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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.

Delayed hypersensitivity reactions to skin test antigens prepared from rapidly growing mycobacteria were measured in patients with postoperative wound infections due to Mycobacterium chelonei and M. fortuitum. Sixteen of 19 patients with M. chelonei infection had more than 10 mm of induration to the M. chelonei purified protein derivative antigen (PPD-CG) and were significantly more likely to react to PPD-CG than patients or hospital personnel who had no evidence of infection. All but one patient had more induration with PPD-CG than with the antigen prepared from M. fortuitum (PPD-F). Three of 4 patients with M. fortuitum infection had greater than or equal to 9mm of induration with PPD-F and were significantly more likely than noninfected patients to react to PPD-F. Three of the 4 patients also had at least as much induration with PPD-F as with PPD-CG. In an outbreak of infections due to M. chelonei, testing with PPD-CG may be useful epidemiologically. Although the data are less clearly defined for PPD-F, testing with this antigen may be of value in an outbreak caused by M. fortuitum.

A prospective study of spread of M-type 1, 2, 13, 14, 25 and 60 group A Streptococcus in 64 families in Qalyub, Egypt, in 1972-1974 showed that type-specific serum bactericidal antibody does not protect against pharyngeal acquisition of homologous organisms. The presence of type-specific antibody also does not appear to affect duration of carriage of the organism. Type-specific immunity must be mediated in another way, such as by local antibody or trough prevention of infection (as evidenced by a host response) following acquisition. This study also confirms the observations of others that administration of penicillin lowers the probability that a person who acquires group A Streptococcus will develop type-specific antibody.

Investigation of an outbreak of prolonged febrile illness in medical center personnel at the University of Rochester School of Medicine and Dentistry revealed lymphocytic choriomeningitis (LCM) virus to be the causative agent. Syrian or golden hamsters (Mesocricetus auratus) were found to be the only animals involved in maintaining the virus and were the source of human infections. Isolations of LCM virus were made from autopsy specimens of 13 of 46 (28%) golden hamsters. Virus isolations were made from 22 of 28 (79%) frozen specimens of 11 tumor lines transplanted repeatedly in golden hamster cheek pouches. No virus isolations were made from 86 autopsied laboratory mice, laboratory rats, Chinese hamsters (Cricetulus griseus), or laboratory rabbits or from 10 tumor cell lines transplanted in laboratory mice. Complement-fixation testing of 301 animal sera from the vivarium also revealed involvement primarily of golden hamsters. The probable source of virus introduction into the Rochester facilities was found to be two LCM-contaminated tumor lines sent from a biological supplier to Rochester in 1969.

A review of the medical records of 123 persons with Legionnaires' disease hospitalized in the 1976 Philadelphia epidemic showed that the manifestations of infection ranged from mild grippe to a severe pneumonia that also involved other organ systems. Early in the illness, constitutional symptoms predominated. Fever, malaise, myalgia, rigors, confusion, headache, and diarrhea were usually followed by nonproductive cough and dyspnea. Physical examination showed few abnormalities other than rales. Moderate leukocytosis with left shift, elevated erythrocyte sedimentation rate, elevation of serum levels of liver enzymes, and hematuria and proteinuria were characteristic. Chest radiograph showed patchy, often nodular, areas of consolidation. Progression of pneumonia led to respiratory failure and the need for mechanical ventilatory assistance for 19 patients; renal failure, primarily after shock, occurred in 18 persons. Twenty-six patients died. Treatment with erythromycin or tetracycline resulted in the lowest case-fatality ratios, but the associations were not statistically significant.

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).

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.

An outbreak of lymphocytic choriomeningitis (LCM) virus infections occurred in Medical Center personnel at the University of Rochester in 1972-1973. A total of 48 infections was discovered, 31 in staff of the radiation therapy area, 12 in the staff of the Vivarium facility, and 5 in other individuals who worked in the Medical Center. Twenty-one of the infections were associated with recent febrile illness with myalgia. Epidemiologic and virologic studies indicated that the source of the infection was Syrian hamsters which were used in tumor research; the tumor cell lines themselves were shown to be contaminated with LCM virus and probably represented the original source of contamination of the Rochester facility. Infection occurred not only through direct contact with infected animals but also from mere presence in the room where the animals were held. This outbreak emphasizes the need for restricting access to animal quarters and for surveillance of hamsters and tumor cell lines and indicate the necessity of separating animal facilities from patient-care facilities.

During September and October 1979, 23 patients admitted to hospitals in the Boston area had systemic Listeria monocytogenes infection. Twenty (87%) of these isolates were L monocytogenes type 4b, whereas only nine (33%) of the isolates serotyped during the preceding 26 months had been 4b. Patients with type 4b Listeria infection during the epidemic period (case patients) differed from patients with sporadic Listeria infection in the preceding two years in that more of the case patients had hospital-acquired infection (15/20 vs 4/18), had received antacids or cimetidine before the onset of listeriosis (12/20 vs 3/18), and had gastrointestinal tract symptoms that began at the same time as fever (17/20 vs 4/18). In addition, more case patients took antacids or cimetidine compared with patients matched for age, sex, and date of hospitalization (12/20 vs 10/40). Three foods were preferred by case patients more frequently than by control patients: tuna fish, chicken salad, and cheese. However, the only common feature appeared to be the serving of these foods with raw celery, tomatoes, and lettuce. The raw vegetables may have been contaminated with Listeria, which was able to survive ingestion because of gastric acid neutralization and subsequently to cause enteritis, bacteremia, and meningitis in susceptible hosts. However, we cannot exclude pasteurized milk as a source of this outbreak.

The disinfection of cooling towers based on manufacturers' treatment protocols, as employed in units installed at various public gathering places in Dallas, Tex. (hotels, municipal auditorium), and at the city health department, was evaluated for effectiveness in controlling Legionella pneumophila and compared with previous laboratory studies. In specimens collected in September and December, 1978, L. pneumophila was isolated from 2 of 4 specimens from untreated cooling towers, 2 of 4 specimens from towers treated with agents deemed ineffective in earlier laboratory tests, 6 of 11 specimens from towers treated with putatively effective agents, and 0 of 4 specimens from towers treated with an agent unknown efficacy. These results suggest the need for further studies to identify biocidal agents effective in eliminating L. pneumophila from air-conditioning cooling towers.

Legionella pneumophila serogroup 6 was isolated from nine of 16 shower heads in a Chicago hospital ward where three patients had contracted Legionnaires' disease caused by serogroup 6 L. pneumophila. Each patient had showered there 2 to 10 days before the onset of disease symptoms. We also isolated the bacteria in two other hospitals, and found the same serogroups as had been causing Legionnaires' disease in those hospitals: serogroup 1 in Pittsburgh and serogroups 1 and 4 in Los Angeles. However, showers from hospital wards where no patients had contracted Legionnaires' disease also yielded L. pneumophila. Shower heads at the Chicago hospital were sterilized with ethylene oxide but rapidly became recontaminated, suggesting that the potable water at these hospitals may have contained the organism. The question of whether aerosols of shower water or other exposures to potable water containing L. pneumophila may cause nosocomial Legionnaires' disease has not been resolved but deserves further study.

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.

Four episodes of serious Hemophilus influenzae type b infection occurred in three children attending a day-care center. This was 100 times the expected annual total. The pharyngeal carriage rate of Hib was 60% for siblings of patients, 20% for adult household contacts, and 5% for well children at the center. No carriers were found in control populations. Escherichia coli K100, which cross-reacts serologically with Hib, was found in rectal swabs of 20% of family contacts of patients and 3.5% of well children at the center. It was recovered from two of seven persons who carried Hib in the pharynx and two of 75 who did not (P = 0.035), suggesting that carriage of one organism may facilitate carriage of the other. In a randomized prospective trial with 85 patient contact, Hib carriage was eradicated in all of four carriers given ampicillin and in all of three given rifampin. There were no statistically significant differences in the rate of adverse reactions in the two treatment groups. No further cases were reported.

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.

During outbreaks of group A meningococcal disease in Seattle, Wash., and Portland, Oreg., we studied the mucosal flora of the affected population and comparison groups to identify possible determinants of susceptibility and resistance to disease. Antimeningococcal immunoglobulin A can block the bactericidal activity of specific antibodies of other classes and has been associated with susceptibility in adults. We used immunoprecipitation and fluorescent-antibody techniques to detect mucosal microorganisms cross-reactive with group A meningococci that might have stimulated such antibodies. Cross-reactive strains of Bacillus pumilus and Streptococcus faecalis were found. Bacterial interference on mucosal surfaces has been shown to reduce susceptibility to other pathogens. With an agar overlay technique, we sought nasopharyngeal microorganisms that inhibited the growth of group A meningococci. Forty-five percent of subjects carried inhibitory strains representing at least nine different species. Inhibitory strains were less common (32%) in residents from "skid row" areas (see D.J. Bogue, Skid Row in American Cities, University of Chicago Press, for a comprehensive definition of these areas) than in a comparison group that did not experience meningococcal disease (61%), suggesting that their presence may be associated with resistance to acquisition of meningococci or to meningococcal disease.

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.

To describe the epidemiology of bacteremia in a large, well defined population, the authors reviewed medical records for residents of Charleston County, South Carolina, who had bacteria isolated from blood in the period 1974 to 1976. The incidence was 80 cases per 100,000 population per year. The most common organisms were Escherichia coli, Staphylococcus aureus, Klebsiella, and Streptococcus pneumoniae. The incidence was highest for neonates, infants, and those 70 years of age and older with annualized attack rates of 1,864,250, and 446 cases per 100,000 population, respectively. The incidence was 3.2 times higher for blacks than for whites and, within races, appeared to be independent of family income. Twenty-five per cent of patients had no clinically apparent focus of infection, 26% had urinary tract infection, and 17% had pneumonia. Thirty-nine per cent of cases were nosocomial, and 30% of patients died.

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.

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.

A three-year epidemic of legionnaires' disease in a hospital was dramatically curtailed following hyperchlorination of the potable water supply. The hypothesis that potable water was the source for the outbreak was further supported by isolation of Legionella pneumophila (the agent of legionnaires' disease) from the hospital water supply, observation that a sudden upsurge had occurred in the number of cases following a peculiar manipulation of the hospital water system, and documentation of a 30-fold increase in concentration of organisms in the water when this manipulation was artificially recreated. Thus, potable water may be an important source of epidemic legionnaires' disease and continuous hyperchlorination a method of control.

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.

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 July 1978 an outbreak of Legionnaires' disease characterized by high fever, prostration, and pneumonia occurred at an Atlanta, Georgia, country club. All eight cases involved club members whose primary club activity was golfing. The degree of golfing activity during the likely exposure period was a risk factor for acquiring the illness. Legionella pneumophila was isolated from the evaporative condenser within the clubhouse. The fact that the stream of air blowing from the exhaust duct of the evaporative condenser was directed toward a nearby practice green and the 10th and 16th tees supports the hypothesis that this outbreak represents airborne dissemination of L. pneumophila from the evaporative condenser to an outdoor site where susceptible golfers contracted the illness.

A two-year controlled trial of benzathine penicillin G treatment of persons who acquired group A streptococci, identified by semimonthly throat cultures, was carried out in Egypt in 110 apparently normal families and 84 families with a child suspected of having rheumatic heart disease. Penicillin treatment was associated with a marked decrease in prevalence of the organism (19.0%-5.4%) and a modest decrease in introductions into families (0.79-0.54 single introductions per person per year) but no decrease in spread within nonrheumatic families. Results in suspected-rheumatic families were similar. It was concluded that the schedule of penicillin treatment used had a minimal effect on streptococcal spread and is unlikely to be an effective control tool. Spread within families was most intense in those episodes in which the household contacts were two to 14 years of age, the introducer had sought medical care, or the introducer ultimately carried the streptococcal strain for three or more months.

Physicians who graduated from 1955 to 1982 from three liberal arts colleges in southeastern Pennsylvania were asked about the ways that their undergraduate education had prepared or failed to prepare them for careers in medicine and about changes that they would, in retrospect, have made in their courses of undergraduate study. For many, college had failed to meet their perceived need, as physicians, for skill in dealing with people, but had provided skills in the form of basic science knowledge and willingness to be different that exceeded the demands of their careers. They wished that in college they had taken more courses in the humanities--especially art, history, music, and English literature--and less chemistry, mathematics, physics, and biology. Would-be physicians should be encouraged to take full advantage of the humanizing opportunities of a liberal arts education with confidence that it will contribute to their future professional and personal lives.

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.

Three patients with severe pneumonia at a community hospital in Columbus, Ohio, were found to have Legionnaires' disease in late August 1977. A subsequent serologic survey of patients with pneumonia at this hospital identified three additional cases. Among patients with pneumonia, hospital exposure in the 2 weeks before onset of illness was significantly associated with Legionnaires' disease (P = 0.003). Serosurveys of hospital employees with a recent history of upper respiratory illness, healthy employees, and workers at the hospital construction site showed that one of 101, one of 107, and none of 114, respectively, has a single reciprocal titer of greater than or equal to 256 to the Legionnaires' disease (LD) bacterium. Serosurveys of patients with pneumonia at three control hospitals identified five additional patients with Legionnaires' disease, three of them with pneumonia that was apparently hospital acquired in a single renal transplant unit. A fourth patient from that unit without clinical illness had a fourfold rise in titer to LD bacterium.