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BACKGROUND Acellular pertussis vaccines were initially licensed based on placebo-controlled efficacy trials, but such trials are no longer ethical. The effectiveness of current pertussis vaccines among properly vaccinated children

Babesiosis is an emerging zoonotic disease caused primarily by Babesia microti, an intraerythocytic protozoan. Babesia microti, like the causal agents for Lyme disease and anaplasmosis, is endemic to the northeastern and upper midwestern United States where it is usually transmitted by the blacklegged tick, Ixodes scapularis. Although babesiosis is usually a mild to moderate illness, older or immunocompromised persons can develop a serious malaria-like illness that can be fatal without prompt treatment. The most common initial clinical signs and symptoms of babesiosis (fever, fatigue, chills, and diaphoresis) are nonspecific and present diagnostic challenges that can contribute to delays in diagnosis and effective treatment with atovaquone and azithromycin (1). Results of one study revealed a mean delay of 12-14 days from symptom onset to treatment (2). Knowledge of the incidence and geographic distribution of babesiosis can raise the index of clinical suspicion and facilitate more prompt diagnosis and lifesaving treatment (1). The first known case of babesiosis in Wisconsin was detected in 1985 (3), and babesiosis became officially reportable in the state in 2001. Wisconsin babesiosis surveillance data for 2001-2015 were analyzed in 3-year intervals to compare demographic, epidemiologic, and laboratory features among patients with cases of reported babesiosis. To determine possible reasons for an increase in reported Babesia infection, trends in electronic laboratory reporting and diagnosis by polymerase chain reaction testing (PCR) were examined. Between the first and last 3-year analysis intervals, there was a 26-fold increase in the incidence of confirmed babesiosis, in addition to geographic expansion. These trends might be generalizable to other states with endemic disease, similar suburbanization and forest fragmentation patterns, and warming average temperatures (4). Accurate surveillance in states where babesiosis is endemic is necessary to estimate the increasing burden of babesiosis and other tickborne diseases and to develop appropriate public health interventions for prevention and practice.

Pregnant women are routinely recommended to receive Tdap and influenza vaccines to prevent disease and complications among mothers and newborns. Monitoring population trends in maternal vaccination is important in order to evaluate the implementation of these recommendations and to identify pockets of need. We present two methods for measuring maternal vaccination among a state population and discuss the strengths and drawbacks of each method. First, we matched maternal information from records of Wisconsin births during 2013-2015 with maternal vaccination records in the Wisconsin Immunization Registry. Second, we used an all-payer health insurance claims database to identify Wisconsin women with deliveries during 2013-2015 and vaccinations received during pregnancy. Both methods produced similar trends and indicated a substantial increase in the percentage of women receiving Tdap during pregnancy, and lower vaccination rates among women who were Medicaid-insured. When available and timely, both methods are useful for monitoring maternal vaccination.

Background During the 2014-2015 influenza season in the United States, 256 cases of influenza-associated parotitis were reported from 27 states. We conducted a case-control study and laboratory investigation to further describe this rare clinical manifestation of influenza. Methods During February 2015-April 2015, we interviewed 50 cases (with parotitis) and 124 ill controls (without parotitis) with laboratory-confirmed influenza; participants resided in 11 states and were matched by age, state, hospital admission status, and specimen collection date. Influenza viruses were characterized using real-time polymerase chain reaction and next-generation sequencing. We compared cases and controls using conditional logistic regression. Specimens from additional reported cases were also analyzed. Results Cases, 73% of whom were aged

During September to October, 2006, state and local health departments and the Centers for Disease Control and Prevention investigated a large, multistate outbreak of Escherichia coli O157:H7 infections. Case patients were interviewed regarding specific foods consumed and other possible exposures. E. coli O157:H7 strains isolated from human and food specimens were subtyped using pulsed-field gel electrophoresis and multiple-locus variable-number tandem repeat analyses (MLVA). Two hundred twenty-five cases (191 confirmed and 34 probable) were identified in 27 states; 116 (56%) case patients were hospitalized, 39 (19%) developed hemolytic uremic syndrome, and 5 (2%) died. Among 176 case patients from whom E. coli O157:H7 with the outbreak genotype (MLVA outbreak strain) was isolated and who provided details regarding spinach exposure, 161 (91%) reported fresh spinach consumption during the 10 days before illness began. Among 116 patients who provided spinach brand information, 106 (91%) consumed bagged brand A. E. coli O157:H7 strains were isolated from 13 bags of brand A spinach collected from patients' homes; isolates from 12 bags had the same MLVA pattern. Comprehensive epidemiologic and laboratory investigations associated this large multistate outbreak of E. coli O157:H7 infections with consumption of fresh bagged spinach. MLVA, as a supplement to pulsed-field gel electrophoresis genotyping of case patient isolates, was important to discern outbreak-related cases. This outbreak resulted in enhanced federal and industry guidance to improve the safety of leafy green vegetables and launched an independent collaborative approach to produce safety research in 2007.

Background We estimated the vaccine effectiveness (VE) of tetanus-diphtheria-acellular pertussis vaccine (Tdap) for preventing pertussis among adolescents during a statewide outbreak of pertussis in Wisconsin during 2012. Methods We used the population-based Wisconsin Immunization Registry (WIR) to construct a cohort of Wisconsin residents born during 1998-2000 and collect Tdap vaccination histories. Reports of laboratory-confirmed pertussis with onset during 2012 were matched to WIR clients. Incidence rate ratios (IRRs) of pertussis and Tdap VE estimates [(1 - IRR)*100%], by year of Tdap vaccine receipt and brand (Boostrix/Adacel), were estimated using Poisson regression. Results Tdap VE decreased with increasing time since receipt, with VEs of 75.3% (95% confidence interval [CI], 55.2%-86.5%) for receipt during 2012, 68.2% (95% CI, 60.9%-74.1%) for receipt during 2011, 34.5% (95% CI, 19.9%-46.4%) for receipt during 2010, and 11.9% (95% CI, -11.1% to 30.1%) for receipt during 2009/2008; point estimates were higher among Boostrix recipients than among Adacel recipients. Among Tdap recipients, increasing time since receipt was associated with increased risk, and receipt of Boostrix (vs Adacel) was associated with decreased risk of pertussis (adjusted IRR, 0.62 [95% CI, .52-.74]). Conclusions Our results demonstrate waning immunity following vaccination with either Tdap brand. Boostrix was more effective than Adacel in preventing pertussis in our cohort, but these findings may not be generalizable to adolescent cohorts that received different diphtheria-tetanus-acellular pertussis vaccines (DTaP) during childhood and should be further examined in studies that include childhood DTaP history.

Carbapenem-resistant Enterobacteriaceae (CRE) are multidrug-resistant gram-negative bacilli that can cause infections associated with high case fatality rates, and are emerging as epidemiologically important health care-associated pathogens in the United States (1). Prevention of CRE transmission in health care settings is dependent on recognition of cases, isolation of colonized and infected patients, effective use of infection control measures, and the correct use of antibiotics. The use of molecular technologies, including polymerase chain reaction (PCR) testing, pulsed-field gel electrophoresis (PFGE), and whole genome sequencing (WGS), can lead to detection of transmission events and interruption of transmission. In Wisconsin, acute care and critical access hospitals report laboratory-identified CRE to the Wisconsin Division of Public Health (WDPH), and clinical laboratories submit CRE isolates to the Wisconsin State Laboratory of Hygiene (WSLH) for molecular testing. During February-May 2015, a total of 49 CRE isolates from 46 patients were submitted to WSLH. On June 8, WSLH informed WDPH of five carbapenemase-producing CRE isolates with closely related PFGE patterns identified among four inpatients at two hospitals in southeastern Wisconsin. An investigation revealed a high degree of genetic relatedness among the patients' isolates, but did not identify the mechanism of transmission between the two facilities. No breaches in recommended practices were identified; after reviewing respiratory care procedures, no further cases were identified. Routine hospital- and laboratory-based surveillance can detect and prevent health care transmission of CRE.

Blastomycosis is a potentially fatal infection caused by Blastomyces dermatitidis, a fungus endemic to North America in areas surrounding the Ohio and Mississippi River valleys and the Great Lakes. The clinical manifestations, diagnostic techniques, and treatment strategies for blastomycosis are relatively well-described in the literature; however, the epidemiologic features of disease are not as clearly defined as those of other endemic mycoses, such as histoplasmosis and coccidioidomycosis. We review the ecologic and epidemiologic aspects of B. dermatitidis and blastomycosis, including geographic distribution, environmental niche, seasonality, and possible risk factors.

Objective.To detect an outbreak-related source of Legionella, control the outbreak, and prevent additional Legionella infections from occurring.Design and Setting.Epidemiologic investigation of an acute outbreak of hospital-associated Legionnaires disease among outpatients and visitors to a Wisconsin hospital.Patients.Patients with laboratory-confirmed Legionnaires disease who resided in southeastern Wisconsin and had illness onsets during February and March 2010.Methods.Patients with Legionnaires disease were interviewed using a hypothesis-generating questionnaire. On-site investigation included sampling of water and other potential environmental sources for Legionella testing. Case-finding measures included extensive notification of individuals potentially exposed at the hospital and alerts to area healthcare and laboratory personnel.Results.Laboratory-confirmed Legionnaires disease was diagnosed in 8 patients, all of whom were present at the same hospital during the 10 days prior to their illness onsets. Six patients had known exposure to a water wall-type decorative fountain near the main hospital entrance. Although the decorative fountain underwent routine cleaning and maintenance, high counts of Legionella pneumophila serogroup 1 were isolated from cultures of a foam material found above the fountain trough.Conclusion.This outbreak of Legionnaires disease was associated with exposure to a decorative fountain located in a hospital public area. Routine cleaning and maintenance of fountains does not eliminate the risk of bacterial contamination. Our findings highlight the need to evaluate the safety of water fountains installed in any area of a healthcare facility.Infect Control Hosp Epidemiol 2012;33(2):185-191

Background The occurrence of hepatitis A in the United States is heterogeneous because of disease cycles with substantial variation in incidence among states and involvement of numerous behavioral risk factors. In spite of the Advisory Committee on Immunization Practices’ (ACIP) 1999 recommendation for routine hepatitis A immunization in states with high rates of disease and the fact that disease rates are at a historic low, outbreaks continue to occur. Methods We reviewed outbreaks of hepatitis A in the United States occurring from 1994 through 2004. We searched PubMed, ProMed, Google, and the CDC Foodborne Disease Outbreak and Epi-X Internet sites to ascertain the number and type of hepatitis A outbreaks. The CDC’s MMWR publication and the Hepatitis Control Report were also searched. Results A total of 256 hepatitis A outbreaks were identified from 1994 through 2004. The mean number of outbreaks was 23 per year (median 25). The number of outbreaks in states with traditionally low/intermediate endemic rates of hepatitis A remained relatively constant during the study period. Outbreaks declined significantly (P = 0.01) in states with previously high rates of disease—most of which have implemented hepatitis A vaccination programs. Conclusions Outbreaks of hepatitis A continue to occur in the United States despite the licensure of two safe and effective vaccines in 1995 and the apparent decline in the number of outbreaks in states with previously high rates of hepatitis A. The recent ACIP recommendation for universal hepatitis A vaccination at age 1 year in all states will contribute to a further reduction in hepatitis A outbreaks.

During a large pertussis outbreak, culture and polymerase chain reaction (PCR) were used to identify 149 case patients; of these case patients, 79 had positive PCR and culture results, 59 had positive PCR results and negative culture results, 11 had negative PCR results and positive culture results (10 PCR-negative, culture-positive specimens were collectedor = 14 days after illness onset). PCR and culture of samples obtainedor = 2 weeks after illness onset and PCR of samples obtained2 weeks after illness onset proved to be most diagnostically useful.

Summary Background Lyme borreliosis is the most common tick-borne disease in the northern hemisphere. It is a multisystem disease caused by Borrelia burgdorferi sensu lato genospecies and characterised by tissue localisation and low spirochaetaemia. In this study we aimed to describe a novel Borrelia species causing Lyme borreliosis in the USA. Methods At the Mayo clinic, from 2003 to 2014, we tested routine clinical diagnostic specimens from patients in the USA with PCR targeting the oppA1 gene of B burgdorferi sensu lato. We identified positive specimens with an atypical PCR result (melting temperature outside of the expected range) by sequencing, microscopy, or culture. We collected Ixodes scapularis ticks from regions of suspected patient tick exposure and tested them by oppA1 PCR. Findings 100 545 specimens were submitted by physicians for routine PCR from Jan 1, 2003 to Sept 30, 2014. From these samples, six clinical specimens (five blood, one synovial fluid) yielded an atypical oppA1 PCR product, but no atypical results were detected before 2012. Five of the six patients with atypical PCR results had presented with fever, four had diffuse or focal rash, three had symptoms suggestive of neurological inclusion, and two were admitted to hospital. The sixth patient presented with knee pain and swelling. Motile spirochaetes were seen in blood samples from one patient and cultured from blood samples from two patients. Among the five blood specimens, the median oppA1 copy number was 180 times higher than that in 13 specimens that tested positive for B burgdorferi sensu stricto during the same time period. Multigene sequencing identified the spirochaete as a novel B burgdorferi sensu lato genospecies. This same genospecies was detected in ticks collected at a probable patient exposure site. Interpretation We describe a new pathogenic Borrelia burgdorferi sensu lato genospecies (candidatus Borrelia mayonii ) in the upper midwestern USA, which causes Lyme borreliosis with unusually high spirochaetaemia. Clinicians should be aware of this new B burgdorferi sensu lato genospecies, its distinct clinical features, and the usefulness of oppA1 PCR for diagnosis. Funding US Centers for Disease Control and Prevention Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Cooperative Agreement and Mayo Clinic Small Grant programme.

Background During October 2011-December 2012, concurrent with a statewide pertussis outbreak, 443 Bordetella parapertussis infections were reported among Wisconsin residents. We examined clinical features of patients with parapertussis and the effect of antibiotic use for treatment and prevention. Methods Patients with polymerase chain reaction results positive for B. parapertussis reported during October 2011-May 2012 were interviewed regarding presence and durations of pertussis-like symptoms and receipt of azithromycin treatment. Data regarding acute cough illnesses and receipt of azithromycin prophylaxis among parapertussis patient household members (HHMs) were also collected. Using multivariate repeated measures log-binomial regression analysis, we examined associations of treatment receipt by the HHM with the earliest illness onset and prophylaxis receipt among other HHMs with the presence of any secondary cough illnesses in the household. Results Among 218 patients with parapertussis, pertussis-like symptoms were frequently reported. Illness durations were significantly shorter among patients with treatment initiated 0-6 days after cough onset, compared with nonrecipients (median durations: 10 vs 19 days, P = .002). Among 361 HHMs from 120 households, compared with nonrecipients, prompt prophylaxis of HHMs was associated with no secondary cough illnesses (relative risk: 0.16; 95% confidence interval, .04-.69). Conclusions Bordetella parapertussis infection causes pertussis-like illness that might be misclassified as pertussis if B. parapertussis testing is not performed. Prompt treatment might shorten illness duration, and prompt HHM prophylaxis might prevent secondary illnesses. Further study is needed to evaluate antibiotic effectiveness for preventing parapertussis and to determine risks and benefits of antibiotic use.

CONTEXT Vaccination coverage rates can be improved through the application of complete and accurate immunization information systems (IISs). OBJECTIVE Evaluate the completeness and accuracy of Wisconsin's IIS, the Wisconsin Immunization Registry (WIR). DESIGN Cross-sectional evaluation, comparing vaccination medical records (MRs) from provider clinics with WIR records. PARTICIPANTS Medical records of patients born during 2009 were randomly selected from 251 Wisconsin clinics associated with the Vaccines for Children Program. MAIN OUTCOME MEASURES Completeness: percentage of patients with client records in the WIR, percentage of patients up-to-date (%UTD) with the 4:3:1:3:3:1:4 vaccination series, and percentage of patients' MR vaccinations matched by administration date (±10 days) and type to vaccinations documented in the WIR. Accuracy: percentages of matched vaccinations with the same administration date, same trade name (TN), and same lot number. RESULTS Of the 1863 selected patient MRs, 98% (n = 1833) had WIR client records and 97% of their 30 899 vaccinations were documented in the WIR. The %UTD was 49.3% using the MR only, 76.5% using the WIR only, and 75.2% as estimated by the National Immunization Survey. Among matched vaccinations, 99% had the same administration date, 96% had the same TN, and 95% had the same lot number. Compared with patients from clinics that entered data into the WIR using data exchange from electronic health records, patients from clinics that entered data using the Web-based user interface were less likely to have client records in the WIR (odds ratio: 0.3; 95% confidence interval: 0.1-0.9) and less likely to have accurate TNs (odds ratio: 0.3; 95% confidence interval: 0.1-0.5). CONCLUSIONS The WIR was complete and accurate among this sample of children born during 2009 and provided a vaccination coverage assessment similar to the National Immunization Survey. Our results provide support for the expectation that meaningful use and other initiatives that increase data exchange from electronic health records to IISs will improve IIS data quality.

BACKGROUND In December 2003 and April 2005, signs and symptoms suggestive of infection developed in two groups of recipients of solid-organ transplants. Each cluster was investigated because diagnostic evaluations were unrevealing, and in each a common donor was recognized. METHODS We examined clinical specimens from the two donors and eight recipients, using viral culture, electron microscopy, serologic testing, molecular analysis, and histopathological examination with immunohistochemical staining to identify a cause. Epidemiologic investigations, including interviews, environmental assessments, and medical-record reviews, were performed to characterize clinical courses and to determine the cause of the illnesses. RESULTS Laboratory testing revealed lymphocytic choriomeningitis virus (LCMV) in all the recipients, with a single, unique strain of LCMV identified in each cluster. In both investigations, LCMV could not be detected in the organ donor. In the 2005 cluster, the donor had had contact in her home with a pet hamster infected with an LCMV strain identical to that detected in the organ recipients; no source of LCMV infection was found in the 2003 cluster. The transplant recipients had abdominal pain, altered mental status, thrombocytopenia, elevated aminotransferase levels, coagulopathy, graft dysfunction, and either fever or leukocytosis within three weeks after transplantation. Diarrhea, peri-incisional rash, renal failure, and seizures were variably present. Seven of the eight recipients died, 9 to 76 days after transplantation. One recipient, who received ribavirin and reduced levels of immunosuppressive therapy, survived. CONCLUSIONS We document two clusters of LCMV infection transmitted through organ transplantation.

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.

In 1991, most physicians in Minnesota and Wisconsin managed patients concerns about anthrax without dispensing prophylactic antimicrobial agents., Media reports suggested increased public demand for anthrax prophylaxis after the intentional anthrax cases in 2001, but the magnitude of anthrax-related prescribing in unaffected regions was not assessed. We surveyed a random sample of 400 primary care clinicians in Minnesota and Wisconsin to assess requests for and provision of anthrax-related antimicrobial agents. The survey was returned by 239 (60%) of clinicians, including 210 in outpatient practice. Fifty-eight (28%) of those in outpatient practice received requests for anthrax-related antimicrobial agents, and 9 (4%) dispensed them. Outpatient fluoroquinolone use in both states was also analyzed with regression models to compare predicted and actual use in October and November 2001. Fluoroquinolone use as a proportion of total antimicrobial use was not elevated, and anthrax concerns accounted for an estimated 0.3% of all fluoroquinolone prescriptions. Most physicians in Minnesota and Wisconsin managed anthrax-related requests without dispensing antimicrobial agents.

Elective rotations in health departments expose medical students to public health practice and career opportunities in applied epidemiology and preventive medicine. State and county epidemiologists and health officers can serve as excellent role models for medical students. In 2000-2001, the authors identified such electives by consulting medical schools' Web sites and by contacting state epidemiologists, teachers of preventive medicine, and medical school associate deans. The authors found that electives were offered in nine state and five local health departments; these are described in detail. Those electives usually focused on infectious diseases, involved students in outbreak investigations when possible, lasted four or more weeks, were open to other students and medical residents, and were overseen by a health department preceptor with a medical school faculty appointment and a commitment to train students. Some electives included more didactic components, encouraged the student to publish a manuscript, or were coordinated by a preventive medicine residency director. The authors observe that health departments can benefit from training enthusiastic medical students via such electives; these students bring fresh ideas to the departments. Medical school catalogs, Web sites, and word of mouth are important means for promoting these electives. Ideally, in the future every medical school will offer a state or local health department elective so that all medical students will become aware of epidemiology and public health career options. The electives reported in this article can help guide additional medical schools and health departments as they initiate such rotations.

Few studies have assessed the accuracy and completeness of Lyme disease surveillance systems. Lyme disease cases were identified through review of medical records for residents of the Marshfield Epidemiologic Study Area (MESA), a population-based cohort of nearly 80,000 in north-central Wisconsin for which comprehensive medical care data are available through the Marshfield Clinic. These cases were compared with cases reported to the Wisconsin Division of Public Health to estimate the completeness of reporting. Annual incidence rates were calculated for MESA using the cases identified from chart review. Division of Public Health data were used to calculate statewide reported incidence rates, as well as rates for an eight-county region that surrounds and includes the MESA region. Of Lyme disease cases meeting the national case definition identified in MESA, 34% were reported to the state. The average incidence of Lyme disease (1992-1998) was 19.1 per 100,000 per year in MESA, 17.0 in the surrounding eight-county region, and 9.0 statewide. Trends in reported incidence across time, gender, and age in the surrounding eight-county region were generally comparable with those observed in MESA. These findings suggest that the passive surveillance system monitored trends in Lyme disease incidence reasonably well despite underreporting of cases.

Much of our understanding of the epidemiologic features of infection with Blastomyces dermatitidis has come from cluster and outbreak investigations which have established the association of human disease with recreational pursuits and the presence of infectious microfoci in areas of moist soil with high organic content. This report describes the clustering of eight cases of pulmonary blastomycosis without an apparent common source exposure which occurred during a 90 day period in a 96 square mile area (population 4,450) within Oconto County, Wisconsin. We conclude that multiple high-risk environmental foci may have existed following a sustained five-year period of diminished precipitation in the cluster area. A case-control study which included family and community controls concluded that multiple earth-disturbing activities engaged in by case-patients was statistically associated with illness. Lymphocyte-proliferation assays of whole blood samples detected previously unrecognized infection withB. dermatitidis among five of 32 family controls.

The incidence of human granulocytic ehrlichiosis (HGE) in the upper Midwest is uncertain. Active surveillance for suspected HGE was conducted from 1997 through 1999 in a 13-county region of northwestern Wisconsin. Suspected HGE cases were classified, according to the national case definition, as confirmed, probable, or not HGE. In total, 112 confirmed cases and 30 probable cases of HGE were identified. The median age of the 142 case patients was 56 years, and 92 (65%) were male; 111 (78%) were residents of the surveillance region. The mean annual incidence of confirmed and probable HGE was 9.3 cases per 100,000 residents; there was no increase from 1997 to 1999. The incidence was highest among persons > or =50 years old and residents of Washburn County. The incidence of HGE in this region exceeded prior estimates, but it was lower than the reported incidence in areas of endemicity in Connecticut.

Objective:To investigate and control a nosocomial outbreak ofBurkholderia cepacialower respiratory tract infection.Design:Outbreak investigation and case-control study.Setting:A 260-bed community hospital.Patients:Participants were mechanically ventilated intensive care patients without cystic fibrosis. A case was defined as a hospitalized patient with a sputum culture positive forB cepaciabetween January 1 and November 6, 1998.Methods:Respiratory therapy infection control policies and practices were reviewed; laboratory and environmental studies and a retrospective case-control study were conducted. Case-patients were matched with control-patients on age, gender, diagnosis, and type of intensive care unit.Results:Nine case-patients were identified;B cepacialikely caused pneumonia in seven and colonization in two. Two respiratory therapy practices probably contributed to the transmission ofB cepacia:multidose albuterol vials were used among several patients, and nebulizer assemblies often were not dried between uses.B cepaciawas grown from cultures of three previously opened multidose vials; pulsed-field gel electrophoresis patterns ofB cepaciafrom seven case-patients and two multidose vials were indistinguishable. Case-patients had longer durations of heated humidified mechanical ventilation (mean, 9.8 days vs 4.4 days;P=.03) and were more likely to have exposure to one particular respiratory therapist than controls (odds ratio, undefined; 95% confidence interval, 4.7-∞P=.001). The association with the respiratory therapist, a temporary employee, persisted after controlling for duration of heated humidified ventilation. No newB cepaciainfections were identified after control measures were implemented.Conclusions:B cepaciaprobably was transmitted among patients through use of extrinsically contaminated multidose albuterol vials. Respiratory therapy departments must pay close attention to infection control practices, particularly among new or temporary staff.

Objective. To determine the impact of the American Academy of Pediatrics/US Public Health Service (AAP/USPHS) joint statement on thimerosal in vaccines on hospital infant hepatitis B vaccination policies in Wisconsin. Methods. The nurse managers of hospital newborn nurseries (n = 110) were surveyed by mail. Nonresponders were resurveyed. Twelve hospitals no longer provided obstetric services. Of the remaining 98 hospitals, 84 (86%) responded to the initial mailing and 14 (14%) responded to the second mailing. The number of hospitals that offered hepatitis B vaccine to infants before July 1999 was compared with that in March 2000. The number of hospitals that had policies in place to vaccinate infants whose mothers' hepatitis B surface antigen status (HBsAg) was positive or unknown during the thimerosal alert (July 1999 through November 1999) was compared with that in March 2000. Results. Before July 1999, 81% of the hospitals representing 84% of reported Wisconsin births routinely offered hepatitis B vaccine to all infants. By March 2000, 50% of hospitals, representing 43% of births, had resumed routine infant hepatitis B vaccination. Physician decision to use a combination Haemophilus influenzae type b hepatitis B vaccine was the most frequently given reason for not reinstituting infant hepatitis B vaccination. During the thimerosal alert, 23% of hospitals did not have policies to vaccinate infants whose mothers were HBsAg-positive and 51% did not have policies to vaccinate infants whose mothers' HBsAg status was unknown. By March 2000, 6% of hospitals still did not have policies to vaccinate infants whose mothers were HBsAg-positive and 24% did not have policies to vaccinate infants whose mothers' HBsAg status was unknown. Conclusion. The AAP/USPHS joint statement on thimerosal in vaccines has resulted in a 38% decrease in the number of hospitals routinely offering infants hepatitis B vaccine. Although thimerosal-free hepatitis B vaccine is now available, some hospitals still do not have appropriate policies in place for vaccinating infants whose mothers' HBsAg status is positive or unknown. In the future, policymakers should include anticipated consequences that may result from changes in immunization policy in their recommendations.

We document the second known case of Cache Valley virus disease in a human. Cache Valley virus disease is rarely diagnosed in North America, in part because laboratories rarely test for it. Its true incidence, effect on public health, and full clinical spectrum remain to be determined.

During March and April 1993, a massive outbreak of Cryptosporidium infection resulted from contamination of the public water supply in Milwaukee, Wisconsin. The health impact of this outbreak in HIV-infected persons was unknown but was perceived as severe. We surveyed HIV-infected persons who resided in the greater Milwaukee area to examine the acute health impact of cryptosporidiosis on this population. Data from a random-digit dialing survey in the general population residing in the same area were used for comparison. The attack rate of watery diarrhea suggestive of cryptosporidiosis was lower in HIV-infected persons (32%) than in the general population (51%). There was no significant difference in attack rate in HIV-infected persons based on CD4+ T-lymphocyte count. In persons with watery diarrhea, HIV-infected persons were more likely to experience cough (42%), fever (52%), and dehydration (55%). In HIV-infected persons with watery diarrhea, persons with CD4+ T-lymphocyte counts

During the spring of 1993 an estimated 403000 residents of the greater Milwaukee, Wisconsin area experienced gastrointestinal illness due to infection with the parasite Cryptosporidium parvum following contamination of the city's water supply. To define the clinical, laboratory and epidemiologic features of outbreak-associated cryptosporidiosis in children, medical and laboratory records for all children submitting stool samples to the microbiology laboratory of the Children's Hospital of Wisconsin between 7 April and 13 May 1993 were reviewed retrospectively. Interviews with parents were also conducted to obtain additional clinical history. Cryptosporidium, as the sole pathogen, was identified in stools from 49 (23%) of the 209 children enrolled in the study. Children with laboratory-confirmed cryptosporidiosis were more likely to live in areas of Milwaukee supplied with contaminated water (RR=1·92, CI=1·19–3·09), to be tested later in their illness (PP=0·01), to have an underlying disease that altered their immune status (RR=2·78, CI=1·60–4·84), and to be older than 1 year of age (RR=2·02, CI=1·13–3·60). Clinical illness in these patients was more prolonged and associated with weight loss and abdominal cramps compared with Cryptosporidium-negative children. In the context of this massive waterborne outbreak relatively few children had documented infection with Cryptosporidium. If many children who tested negative for the parasite were truly infected, as the epidemiologic data suggest, existing laboratory tests for Cryptosporidium were insensitive, particularly early in the course of illness.

Objective We describe the impact of the 1993 waterborne cryptosporidiosis outbreak on metropolitan Milwaukee child care homes and centers. Methods Information on outbreak-related illness and changes in policies and practices was collected from directors of 117 facilities. Stool specimens from 129 diapered children from 11 centers were screened for Cryptosporidium. Results Most (74%) facility directors reported children or staff with diarrhea during the outbreak; however, only 4 (3.4%) facilities closed because of illness among staff or children. During the outbreak child care homes were less likely to exclude children with diarrhea than were child care centers. Among diapered children attending centers the Cryptosporidium prevalence was 30%; 29% of infected children had no history of diarrhea associated with the Milwaukee outbreak. Conclusions Facilities continued to operate during the outbreak despite considerable illness among children and staff. The news media were effective means for providing public health information to child care facilities. Although secondary transmission undoubtedly took place in child care facilities, the presence of children with asymptomatic Cryptosporidium infections did not result in an increased risk of diarrhea in infant and toddler rooms.

Pertussis remains difficult to control. Imperfect sensitivity of diagnostic tests and lack of specific guidance regarding interpretation of negative test results among patients with compatible symptoms may contribute to its spread. In this study, we examined whether additional pertussis cases could be identified if persons with negative pertussis test results were routinely investigated. We conducted interviews among 250 subjects aged ≤18 years with pertussis polymerase chain reaction (PCR) results reported from 2 reference laboratories in Wisconsin during July-September 2010 to determine whether their illnesses met the Centers for Disease Control and Prevention's clinical case definition (CCD) for pertussis. PCR validity measures were calculated using the CCD as the standard for pertussis disease. Two Bayesian latent class models were used to adjust the validity measures for pertussis detectable by 1) culture alone and 2) culture and/or more sensitive measures such as serology. Among 190 PCR-negative subjects, 54 (28%) had illnesses meeting the CCD. In adjusted analyses, PCR sensitivity and the negative predictive value were 1) 94% and 99% and 2) 43% and 87% in the 2 types of models, respectively. The models suggested that public health follow-up of reported pertussis patients with PCR-negative results leads to the detection of more true pertussis cases than follow-up of PCR-positive persons alone. The results also suggest a need for a more specific pertussis CCD.

Objective. To assess the extent to which hospitals in a midwestern state with low acute hepatitis B virus (HBV) morbidity offered hepatitis B (Hep B) vaccine to all infants, whether offering infants Hep B vaccine was associated with hospital geographic location or size, as measured by the number of births, and how hospital staff resolved key programmatic issues. Methods. The managers of hospital newborn nurseries (N = 110) were surveyed by mail. The written response rate was 72%; all of the nonresponders were interviewed by telephone. The outcome measured was the number of hospitals offering Hep B vaccine to all infants by geographic region and hospital size. Results. Sixty-five percent of the hospitals routinely offered Hep B vaccine to all infants; these hospitals accounted for 80% of reported Wisconsin births. In univariate analysis, the decision to offer infants Hep B vaccine was associated with both hospital size and hospital location. After controlling for size, hospitals in the northeastern region were eight times more likely (relative risk, 8.21; 95% confidence interval, 1.30, 51.79) to offer infants Hep B vaccine than hospitals in the southeastern (referent) region. Regional differences in reported rates of acute HBV infection do not explain this finding, because morbidity in the northeastern region (1 per 100 000) is among the lowest in Wisconsin. Although more than 80% of hospitals with Hep B vaccination programs required written informed consent for vaccination, had standing orders for administering Hep B vaccine to infants whose mothers' hepatitis B surface antigen (HBsAg) test results were known, and had mechanisms to notify the infants' physicians that the infants had been vaccinated, only 38% had standing orders for testing mothers whose HBsAg test results were unknown. Conclusions. Hospitals are not necessarily deterred from implementing infant Hep B vaccination programs by low community HBV morbidity. Hospitals should develop policies to assure that parturient women with unknown HBsAg status are screened and their infants are appropriately treated.

We evaluated risk factors for recurrent Chlamydia trachomatis infections in women.We used a retrospective cohort design to examine predictors of recurrent infection in the 38,866 female residents of Wisconsin whose first reported C. trachomatis infection occurred between 1985 and 1989.Young age at first reported infection was the strongest predictor of recurrent C. trachomatis infection, after adjustment for covariates. Adolescents15 years old had an eightfold increased risk, those 15 to 19 years old had a fivefold increased risk, and women 20 to 29 years old had a twofold increased risk of recurrent C. trachomatis infection, compared with that among women 30 to 44 years old. In 54% of those aged15 at initial infection and 30% of those aged 15 to 19, recurrence developed. Other characteristics associated with recurrence included black race, residence in Milwaukee County, coinfection with gonorrhea, and past sexually transmitted diseases; receiving care in a family-planning clinic appeared protective.Implementation of strategies to reduce the markedly elevated risk of recurrent chlamydia infections is urgently needed in female adolescents.

Background: Blastomycosis is a potentially fatal infection caused by the fungus Blastomyces dermatitidis. During January 1 through March 5, 2006, twenty-one laboratory confirmed cases of blastomycosis were reported among residents of an endemic area in north-central Wisconsin; a striking increase compared with previous years. The objective of the study was to determine if an observed increase in blastomycosis among residents of an urban area in north-central Wisconsin was caused by a point-source exposure and to identify its source. Methods: We compared epidemiologic features, and signs and symptoms of B. dermatitidis infection among 46 historic (1999–2005) and 21 possible outbreak case patients. In addition, a case-control study was conducted to compare risk factors of the outbreak case patients with those of 64 age, gender, and geographically-matched control subjects. We conducted site inspections, evaluated meteorological data, genetically compared outbreak and non-outbreak isolates, and attempted environmental detection of B. dermatitidis using polymerase chain reaction, in vitro isolation, and in vivo isolation by tail vein injection of mice. Results: The unusual risk profile of this outbreak included: residence within non-rural city limits with limited time spent outdoors and an equivalent gender ratio and young median age among case patients consistent with common source rather than unrelated exposures. Thirteen of fourteen outbreak-associated clinical isolates of B. dermatitidis clustered in the same genetic group by PCR-RFLP analysis. Inspections near the cluster center suggested a yard waste collection site as the probable exposure source. B. dermatitidis nucleic acid was detected in one of 19 environmental samples. Environmental and meteorological conditions and material management practices were identified that may have facilitated growth and dispersal of B. dermatitidis conidia near this residential area. Conclusions: Results of our investigation of this large non-rural outbreak of blastomycosis suggest bioaerosol hazards may exist near yard waste collection and composting facilities, especially where pine tree litter is present, in B. dermatitidis endemic areas.

Background. Studies in developing countries have shown that children with measles have low serum retinol concentrations and that lower retinol levels are associated with measles-related mortality. Vitamin A therapy has been shown to reduce mortality among African children with acute measles. Objectives. To determine whether serum retinol concentration is low among children with measles in the United States and to determine whether retinol concentration is associated with illness severity. Setting. Pediatric referral hospital and clinic in Milwaukee, WI, during the measles outbreak of 1989-1990. Patients. One hundred fourteen patients ≤5 years of age evaluated for serologically confirmed measles with serum obtained within 5 days following rash onset. Methods. Serum retinol concentration was determined by high-performance liquid chromatography. Clinical data were collected by hospital record review. A modified Pediatric Risk of Mortality (PRISM) score was used to assess physiologic instability as a measure of illness severity. Results. Retinol concentrations ranged from 0.25 to 1.18 µmol/L (median 0.58 µmol/L); 82 (72%) patients had low retinol concentration (≤0.70 µmol/L). Median retinol concentrations were lower among hospitalized patients (0.56 vs 0.70, P = .006) and patients with pneumonia (0.52 vs 0.64, P = .02) but higher among children with otitis media (0.63 vs 0.54, P = .01). Higher modified PRISM scores, reflecting greater physiologic instability, were associated with lower retinol concentration (β coefficient -.0147, P = .025). In multivariate analysis, higher modified PRISM scores were associated with lower retinol concentration (β coefficient -.0144, P = .025) even after controlling for hospitalization, presence of complications, race, age, receipt of Aid to Families With Dependent Children, gender, and interval from rash onset until serum was collected. Conclusions. Among these children with measles in an urban United States community, retinol concentrations were depressed, and the degree of depression was associated with illness severity. Vitamin A therapy should be considered for children with measles in the United States who require hospitalization.

The effectiveness of selective screening for control of Chlamydia trachomatis is unknown. In 1986, a statewide screening program began in family planning clinics in Wisconsin after the prevalence of infection among women was found to be 10.7% in four nonurban clinics and 13.7% in an urban Milwaukee clinic. In 1990, endocervical specimens were obtained from 1,757 women attending these same clinics; 5.2% of women in the non-urban clinics and 6.9% in the Milwaukee clinic tested positive for C. trachomatis. Prevalence of infection had decreased similarly (by 53% overall) in both high- and low-risk groups in all five clinics. Although reported condom use increased from 16% to 31%, most other demographic and behavioral risk factors for infection did not significantly change; in contrast, the prevalence of clinical signs of infection decreased. The percentage of infections identified by selective screening criteria decreased from 77% to 55%. Selective screening and attendant activities, as well as an increase in condom use, were associated with a decrease in prevalence of C. trachomatis infection in this population.

OBJECTIVES. Nationwide, human immunodeficiency virus type 1 (HIV-1) seroprevalence surveys using dried neonatal blood specimens are critical to estimating HIV-1 seroprevalence among childbearing women. However, the noninclusion of blood specimens deemed "quantity not sufficient" (QNS) for HIV-1 antibody testing potentially introduces bias. In Wisconsin beginning in 1990, we modified the survey protocol to reduce QNS rates and assess bias introduced by QNS specimens. METHODS. The HIV-1 antibody assay was modified to use four 1/8-in blood spots when a single 1/4-in blood spot could not be obtained. Both methods obtain identical blood volumes for testing. RESULTS. During a 27-month period, 7396 (4.8%) of 154,683 specimens were deemed QNS using 1/4-in blood spots. Of these, 6590 (89%) were of sufficient quantity to be tested using four 1/8-in blood spots; 6 (0.09%) specimens tested with 1/8-in blood spots were HIV-1 Western blot assay positive compared with 44 (0.03%) of 147,287 1/4-in specimens (odds ratio = 3.0; 95% confidence interval = 1.2, 7.4). CONCLUSIONS. Because noninclusion of QNS specimens potentially introduces bias, incorporating the results of HIV-1 antibody testing of QNS specimens using four 1/8-in blood spots can improve the accuracy of HIV-1 seroprevalence estimates in these serologic surveys.

Giardia lamblia is the most commonly reported enteric pathogen in Wisconsin. Since giardiasis became a notifiable disease, the annual number of cases reported to the Wisconsin Division of Health has increased more than 20-fold, from 2.2 cases per 100,000 population in 1981 to 49.1 cases per 100,000 population in 1988. To better understand the nature of this increasing trend, we reviewed records of G. lamblia infections reported to the Wisconsin Division of Health from 1981 to 1988. Although the increase in reported cases was a general phenomenon that was not limited to a few high-risk groups, the highest annual incidence and greatest increase occurred in children 1–4 years old; 34% of the cases in this age group occurred in children who attended day care centers. A remarkably consistent late summer (August) increase was observed across all demographic and risk groups, suggesting that G. lamblia may be more common in the environment during late summer, or that risk factors for transmission may differ during these months. Additional studies are needed to further explain the increasing incidence and seasonal nature of reported giardiasis and to identify opportunities for prevention.

Background. Escherichia coli O157:H7 infection often causes hemorrhagic colitis and hemolytic uremic syndrome. Methods. In 2006, the Wisconsin Division of Public Health and the Wisconsin State Laboratory of Hygiene, in cooperation with other local, state, and federal partners, investigated an outbreak of E. coli O157: H7 infection. Results. In September 2006, the Wisconsin Division of Public Health and the Wisconsin State Laboratory of Hygiene were able to link geographically dispersed E. coli O157: H7 isolates recovered from the stool samples of ill persons, all of which had the same pulsed-field gel electrophoresis pattern (i.e outbreak pattern). Investigators conducted a case-control study with control subjects (n = 86) matched to case patients (n = 49) by age, sex, and residential location. All case patients' onsets of illness occurred during the period from 20 August through 14 September 2006. Illness was associated with spinach consumption (matched odds ratio, 82.1; 95% confidence interval, 14.7 to >1000). Of the 49 case patients, 26 (53%) recalled eating brand A spinach. On multibrand analysis, only brand A was associated with illness (undefined matched odds ratio; 95% confidence interval, 6.8-infinity). Wisconsin's agriculture laboratory isolated E. coli O157:H7 with the outbreak pattern from spinach in 2 brand A packages, both produced on 15 August 2006. Conclusions. The rapid multijurisdictional epidemiologic and laboratory response, including timely pulsed-field gel electrophoresis pattern analysis and PulseNet posting, facilitated prompt voluntary recall of brand A spinach.

The epidemiologic features and clinical spectrum of pertussis in the elderly are poorly understood. In October 1985, the Wisconsin Division of Health investigated an outbreak of pertussis in residents of a nursing home in rural Wisconsin. Clinical information and nasopharyngeal swab and acute- and convalescent-phase serum specimens were obtained from all consenting residents and employees. Of 105 residents, 38 (36.2%) were seropositive, including four who were culture-positive for Bordetella pertussis. Culture-positive residents (age range, 52-81 years) had cough lasting 43-54 days. Three of these residents had paroxysmal cough, and all four had cough that interrupted sleep; none of the residents had cough with apnea or vomiting, and all recovered without sequelae. Of six seropositive residents with clinical pertussis, five lived on the south wing of the facility. Of 104 employees, 8 (7.7%) were seropositive, but none were culture-positive for B. pertussis. The higher attack rate for residents and the clustering of clinical cases were consistent with ongoing transmission within the nursing home.

Hospitals and nursing homes were surveyed in 2006 to obtain information on employee influenza vaccination programs and baseline rates of influenza vaccination among employees. Results were used to make recommendations for improving employees' 2007 influenza vaccination rates. Facilities should continue to provide convenient and free vaccination programs, offer education to promote vaccination, and use signed declination forms.

On March 25, 2015, the Wisconsin Division of Public Health was notified of a possible respiratory syncytial virus (RSV) infection outbreak among infants hospitalized in a neonatal intensive care unit (NICU). On March 23, the index patient (neonate A), aged 3 days, had feeding intolerance and apnea. A nasopharyngeal swab specimen collected from neonate A was tested using a single-manufacturer rapid RSV antigen detection test (RRADT) at the hospital laboratory; the result was positive. The following day, because of concern about the possibility of more widespread RSV infection, RRADT was used to test nasopharyngeal swab specimens from neonate B, aged 1 month, who had resided in a different hospital room in the NICU and had developed an increased oxygen requirement, apnea, and poor feeding that day, as well as from two asymptomatic neonates who were hospitalized in the same room with neonate A; all three were positive. Later that day, nasopharyngeal swab specimens from the remaining 16 asymptomatic NICU patients were tested using the same RRADT; seven tests were positive, making a total of 11 positives. All 20 RRADTs were performed at the hospital laboratory.

THE PRIVACY RULE, as part of the Health Insurance Portability and Accountability Act, was implemented in 2003 as a response to public concern over potential abuses of private health information. Although the Privacy Rule was not intended to place limits on clinical research, its complexity has caused much confusion throughout the academic medicine and research communities. Many clinical and translational researchers have created clinical databases or human tissue banks to facilitate future research. Maintenance of such databases is considered a research activity under the Privacy Rule, and researchers are, therefore, subject to its regulations. We present a novel Internet-based method to generate and maintain a neurooncology patient registry and human tissue bank. Through our web site, we secure both Health Insurance Portability and Accountability Act research authorization and informed consent, enabling us to contact the treating physician for clinical data and pathological specimens. Considering the importance of continued use of clinical databases and tissue banks in the genetic era of medicine, our method offers one way for researchers to adapt to the changing world of clinical research.

The reported incidence of pertussis is increasing, especially among the adolescent population. Current outbreak management strategies include investigating cases, contact follow-up, diagnostic testing, and antibiotic prophylaxis and treatment. The cost of these methods is substantial and can be attributed to the mobilization within public health departments to control the outbreaks.Through an extensive review of the literature, the clinical and economic effects of pertussis outbreaks in various nonhousehold settings are discussed.The reported incidence of pertussis among adolescents and adults in the United States since the early 1980s continues to rise. The challenges of preventing and controlling pertussis outbreaks involve diagnosing pertussis in a timely, accurate, and standardized fashion and understanding the true burden of disease in different age and socioeconomic groups. The economic effects of pertussis have been demonstrated to be significant to individuals and communities, both locally and globally. Costs associated with pertussis often include diagnostic testing, hospitalization, emergency and/or medical office visits, antibiotic and symptomatic treatment, lost work days, and other reductions in productivity. In outbreak settings, increased surveillance, antibiotic prophylaxis, isolation of infected cases, and enhanced communication and education add to the economic burden of this disease. The potential opportunity to apply the use of pertussis booster vaccination to these populations, particularly among adolescents, likely would reduce the occurrence of pertussis and minimize the clinical and economic repercussions of pertussis outbreaks.In the near future, it is anticipated that evaluating the effects of a licensed acellular pertussis booster vaccine in personsor =10 years of age will become routine in pertussis prevention and outbreak-control activities.

BACKGROUND Although rapid diagnosis of Lyme disease is essential for effective treatment, there is concern about inappropriate testing. We conducted a prospective, cross-sectional survey of clinicians to assess the use and appropriateness of Lyme disease serologic tests (LDSTs). METHODS LDSTs performed at 2 large Wisconsin reference laboratories were systematically sampled for 12 consecutive months. A standardized questionnaire was used to gather data about the submitting clinician and the patient tested. Tests were categorized as appropriate, inappropriate, or discretionary, and associations were assessed using logistic regression analysis. A test was defined as inappropriate if the patient was asymptomatic, had erythema migrans, or was treated empirically, or if the test was ordered as a test of cure. RESULTS We surveyed 303 clinicians regarding 356 LDSTs: 72 tests (20%) were appropriate, 95 (27%) were inappropriate, and 189 (53%) were discretionary. Tests were more likely to be inappropriate if they were ordered by an emergency or urgent care physician compared with other specialists (adjusted odds ratio [AOR] 5.2, 95% confidence interval [CI], 1.3–20.6), or if preceded by a known tick bite (AOR 6.8, 95% CI, 2.6–17.6). The patient rather than the clinician requested 26% of tests, which were more likely to be inappropriate than clinician-requested tests (crude odds ratio [COR] 5.8, 95% CI, 2.5–13.6). Tests were more likely to be patient-requested if they were ordered by an internist (AOR 2.6, 95% CI, 1.4–4.8) or if the patient was ≥40 years old (AOR 2.2, 95% CI, 1.3–3.9). CONCLUSIONS Many LDSTs are ordered inappropriately, often influenced by patient demand. Education of clinicians and patients about testing indications and contraindications is needed to reduce the number of inappropriate LDSTs.

During May and June 2003, an outbreak of febrile illness with vesiculopustular eruptions occurred among persons in the midwestern United States who had had contact with ill pet prairie dogs obtained through a common distributor. Zoonotic transmission of a bacterial or viral pathogen was suspected.We reviewed medical records, conducted interviews and examinations, and collected blood and tissue samples for analysis from 11 patients and one prairie dog. Histopathological and electron-microscopical examinations, microbiologic cultures, and molecular assays were performed to identify the etiologic agent.The initial Wisconsin cases evaluated in this outbreak occurred in five males and six females ranging in age from 3 to 43 years. All patients reported having direct contact with ill prairie dogs before experiencing a febrile illness with skin eruptions. We found immunohistochemical or ultrastructural evidence of poxvirus infection in skin-lesion tissue from four patients. Monkeypox virus was recovered in cell cultures of seven samples from patients and from the prairie dog. The virus was identified by detection of monkeypox-specific DNA sequences in tissues or isolates from six patients and the prairie dog. Epidemiologic investigation suggested that the prairie dogs had been exposed to at least one species of rodent recently imported into the United States from West Africa.Our investigation documents the isolation and identification of monkeypox virus from humans in the Western Hemisphere. Infection of humans was associated with direct contact with ill prairie dogs that were being kept or sold as pets.

We conducted a case-control study in Wisconsin to determine whether some patients have long-term adverse health outcomes after antibiotic treatment for human granulocytic ehrlichiosis (HGE). A standardized health status questionnaire was administered to patients and controls matched by age group and sex. Consenting patients provided blood samples for serologic testing. Among the 85 previously treated patients, the median interval since onset of illness was 24 months. Compared with 102 controls, patients were more likely to report recurrent or continuous fevers, chills, fatigue, and sweats. Patients had lower health status scores than controls for bodily pain and health relative to 1 year earlier, but there was no significant difference in physical functioning, role limitations, general health, or vitality measures. The HGE antibody titer remained elevated in one patient; two had elevated aspartate aminotransferase levels. HGE may cause a postinfectious syndrome characterized by constitutional symptoms without functional disability or serologic evidence of persistent infection. uman granulocytic ehrlichiosis (HGE) is a recently identified tickborne infectious disease caused by a bacterium species of the genus Ehrlichia that preferentially infects granular leukocytes (1). HGE was first described in the United States in 1994 in residents of Wisconsin and Minnesota (2). During 1986 through 1997, 449 HGE cases were identified in the United States, mostly in the Northeast and Upper Midwest, despite limited reporting requirements (3). The primary vector of HGE is Ixodes scapularis (4), commonly known as the deer tick, which is also the vector of Lyme disease. Onset of clinical signs and symptoms of acute HGE typically follow a 5- to 10-day incubation period. The acute illness is nonspecific and often includes fever, chills, headache, and myalgia. Abnormal laboratory findings may include leukopenia, thrombocytopenia, and mildly elevated liver enzymes (5). Seventeen percent to 56% of patients with HGE are hospitalized, and the case-fatality rate may be 0.7%-4.9% (3,5). Patients treated with doxycycline usually defervesce within 24 to 48 hours (5). The acute phase of HGE is well characterized. The potential for persistent infection has been suggested but has not been evaluated. We conducted an exploratory case-control study of patients previously treated for HGE to assess health status, symptoms, and changes in serologic status. Methods

Background Bronchoscopy-related transmission of Mycobacterium tuberculosis is rarely reported. In August 1999, five M tuberculosis-positive bronchial washing culture findings were noted in patients who underwent bronchoscopy in July in a hospital that reported only eight M tuberculosis-positive culture findings from 1995 to 1998, prompting further investigation. Methods A case was defined as a M tuberculosis-positive culture finding from specimens obtained from patients who underwent bronchoscopy during January to August of 1999. Bronchoscopy and laboratory records, procedures, and practices were reviewed. M tuberculosis isolates were compared using restriction fragment length polymorphism (RFLP) analysis. Results During July 1999, 19 bronchoscopic procedures were performed in 19 patients. Bronchial washing specimens for mycobacterial culture were obtained from 18 patients. Ten cases were identified. Two case patients, including the index patient, had signs and symptoms of active tuberculosis prior to bronchoscopy. M tuberculosis infections developed in two more case patients despite starting a standard four-drug antituberculous regimen within 3 weeks after bronchoscopy. Six case patients had positive culture findings but no evidence of infection. All M tuberculosis isolates were antituberculosis-drug susceptible, and all but one were indistinguishable by RFLP analysis. Three bronchoscopes were used during the outbreak period; one bronchoscope was used in 9 of the 10 case patients (relative risk, 8.1; 95% confidence interval, 1.3 to 52). A hole was discovered in the sheath of this bronchoscope. Leak testing, a critical step in bronchoscope reprocessing, was not routinely performed at this institution. Conclusions M tuberculosis contamination of the bronchoscope occurred during the index patient's procedure. The hole in the sheath provided access to a space that was difficult to mechanically clean and chemically disinfect. The reprocessing recommendations of bronchoscope manufacturers, including leak testing after each use, should be closely followed.

PURPOSE: The study assesses the completeness of tuberculosis disease (TB) reporting in Wisconsin and evaluates the usefulness of laboratory and hospital discharge data as supplemental case ascertainment sources. METHODS: All 1995 hospital billing records with a discharge diagnosis code of TB (ICD-9 CM 010–018) were retrieved and matched to Wisconsin TB registry records. A hospital discharge summary was obtained for persons not in the registry to verify the TB diagnosis. A list of persons with specimens from which Mycobacterium tuberculosis was isolated in 1995 was requested from all Wisconsin and pertinent out-of-state laboratories and compared with the TB registry. RESULTS: Of the 88 TB cases identified from laboratory lists, one (1.1%) was unreported. Of the 51 TB cases identified from hospital discharge records, one (2.0%) was unreported. The positive predictive values of laboratory and hospital discharge data for a verified TB case were 98.9% and 38.3%, respectively. CONCLUSIONS: In Wisconsin during 1995, nearly all TB cases among hospitalized persons or persons from whom M. tuberculosis was isolated were reported. Most persons having a TB diagnosis code did not have TB.

Following the 1993 Milwaukee cryptosporidiosis outbreak, we examined data from eight sources available during the time of the outbreak. Although there was a remarkable temporal correspondence of surveillance peaks, the most timely data involved use of systems in which personnel with existing close ties to public health programmes perceived the importance of providing information despite workload constraints associated with an outbreak. During the investigation, surveillance systems which could be easily linked with laboratory data, were flexible in adding new variables, and which demonstrated low baseline variability were most useful. Geographically fixed nursing home residents served as an ideal population with non-confounded exposures. Use of surrogate measurements of morbidity can trigger worthwhile public health responses in advance of laboratory-confirmed diagnosis and help reduce total morbidity associated with an outbreak. This report describes the relative strengths and weaknesses of these surveillance methods for community-wide waterborne illness detection and their application in outbreak decision making.

OBJECTIVES: This study estimated the magnitude of cryptosporidiosis-associated mortality in the Milwaukee vicinity for 2 years following a massive waterborne outbreak. METHODS: Death certificates were reviewed. RESULTS: During approximately 2 years before the outbreak, cryptosporidiosis was listed as an underlying or contributing cause of death on the death certificates of four Milwaukee-vicinity residents. In the approximately 2 years after the outbreak, this number was 54, of whom 85% had acquired immunodeficiency syndrome (AIDS) listed as the underlying cause of death. In the first 6 months after the outbreak, the number of death certificates indicating AIDS, but not cryptosporidiosis, as a cause of death was 19 (95% confidence interval = 12.26) higher than preoutbreak trends would have predicted. CONCLUSIONS: Waterborne outbreaks of cryptosporidium infection can result in significant mortality, particularly among immunocompromised populations. Any discussion of policies to ensure safe drinking water must consider the potential fatal consequences of waterborne cryptosporidiosis among immunocompromised populations.

Consumers in the United States continue to eat raw or undercooked foods of animal origin despite public health warnings following several well-publicized outbreaks. We investigated an outbreak of Salmonella serotype Typhimurium infection in 158 patients in Wisconsin during the 1994 Christmas holiday period. To determine the vehicle and source of the outbreak, we conducted cohort and case-control studies, and environmental investigations in butcher shop A. Eating raw ground beef purchased from butcher shop A was the only item significantly associated with illness [cohort study: relative risk=5·8, 95% confidence interval (CI)=1·5–21·8; case control study: odds ratio=46·2, 95% CI=3·8–2751]. Inadequate cleaning and sanitization of the meat grinder in butcher shop A likely resulted in sustained contamination of ground beef during an 8-day interval. Consumer education, coupled with hazard reduction efforts at multiple stages in the food processing chain, will continue to play an important role in the control of foodborne illness.