37(2):458-67. · 1.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Physicians who are insufficiently prepared to make choices on antibiotic selection may use antibiotics inappropriately. We surveyed medical students' perceptions and attitudes about their training on antimicrobial use to identify gaps in medical education. Medical students at an urban medical school in the northeast were e-mailed a link to an online survey. The survey was online for 1 week, after which time the survey responses were downloaded and analyzed. Thirty percent of medical students responded to the survey (n = 304). The majority of third- and fourth-year medical students believe that antibiotics are overused in the hospital and in outpatient areas. Over three quarters of the students would like more education on antibiotic selection, and 83% wanted this education to be during the third year of medical school. The resources they used the most for antibiotic selection included other physicians and handheld programs such as Epocrates, but no clear resource emerged as the dominant preference. Medical students recognized the importance of judicious antibiotic use and would like greater instruction on how to choose antibiotics appropriately. Medical school curricula should be expanded in the third year of medical school to provide students with additional training timed with their clinical rotations.
[Show abstract][Hide abstract] ABSTRACT: In October 2008, an investigation was conducted into a cluster of gram-negative bloodstream infections after invasive pain management procedures at an outpatient facility to identify additional cases and determine the source of illness.
We conducted a retrospective cohort study to determine exposures associated with illness. Eligible patients had an invasive procedure in the 4 days before or after the procedure date of the initial case-patients. Infection control assessments were made, and environmental specimens collected.
Four laboratory-confirmed case-patients (3 with Klebsiella pneumoniae and 1 with Enterobacter aerogenes) and 5 suspect case-patients were identified. In addition to the 9 confirmed and suspect case-patients, 45 patients were interviewed. All confirmed and suspect case-patients had a sacroiliac joint steroid injection procedure; injection into the sacroiliac joint was associated with illness (9/22 versus 0/31; P < 0.0001). Multiple breaches in infection control were noted including the reuse of single-use vials for multiple patients. The 3 K. pneumoniae with positive blood cultures were indistinguishable by pulse-field gel electrophoresis, and the E. aerogenes-positive blood culture was indistinguishable by pulse-field gel electrophoresis to the culture from an open vial of 100-mL iodixanol contrast solution.
Infection was associated with pain management procedures, specifically those involving injection to the sacroiliac joint. Lapses in infection control likely led to the contamination of single-use vials that were then used for multiple patients. Reuse of medication vials should be restricted, and affordable single-dose vials should be made available.
Regional anesthesia and pain medicine 11/2010; 35(6):496-9. · 4.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined New York City Department of Health and Mental Hygiene surveillance data on hepatitis A, malaria, and typhoid to determine the proportion of these diseases related to travel and their geographic distribution. We found that 61% of hepatitis A cases, 100% of malaria cases, and 78% of typhoid cases were travel related and that cases clustered in specific populations and neighborhoods at which public health interventions could be targeted. High-risk groups include Hispanics (for hepatitis A), West Africans living in the Bronx (for malaria), and South Asians (for typhoid).
American Journal of Public Health 07/2010; 100(7):1249-52. · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Pennsylvania on February 16, 2006, a New York City resident collapsed with rigors and was hospitalized. On February 21, the Centers for Disease Control and Prevention and the New York City Department of Health and Mental Hygiene were notified that Bacillus anthracis had been identified in the patient's blood. Although the patient's history of working with dried animal hides to make African drums indicated the likelihood of a natural exposure to aerosolized anthrax spores, bioterrorism had to be ruled out first. Ultimately, this case proved to be the first case of naturally occurring inhalational anthrax in 30 years. This article describes the epidemiologic and environmental investigation to identify other cases and persons at risk and to determine the source of exposure and scope of contamination. Because stricter regulation of the importation of animal hides from areas where anthrax is enzootic is difficult, public healthcare officials should consider the possibility of future naturally occurring anthrax cases caused by contaminated hides. Federal protocols are needed to assist in the local response, which should be tempered by our growing understanding of the epidemiology of naturally acquired anthrax. These protocols should include recommended methods for reliable and efficient environmental sample collection and laboratory testing, and environmental risk assessments and remediation.
Journal of public health management and practice: JPHMP 04/2010; 16(3):189-200. · 0.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Isolated cases of camphor-induced seizures have been reported in young children after gastrointestinal, dermal, and inhalation exposure. In 1982, after a series of unintentional ingestions of camphor products, the US Food and Drug Administration restricted the camphor content to <11% in some products intended for medicinal use. Camphor products intended for use as pesticides must be registered with the US Environmental Protection Agency. Still, many imported camphor-containing products fail to meet Food and Drug Administration and Environmental Protection Agency requirements for labeling and content.
To describe a cluster of cases of camphor-associated seizure activity resulting from the availability of imported camphor products in certain ethnic populations that use it as a natural remedy.
We present 3 cases of seizures associated with imported, illegally sold camphor in young children who presented to a large, urban children's hospital in Bronx, New York, during a 2-week period.
The children's ages ranged from 15 to 36 months. Two children ingested camphor, and 1 child was exposed through repetitive rubbing of camphor on her skin. All 3 patients required pharmacologic intervention to terminate the seizures. One patient required bag-valve-mask ventilation for transient respiratory depression. All 3 patients had leukocytosis, and 2 patients had hyperglycemia. Exposure occurred as a result of using camphor for spiritual purposes, cold remedy, or pest control. After identification of these cases, the New York City Department of Health released a public health warning to keep camphor products away from children. Similar warnings were issued later by other state health departments.
These cases highlight the toxicity associated with camphor usage in the community and that inappropriate use of illegally sold camphor products is an important public health issue. Camphor may be a common, yet unrecognized, source of seizures in children in certain ethnic populations that use it as a natural remedy. Efforts are needed to educate the communities about the hazards of using camphor products and to limit the illegal availability of these products.
[Show abstract][Hide abstract] ABSTRACT: An outbreak of serogroup C meningococcal disease that involved illicit drug users and their contacts occurred in Brooklyn, New York, during 2005 and 2006.
The objectives of this study were to identify the population at risk for meningococcal disease, describe efforts to interrupt disease transmission, and assess the impact of a vaccine initiative. Descriptive and molecular epidemiological analysis was used to define the extent of the outbreak and the common risk factors among outbreak-related cases. A vaccine initiative that used community-based service providers was targeted to illicit drug users and their close contacts. The vaccine initiative was assessed through cessation of outbreak-related cases and the reduction in carriage rate.
The investigation identified 23 outbreak-related cases of serogroup C meningococcal disease; 17 isolates were indistinguishable and 4 isolates were closely related according to pulsed-field gel electrophoresis. Two additional culture-negative cases had epidemiological links to laboratory-confirmed cases. The median age of patients with outbreak-related cases was 41 years, and 19 (83%) of 23 patients reported an association with illicit drug use. There were 7 outbreak-related deaths. Vaccination was administered to 2763 persons at 29 community locations, including methadone treatment centers, syringe-exchange programs, and soup kitchens. Three additional cases of meningococcal disease due to strains with the same pulsed-field gel electrophoresis pattern were identified after the vaccination initiative.
Community-based outbreaks of meningococcal disease are difficult to control, and the decision to vaccinate is not straightforward. Current national guidelines for implementing a vaccination campaign are not strict criteria and cannot be expected to accommodate the myriad of factors that occur in community-based invasive meningococcal disease outbreaks, such as the inability to enumerate the population at risk.
[Show abstract][Hide abstract] ABSTRACT: We present an outbreak of E. coli O157:H7 diarrhea in an urban child care center. Eleven of 45 attendees with diarrhea had positive tests (stool culture or shiga-like toxin assay) for E. coli O157:H7. Two of these 11 (18%) progressed to hemolytic uremic syndrome. Diarrheal illness in child care centers should be considered a public health risk. Staff education, hand washing, and cohorting or exclusion of attendees with diarrhea must be performed to help control infectious outbreaks.
[Show abstract][Hide abstract] ABSTRACT: The importance of understanding age when estimating the impact of influenza on hospitalizations and deaths has been well described, yet existing surveillance systems have not made adequate use of age-specific data. Monitoring influenza-related morbidity using electronic health data may provide timely and detailed insight into the age-specific course, impact and epidemiology of seasonal drift and reassortment epidemic viruses. The purpose of this study was to evaluate the use of emergency department (ED) chief complaint data for measuring influenza-attributable morbidity by age and by predominant circulating virus.
We analyzed electronically reported ED fever and respiratory chief complaint and viral surveillance data in New York City (NYC) during the 2001-2002 through 2005-2006 influenza seasons, and inferred dominant circulating viruses from national surveillance reports. We estimated influenza-attributable impact as observed visits in excess of a model-predicted baseline during influenza periods, and epidemic timing by threshold and cross correlation. We found excess fever and respiratory ED visits occurred predominantly among school-aged children (8.5 excess ED visits per 1,000 children aged 5-17 y) with little or no impact on adults during the early-2002 B/Victoria-lineage epidemic; increased fever and respiratory ED visits among children younger than 5 y during respiratory syncytial virus-predominant periods preceding epidemic influenza; and excess ED visits across all ages during the 2003-2004 (9.2 excess visits per 1,000 population) and 2004-2005 (5.2 excess visits per 1,000 population) A/H3N2 Fujian-lineage epidemics, with the relative impact shifted within and between seasons from younger to older ages. During each influenza epidemic period in the study, ED visits were increased among school-aged children, and each epidemic peaked among school-aged children before other impacted age groups.
Influenza-related morbidity in NYC was highly age- and strain-specific. The impact of reemerging B/Victoria-lineage influenza was focused primarily on school-aged children born since the virus was last widespread in the US, while epidemic A/Fujian-lineage influenza affected all age groups, consistent with a novel antigenic variant. The correspondence between predominant circulating viruses and excess ED visits, hospitalizations, and deaths shows that excess fever and respiratory ED visits provide a reliable surrogate measure of incident influenza-attributable morbidity. The highly age-specific impact of influenza by subtype and strain suggests that greater age detail be incorporated into ongoing surveillance. Influenza morbidity surveillance using electronic data currently available in many jurisdictions can provide timely and representative information about the age-specific epidemiology of circulating influenza viruses.
PLoS Medicine 09/2007; 4(8):e247. · 15.25 Impact Factor