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Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.

The search for the cause of the large outbreak of severe pneumonia that affected attendees of a convention of war veterans in Philadelphia in 1976 was complicated by a number of factors. The 2-10 day incubation period meant that cases were dispersed across Pennsylvania at time of onset, and matters were further complicated by the lack of a centralised record of attendance of the convention. Known methods for culture, serology, tissue staining, and toxicology gave negative results. The reliance on a clinical case definition, and the need to coordinate local, state, and federal jurisdictions both hindered efforts. Intense public scrutiny, anxiety, and promotion of implausible theories, researchers' memories of prior unsolved major investigations, and the inherent difficulty of documenting airborne spread also had an impact. The novel bacterial agent Legionella pneumophila was identified and its spread defined by persistent application of basic epidemiological and laboratory principles, including the willingness to re-examine one's assumptions.

In 1996, an Ad Hoc Committee on Health Research Relating to Future Intervention Options (formed under the auspices of the World Health Organization) described a model for setting priorities in research funding. This model, however, as presented in the Ad Hoc Committee's report entitled Investing in health research and development, fails in the following important situations: (i) when there is a health problem about which little is known; (ii) when current control measures are unsustainable; (iii) when there are complex risk factors, like "social factors", which affect many different diseases; and (iv) when the disease burden and resources for control vary greatly from one place to another. In situations of uncertainty or complexity, a method of priority-setting that emphasizes certainty and simplicity may actually mislead. A transparent, matrix-based process--illustrated with an example of priority-setting for malaria--may permit such uncertainty and complexity to be better taken into account in setting health research priorities.

An explosive, common-source outbreak of pneumonia caused by a previously unrecognized bacterium affected primarily persons attending an American Legion convention in Philadelphia in July, 1976. Twenty-nine of 182 cases were fatal. Spread of the bacterium appeared to be air borne. The source of the bacterium was not found, but epidemiologic analysis suggested that exposure may have occurred in the lobby of the headquarters hotel or in the area immediately surrounding the hotel. Person-to-person spread seemed not to have occurred. Many hotel employees appeared to be immune, suggesting that the agent may have been present in the vicinity, perhaps intermittently, for two or more years.

The efficacy of pneumococcal vaccine in groups of patients in the United States at high risk for pneumococcal disease was estimated by comparing distributions of serotypes of Streptococcus pneumoniae isolated from vaccinated and unvaccinated persons. Between May 1978 and March 1984, 187 blood isolates and 62 cerebrospinal fluid isolates from vaccinated patients, and 1447 blood isolates and 191 cerebrospinal fluid isolates from unvaccinated patients were serotyped at the Centers for Disease Control. The study did not include patients who were less than 2 years old or who had Hodgkin's disease, multiple myeloma, or immunoglobulin deficiency. In patients with bacteremic disease, the overall efficacy of pneumococcal vaccine was estimated at 64% (95% confidence limits, 47% to 76%); efficacy did not differ significantly with age. In persons over 65 years of age with diabetes mellitus, chronic heart disease, pulmonary disease, or no underlying illnesses, efficacy was 61% (95% confidence limits, 1% to 85%). These findings support the use of pneumococcal vaccine in selected populations in the United States.

Interviews conducted during outbreaks of group A meningococcal disease in skid row communities suggested that heavy alcohol use was associated with increased risk of disease. Frequent moving within skid row and from one skid row to another was characteristic of a subpopulation with increased risk of disease and may have facilitated spread within and between skid rows. The observations discussed herein have important implications for control of communicable diseases in and near skid rows.

To determine the risk factors associated with toxic-shock syndrome (TSS) in menstruating women, we conducted a retrospective telephone study of 52 cases and 52 age-matched and sex-matched controls. Fifty-two cases and 44 controls used tampons (P < 0.02). Moreover, in case-control pairs in which both women used tampons, cases were more likely than controls to use tampons throughout menstruation (42 of 44 vs. 34 of 44, respectively; P < 0.05). There were no significant differences in brand of tampon used, degree of absorbency specified on label, frequency of tampon change, type of contraceptive used, frequency of sexual intercourse, or sexual intercourse during menstruation. Fourteen of 44 cases had one or more definite or probable recurrences during a subsequent menstrual period. In a separate study, Staphylococcus aureus was isolated from 62 of 64 women with TSS and from seven of 71 vaginal cultures obtained from healthy controls (P < 0.001).

From March 10 through October 29, 1975, Listeria monocytogenes infection occurred in seven neonates born at a 401-bed general hospital in Greenville, S.C. In the preceding 19 months, there had been only one case. Six of the seven isolates from the infected infants were of serotype JB. Risk of listeriosis in neonates was associated with being born to mothers of low socioeconomic status and being born to mothers who had had vaginitis during pregnancy. Nosocomial transmission of L. monocytogenes appeared unlikely, but the source of the infection is unknown. Of the media used in this study for isolation of L. monocytogenes from mixed cultures, McBride's agar and McBride's agar with nalidixic acid were most useful.

Group C meningococci were isolated during an epidemic of meningococcal meningitis which occurred between January and May 1979 in eastern Upper Volta, an area previously associated with endemic and epidemic group A disease. A total of 539 cases of meningitis, 55 of which were fatal, were reported, giving an attack rate of 517 cases per 100 000 inhabitants. Attack rates were higher for children under 15 years of age. Clinical and bacteriological data suggested that the group C meningococci were sulfonamide-resistant. The last meningococcal epidemic in Upper Volta occurred in 1970 and was nationwide. Epidemic cycles of group A meningococcal meningitis have occurred at 10-15 year intervals in the sub-Saharan region, raising concern that the current increase in activity may presage more wide-spread disease in the next dry season.

To determine the risk of severe Haemophilus influenzae illness among household contacts of patients with H. influenzae meningitis, we studied prospective data obtained in 19 states from January 1, 1977, to June 30, 1978. H. influenzae meningitis was reported in 1403 patients, and 1147 (82 per cent) of the exposed families were investigated for the occurrence of H. influenzae disease within 30 days after its onset in the index patient. During this interval, nine of 1687 household contacts (0.5 per cent) under the age of six years had systemic disease confirmed to be caused by H. influenzae Type b. The risk in children less than one year of age was 6 per cent, and the risk in those less than four years of age was 2.1 per cent. None of 2624 contacts above the age of five was affected. In the 30 days after onset of meningitis, the risk of this infection alone, aside from other types of serious H. influenzae disease, is 585 times greater in household contacts than the age-adjusted risk in the general population. The risk of H. influenzae disease in household contacts under six years of age is similar to the risk of secondary meningococcal disease in all household contacts--indicating a need for effective antimicrobial prophylaxis.

Between June 18 and July 9, 1979, Legionnaires' disease (LD) developed in 13 persons who had visited a hotel complex in Wisconsin. All had visited the part of the hotel that contains the restaurants and meeting rooms (building A). Legionnaires' disease occurred in 1% who had been exclusively in the meeting rooms and in 0.1% who had eaten only at the hotel restaurants. Furthermore, 1.5% exposed to meeting room 1 and none of those exposed only to the other meeting rooms had LD. Legionella pneumophila was isolated from water in the cooling tower on top of building A. Located within 5 m downwind of the cooling-tower exhaust, a chimney with an open damper allowed cooling-tower exhaust (as demonstrated by air tracer studies) to enter meeting room 1 via the fireplace. Although cases did not occur after the cooling-tower water was treated by continuous hyperchlorination and the chimney was sealed, a seven-day lag occurred between treatment and elimination of the organism from the tower water.

Several lines of evidence have been examined in attempts to implicate potable water as a source for legionellosis. Success has been mixed. The strongest evidence has been the similarity of strains recovered from patients and from potable water and the cessation of outbreaks following institution of measures to eradicate Legionella from potable water systems. Epidemiologic efforts to identify the effective mode of exposure to water (e.g. ingestion) have been remarkably unsuccessful. Although L pneumophila can clearly be acquired on occasion from potable water, the proportion of cases traceable to this source is unknown, as is the role of potable water as a source of infection by other Legionellae. Hyperchlorination, raising hot water temperatures to greater than 55 degrees C, and replacing rubber gaskets are useful methods for controlling outbreaks of legionellosis traced to potable water systems but are not yet justified as routine preventative methods in the absence of such an outbreak.

To determine the risk of severe secondary illness in household contacts of patients with Haemophilus influenzae meningitis, telephone interviews were conducted with contacts of patients with reported cases. Four probable or proved secondary cases of severe disease were identified for a secondary attack rate of 0.4%. The secondary attack rate for household contacts of patients 2 years of age and younger was 4.9%. Until safe, effective prophylactic measures become available, physicians should explain to parents that any person who becomes ill in the month after a household case of H influenzae meningitis should be brought to the attention of a physician for appropriate evaluation and treatment.

During 1971-77 the incidence of bacterial meningitis among Alaskan Eskimos was 84.4 cases per 100 000 population per year, which is more than 10 times that for most other U.S. populations. Haemophilus influenzae (HI) accounted for 68% of meningitis cases. The average annual incidence of HI disease per 100 000 children below 5 years of age was 409 for patients with meningitis only and 491 for patients with all systemic HI disease. Children with HI meningitis in Alaska tended to be younger than those in other U.S. populations, 98% of the children affected being less than 18 months of age. The risk for all HI disease was 2.4% during the first year of life. The spectrum of HI disease in Alaska differs from that in other populations in that no patient had epiglottitis and 5% of children had recurrent HI disease. Alaskan newborns and children over 4 years old had HI anticapsular antibody titres that were nearly thrice those for children of similar ages in other U.S. populations (p less than 0.005). The pharyngeal carriage of HI type b (5%) and the rectal carriage of Escherichia coli K100 (2%), an organism with a capsule antigenically similar to HI type b, did not differ from those in other populations. The high incidence of disease almost exclusively in the very young and the early development of antibody in this population suggest that the high rate of disease is due to early exposure to HI type b rather than to an unusual susceptibility to HI type b.

In January 1977 an unsolved outbreak of infection at St. Elizabeth's Hospital (Washington, D.C.) that occurred in 1965 was linked with Legionnaires' disease. The link was made by fluorescent antibody testing with the bacterium isolated from tissues of persons with Legionnaires' disease in the 1976 outbreak in Philadelphia. In July and August 1965, an epidemic of severe respiratory disease characterized by abrupt onset of high fever, weakness, malaise, and nonproductive cough, frequently accompanied by radiographic evidence of pneumonia, affected at least 81 patients at St. Elizabeth's Hospital, a general psychiatric hospital. Fourteen (17%) of the affected patients died. Intensive epidemiologic and laboratory investigations in 1965 did not determine the etiology. The etiologic organism may have become airborne from sites of soil excavation.

Of an estimated 17632 participants of the 1979 Peachtree Road Race, a 10-km race held at 0800 on 4 July in Atlanta, Georgia, 29 had severe heat injury (collapse with altered mental status and rectal temperature of 39.7 degrees C or greater); all 29 recovered promptly. The temperature was 24.0 degrees C; the relative humidity, 83%; and the wet bulb-globe index, 23.0 degrees C. Compared with unaffected participants matched by age, sex, and predicted finishing time, case-runners were taller, had slower best recent 1.6-km and 10-km times, had run less in June, were more likely to achieve 89% of estimated maximum aerobic capacity during the race, less often splashed with water, were more likely to have underestimated their predicted finishing times based on their best recent 10-km times, and were more likely to live in Georgia. Height, sprinkler use, and underestimating predicted finishing times were each significant in the presence of the others. These observations suggest that participants of similar races, particularly those taller than 179.2 cm, should splash with water at least twice and base their predicted finishing times on their best recent 10-km times; adherence to these recommendations by runners at risk should reduce their severe heat injury risk at least 8.1 times.

An outbreak of pharyngitis associated with beta-hemolytic streptococci of Lancefield group G occurred among persons who had attended a convention that was held June 21-24, 1979, in a Florida hotel. Seventy-two (31 per cent) of 231 interviewed conventioneers were ill. Group G streptococci were isolated from the throats of 10 (63 per cent) of 16 persons with pharyngitis and 1 (2 per cent) of 41 persons without pharyngitis (p less than 10(-5)). Antistreptolysin O titers in convalescent-phase serum samples from persons with pharyngitis were significantly higher than those from age-matched controls. Fifty-seven (51 per cent) of 111 conventioneers who had attended a convention luncheon developed pharyngitis compared with 12 (10 per cent) of 117 persons who did not (p less than 10(-9)). All persons who had attended the luncheon and had become ill had eaten a chicken salad served at the luncheon. Their median incubation period was two days. The cook who had prepared this chicken salad developed pharyngitis after the luncheon and had a throat culture positive for group G streptococci. No instances of rheumatic fever were identified and secondary illness in household contracts was rare. This outbreak indicates that group G streptococci can cause outbreaks of pharyngitis similar to those caused by group A streptococci and suggests that penicillin therapy and prophylaxis may not be needed.

An epidemic of disease due to sulfonamide-sensitive serogroup B Neisseria meningitidis occurred in 1975-1976 in southwestern Alabama. Ten cases occurred in a circumscribed area and resulted in an annual attack rate of 20 cases per 100,000 population. None of the cases were in siblings, and none of the patients had had direct contact with each other. A case-control household study suggested that crowding and person-to-person transmission via carriers may have been contributing risk factors. Seven of the patients were from a triracial ethnic group concentrated in a small isolated rural community within the epidemic area. When three additional cases occurred in this community, a program of community-wide prophylaxis was undertaken as an epidemic control measure, and a large portion of the population participated. No serious side effects were reported. Carrier surveys before and after treatment indicated that compliance with the drug regimen was good and that the drug regimen was associated with a sharp reduction in carriage of N. meningitidis. No cases occurred in the treated population in the five months after treatment.

A recipient of a renal homograft developed disseminated infection caused by Mycobacterium kansaii. He initially presented with cellulitis and abscesses in one foot, and was thought to have a pyogenic bacterial infection. The daily administration of prednisone and azathioprine appears to have prevented the typical cell-mediated granulomatous reaction to mycobacterial infection and to have contributed to the patient's atypical inflammatory response. A switch to alternate-day prednisone combined with antimycobacterial medication resulted in rapid healing without rejection of the homograft.

As of 30 September 1979, 1005 confirmed cases of sporadic legionellosis caused by Legionella pneumophila serogroups 1 to 4 in U.S. residents had been reported to the Centers for Disease Control; 19% were fatal. All but 2% of the 1005 cases were associated with pneumonia documented by chest radiograph. About 75% of the cases occurred in June through October. The risk of acquiring sporadic legionellosis was increased among males and persons 50 years or older; persons with renal disease necessitating dialysis or transplantation, with chronic bronchitis or emphysema, with diabetes mellitus, and with cancer (10 selected sites or types); persons who smoke; and persons being treated with immunosuppressive drugs. Increasing age and chronic bronchitis or emphysema were associated with increased risk of death. The sensitivity of culturing L. pneumophila from specimens positive by direct immunofluorescence was estimated to be 45%. The distribution of serogroups 1, 2, 3, and 4 of L. pneumophila in 57 fresh, not previously examined direct fluorescent antibody-positive specimens was 84%, 11%, 4%, and 2%, respectively; all 26 strains isolated from these specimens were of one of these four serogroups.

Two outbreaks of postoperative wound infections due to organisms of the Mycobacterium fortuitum complex (Mycobacterium chelonei and M. fortuitum) occurred among patients who underwent open-heart surgery. In one hospital, 19 of 80 patients who underwent cardiac surgery within a 10-week period developed sternal infection with M. chelonei. In the second hospital, four of nine patients who underwent cardiac surgery within a two-week period developed sternal incisional infection with M. fortuitum. Although epidemiologic investigations uncovered factors that were significantly associated with the development of infection, the source of the infections could not be determined. The results of numerous cultures were negative, but because the investigations were conducted at least two months after many of the patients had had surgery, the materials in use at the time of the surgery were not available for culture. These results emphasize that physicians should be aware that rapidly growing mycobacteria may produce postoperative wound infections.

From 1977 to 1981, 18,642 cases of bacterial meningitis were reported to the Centers for Disease Control. We analyzed data from 27 states with full participation from 1978 through 1981. Hemophilus influenzae was the most frequent cause of bacterial meningitis (48.3%), followed by Neisseria meningitidis (19.6%) and Streptococcus pneumoniae (13.3%). Overall attack rates for males were greater than for females (3.3 v 2.6 cases per 10(5) population per year). Attack rates were highest in children under 1 year of age (76.7 per 10(5) population per year). Case-fatality ratios were highest for gram-negative and miscellaneous causes of bacterial meningitis (33.7%) and lowest for meningitis caused by H influenzae (6.0%). Neisseria meningitidis and S pneumonia meningitis occurred preponderantly during the winter, while H influenzae meningitis had peak activity in the spring and fall. Ampicillin resistance among H influenzae increased from 18.7% in 1978, to 23.9% in 1981. Serogroup B Neisseria meningitidis was the most common serogroup identified during the reporting period (51.1%), followed by serogroup C (22.3%), serogroup Y (5.8%), and serogroup A (4.7%) infections.

Trials of pneumococcal vaccine in healthy young adult populations suggest 75 to 95 per cent type-specific efficacy. Trials have not been done, however, in groups for which pneumococcal vaccine is currently recommended in the United States. To assess efficacy in the immunocompromised groups now receiving the vaccine, we compared serotypes of 35 isolates of Streptococcus pneumoniae isolated from blood or cerebrospinal fluid one month or longer after the patient had received commercially available pneumococcal vaccine with serotypes of 392 isolates from unvaccinated persons surveyed in a study of the nationwide distribution of pneumococcal serotypes. Proportions of infections with vaccine serotypes were unexpectedly similar. An alternative approach to estimation of vaccine efficacy suggested an average efficacy of 36 per cent in persons of all ages. The estimated efficacy was lowest in children two to 10 years old (less than or equal to 0 per cent) and in persons with preexisting diseases that are thought to predispose to pneumococcal disease (less than or equal to 0 per cent), and highest in the group over 10 years old (60 per cent). The possibility that efficacy is low in high-risk, immunocompromised populations makes it important to evaluate clinical efficacy and not just serum antibody responses in such groups.

Bacteria recently recognized as nosocomial pathogens generally fall into three categories: those that grow slowly, those that are fastidious in their nutritional or atmospheric requirements and those that resemble commensals. Each characteristic has contributed to the delay in perceiving their importance. Mycobacterium chelonei and Myco. fortuitum--which grow slowly, although characterized as "rapid-growing" mycobacteria--cause sternal osteomyelitis, pericarditis and endocarditis after cardiac surgery as well as other wound infections after many types of surgery. Myco. chelonei-like organisms have been found to cause "sterile" peritonitis in patients receiving long-term peritoneal dialysis. Legionella pneumophila and L. micdadei are fastidious bacteria that were more difficult to detect because they stain poorly with the Gram method. They cause pneumonia and lung abscess, especially in immunocompromised people. Clostridium difficile is an anaerobe that causes toxin-mediated pseudomembranous colitis in persons given antibiotics that inhibit competing gut bacteria. Chylamydia trachomatis, an intracellular organism that has not been grown in vitro, causes pneumonia and conjunctivitis in young infants who acquire the organism from their mothers at birth. Group JK bacteria cause septicemia in patients whose immune responses have been suppressed and must be distinguished from "diphtheroid" contaminants in blood cultures. Clinicians, microbiologists and epidemiologists must be alert to the characteristics of these organisms that make them easily overlooked and should also anticipate the existence of other bacteria not yet identified.

In January 1980, an outbreak of 138 cases of acute pulmonary disease occurred among employees of a Michigan limestone quarry. The source of exposure was a vessel repair building (relative risk = 5.8) and the time of exposure was January 10 (relative risk = 2.4). Work activities associated with the specific place and time suggested exposure to a pulley which had been stored in a ring-billed gull nesting area as the cause of illness. Histoplasma capsulatum was recovered from the nesting area, the pulley, and the sputum of several patients. Early serologic testing confirmed the diagnosis of acute pulmonary histoplasmosis.

As of April 30, 1980, 83 nosocomial cases of sporadic legionellosis had been reported to the Centers for Disease Control (CDC). In all 83 cases the patients had pneumonia; the median age of the patients was 56.5 years. All but one patient were hospitalized at the time of onset. Of 71 patients for whom the outcome is known, 22 (31 percent) died of causes directly attributed to their infection. Eleven patients had end-stage renal disease, 28 were receiving systemic immunosuppressive medications, 17 had cancer, 12 had chronic bronchitis or emphysema, 29 were smokers, and four had diabetes mellitus. Risks of acquiring nosocomial sporadic legionellosis for patients with these conditions relative to the general United States population = 340, 26, 11, 3.7, 1.9 and 1.3, respectively. These risk factors are similar to those identified for sporadic community-acquired legionellosis and for epidemic nosocomial legionellosis. Methods for preventing nosocomial legionellosis are not known, but comparing Legionella to other water-associated organisms which have been spread from medical devices to cause pneumonia may be fruitful.

Thirty-nine cases of Legionnaires' disease in a 16-month period were identified in visitors to and residents of Bloomington, Indiana. Thirty-five patients had spent at least one night at the Indiana Memorial Union in the 2 weeks before becoming ill. Five of 32 sporadic cases nationwide between 1 January and 31 March 1978 were retrospectively shown to be in persons who had recently visited the Union. The risk of acquiring Legionnaires' disease as a Union visitor was at least 17 times greater than that for Bloomington residents 20 years or older. Employees who had worked at the Union 5 years or longer were more likely to be seropositive than workers in other Bloomington hotels. Legionnaires' disease bacterium was isolated from five environmental sites in Bloomington. A cooling tower may have been involved in disease spread, but it was not the only source. Hypochlorite solution was added to cooling tower water as a precautionary measure; however, one case was confirmed in a man with Union exposure 9 days after hypochlorite treatment had begun.