Biomedical subjects

M L Cartter

Publications and source records attributed to M L Cartter.

At least 19 recordsLinked to original sources

PubMed2001

Hemolytic-Uremic Syndrome and Escherichia coli O121 at a Lake in Connecticut, 1999.

OBJECTIVE: Non-O157 Shiga toxin-producing Escherichia coli (STEC) have emerged as an important public health problem. Outbreaks attributed to non-O157 STEC rarely are reported. In 1999, follow-up of routine surveillance reports of children with hemolytic- uremic syndrome (HUS) identified a small cluster of 3 cases of HUS, all of whom had spent overlapping time in a Connecticut lake community in the week before onset of symptoms. We conducted an investigation to determine the magnitude and source of the outbreak and to determine risk factors associated with the transmission of illness. METHODS: We conducted a cohort study and an environmental investigation. The study population included all people who were at the lake in a defined geographic area during July 16-25, 1999. This time and area were chosen on the basis of interviews with the 3 HUS case-patients. A case was defined as diarrhea (>/=3 loose stools/d for >/=3 days) in a person who was at the lake during July 16-25, 1999. Stool samples were requested from any lake resident with diarrheal illness. Stools were cultured for Salmonella, Shigella, Campylobacter, and E coli O157. Broth cultures of stools were tested for Shiga toxin. Case-patients were asked to submit a serum specimen for antibody testing to lipopolysaccharides of selected STEC. Environmental samples from sediment, drinking water, lake water, and ice were obtained and cultured for E coli and tested for Shiga toxin. An environmental evaluation of the lake was conducted to identify any septic, water supply system, or other environmental condition that could be related to the outbreak. RESULTS: Information was obtained for 436 people from 165 (78%) households. Eleven (2.5%) people had illnesses that met the case definition, including the 3 children with HUS. The attack rate was highest among those who were younger than 10 years and who swam in the lake on July 17 or 18 (12%; relative risk [RR]: 7.3). Illness was associated with swimming (RR = 8.3) and with swallowing water while swimming (RR = 7.0) on these days. No person who swam only after July 18 developed illness. Clinical characteristics of case-patients included fever (27%), bloody diarrhea (27%), and severe abdominal cramping (73%). Only the 3 children with HUS required hospitalization. No bacterial pathogen was isolated from the stool of any case-patient. Among lake residents outside the study area, E coli O121:H19 was obtained from a Shiga toxin-producing isolate from a toddler who swam in the lake. Serum was obtained from 7 of 11 case-patients. Six of 7 case-patients had E coli O121 antibody titers that ranged from 1:320 to >1:20 480. E coli indicative of fecal contamination was identified from sediment and water samples taken from a storm drain that emptied into the beach area and from a stream bed located between 2 houses, but no Shiga toxin-producing strain was identified. CONCLUSIONS: Our findings are consistent with a transient local beach contamination in mid-July, probably with E coli O121:H19, which seems to be able to cause severe illness. Without HUS surveillance, this outbreak may have gone undetected by public health officials. This outbreak might have been detected sooner if Shiga toxin screening had been conducted routinely in HUS cases. Laboratory testing that relies solely on the inability of an isolate to ferment sorbitol will miss non-O157 STEC, such as E coli O121. Serologic testing can be used as an adjunct in the diagnosis of STEC infections. Lake-specific recommendations included education, frequent water sampling, and alternative means for toddlers to use lake facilities.

Adolescent↗

PubMed2000

The emergence of another tickborne infection in the 12-town area around Lyme, Connecticut: human granulocytic ehrlichiosis.

Human granulocytic ehrlichiosis (HGE) is an emerging tickborne infection, increasingly recognized in areas in which Lyme disease is endemic, but there are few data on the incidence of HGE. Prospective population-based surveillance was conducted in the 12-town area around Lyme, Connecticut, by means of both active and passive methods, from April through November of 1997, 1998, and 1999. Five hundred thirty-seven residents presenting to their primary care provider with an acute febrile illness suggestive of HGE were identified. Of these, 137 (26%) had laboratory evidence (by indirect fluorescent antibody staining or polymerase chain reaction) of HGE; 89 were confirmed cases, and 48 were probable cases. The incidence of confirmed HGE was 31 cases/100,000 in 1997, 51 cases/100,000 in 1998, and 24 cases/100,000 in 1999. A subset of sera was tested by use of immunoblot assays, and results were in agreement with indirect fluorescent antibody methods for 86% of samples analyzed. Thus, HGE is an important cause of morbidity and is now the second most common tickborne infection in southeastern Connecticut.

Adolescent↗

PubMed2000

Long-term outcomes of persons with Lyme disease.

CONTEXT: Few data exist about the long-term outcomes of patients with Lyme disease. OBJECTIVE: To assess the long-term outcomes of patients with Lyme disease. DESIGN: Two-part project including a community-based longitudinal cohort study and a matched cohort study. SETTING AND PARTICIPANTS: Six hundred seventy-eight patients identified from a random sample of all reports of Connecticut residents with suspected Lyme disease submitted to the Connecticut Department of Public Health from 1984-1991 were evaluated in the longitudinal study; for a random subsample of 212 patients from the larger study, 212 age-matched controls without Lyme disease also were enrolled. MAIN OUTCOME MEASURES: Self-reports or parents' reports of symptoms and ability to perform certain daily activities since diagnosis of Lyme disease; scores on the 36-Item Short-Form Health Survey and the Center for Epidemiologic Studies-Depression scale, for adults, by case-definition status and between patients and controls. RESULTS: Of the 678 patients, 51.6% were female, 34.4% were children, and 64.3% met the national surveillance case definition for Lyme disease. Most patients (85.6%) were treated with antimicrobial agents. Interviews were conducted a median of 51 months after diagnosis (range, 15-135 months). An increased frequency of symptoms (eg, pain, fatigue) or of difficulty with daily activities (eg, performing housework, exercising) was reported by 69% of the patients, although few (19%) of these problems were attributed to Lyme disease. Whenever there was a statistically significant difference in the frequencies of either increased symptoms or increased difficulties with typical activities between those who did or did not meet the surveillance case definition, in all instances the greater frequency of problems was in the group that did not meet the case definition. The frequencies of reports of both increased symptoms and increased difficulties with typical activities among patients who had been diagnosed as having Lyme disease were similar to those among age-matched controls without Lyme disease. CONCLUSIONS: In this cohort, although many patients reported increases in symptoms and/or increased difficulties with typical daily activities between 1 and 11 years after diagnosis of Lyme disease, the frequencies of these reports were similar to the frequencies of such reports among age-matched controls without Lyme disease.

Adult↗

PubMed2000

An outbreak of Escherichia coli O157:H7 infections and haemolytic uraemic syndrome associated with consumption of unpasteurized apple cider.

During October 1996, an outbreak of Escherichia coli O157:H7 infections among Connecticut residents occurred. An epidemiologic investigation included enhanced surveillance and a case-control study. Clinical isolates of Escherichia coli O157:H7 were typed by pulsed-field gel electrophoresis (PFGE). Implicated cider samples were analysed by culture and polymerase chain reaction (PCR). Consumption of implicated cider was associated with illness; (matched odds ratio = undefined, 95 % confidence interval = 3.5-infinity). Ultimately, a total of 14 outbreak-associated patients were identified. All isolates analysed by PFGE yielded the outbreak-associated subtype. Escherichia coli O157:H7 was not cultured from three cider samples; PCR analysis detected DNA fragments consistent with Escherichia coli O157:H7 in one. This outbreak was associated with drinking one brand of unpasteurized apple cider. PFGE subtyping supported the epidemiologic association. PCR analysis detected microbial contaminants in the absence of live organisms. Washing and brushing apples did not prevent cider contamination.

Adolescent↗

PubMed1999

The changing epidemiology of meningococcal disease in the United States, 1992-1996.

New meningococcal vaccines are undergoing clinical trials, and changes in the epidemiologic features of meningococcal disease will affect their use. Active laboratory-based, population-based US surveillance for meningococcal disease during 1992-1996 was used to project that 2400 cases of meningococcal disease occurred annually. Incidence was highest in infants; however, 32% of cases occurred in persons >/=30 years of age. Serogroup C caused 35% of cases; serogroup B, 32%; and serogroup Y, 26%. Increasing age (relative risk [RR], 1.01 per year), having an isolate obtained from blood (RR, 4.5), and serogroup C (RR, 1.6) were associated with increased case fatality. Among serogroup B isolates, the most commonly expressed serosubtype was P1.15; 68% of isolates expressed 1 of the 6 most common serosubtypes. Compared with cases occurring in previous years, recent cases are more likely to be caused by serogroup Y and to occur among older age groups. Ongoing surveillance is necessary to determine the stability of serogroup and serosubtype distribution.

Adolescent↗

PubMed1999

Reporting of vancomycin-resistant enterococci in Connecticut: implementation and validation of a state-based surveillance system.

OBJECTIVE: To assess state-based surveillance for isolation from a sterile site of vancomycin-resistant enterococci (VRE) in Connecticut. DESIGN: Clinical laboratory reporting (passive surveillance) of VRE isolates to the Connecticut Department of Public Health (CDPH) was followed by state-initiated validation, laboratory proficiency testing, and review of hospital demographic characteristics. SETTINGS: All 45 clinical laboratories and all 37 (36 for 1995 and 1996) acute-care hospitals in Connecticut were included in the study. MAIN OUTCOME MEASURES: The outcome measures included determination of the statewide incidence of VRE and the accuracy of passive reporting, determination of clinical laboratory proficiency in detecting VRE, and analysis of hospital characteristics that might be associated with an increased incidence of VRE. RESULTS: During 1994 through 1996, 29 (78%) of 37 hospital-affiliated clinical laboratories and 1 (11%) of 9 commercial or other laboratories in Connecticut reported to the CDPH the isolation of VRE from sterile sites; 158 isolates were reported for these 3 years. Based on verification, we discovered that these laboratories actually detected 58 VRE isolates in 1994, 104 in 1995, and 104 in 1996 (total, 266). The age-standardized incidence rate of VRE was 14.1 cases per million population in 1994 and 26.8 cases per million population for both 1995 and 1996. Laboratory proficiency testing revealed that high-level vancomycin resistance was identified accurately and that low- and moderate-level resistance was not detected. The incidence of VRE isolates was three times greater in hospitals with over 300 beds compared with categories of hospitals with fewer beds. Increases in the number of VRE isolates were at least twice as likely in hospitals located in areas with a higher population density, or with a residency program or trauma center in the hospital. CONCLUSIONS: Passive reporting of VRE isolates from sterile sites markedly underestimated the actual number of iso lates, as determined in a statewide reporting system. Statewide passive surveillance systems for routine or emerging pathogens must be validated and laboratory proficiency ensured if results are to be accurate and substantial underreporting is to be corrected.

Adolescent↗

PubMed1998

Public awareness of rabies and compliance with pet vaccination laws in Connecticut, 1993.

OBJECTIVE: To determine the degree of public awareness of rabies and compliance with cat and dog vaccination laws in Connecticut in 1993. DESIGN: Monthly telephone surveys. SAMPLE POPULATION: 1,810 households. PROCEDURE: A telephone interview was conducted, using rables-related questions contained in the Behavioral Risk Factor Surveillance System, with an adult member from households randomly selected statewide by telephone number. Results of the surveys for the year were aggregated, and weighted data were analyzed. RESULTS: Ninety percent of respondents had heard about rabies during the preceding year, and 84% considered it a problem in Connecticut. Forty-seven percent of households surveyed owned dogs or cats. Ninety-three percent of dogs and 80% of cats were reported to be vaccinated against rabies. Twenty-two percent of households with cats had at least 1 cat that was not current on rabies vaccination. CLINICAL RELEVANCE: In Connecticut, an epizootic of rabies in raccoons was accompanied by a high degree of awareness of rabies and rate of reported vaccination of dogs and cats. However, vaccination of cats was less common than that of dogs. Public education efforts should emphasize the necessity to vaccinate cats and to avoid contact with unknown cats in rabies epizootic or enzootic areas. A surveillance system can be used to help evaluate public health programs.

Adult↗

PubMed1998

Residential setting as a risk factor for Lyme disease in a hyperendemic region.

The hypothesis that residence in a uniform medium-density residential development is associated with lower incidence of Lyme disease is tested with data from a rural, 12-town region of south-central Connecticut where the disease is hyperendemic. The residential setting for 424 cases identified by active surveillance from 1993 through 1995 was determined. Cases located within the Eastern Coastal ecologic region, where tick densities are known to be higher than inland and where most of the population in the region resides, were selected for further analysis. Within this region, residence in a homogeneous area of medium-density development at least 30 acres (12 ha) in size was associated with a two- to 10-fold lower level of risk than residence in surrounding less developed areas, depending on the estimate of residential population. Type of residential development may be an important factor to consider, in addition to other environmental variables, in studies of peridomestic vector-borne disease in human populations.

Connecticut↗

PubMed1998

Temporal correlations between tick abundance and prevalence of ticks infected with Borrelia burgdorferi and increasing incidence of Lyme disease.

The abundance of host-seeking Ixodes scapularis nymphs, the principal vector for the Lyme disease agent, Borrelia burgdorferi, in Old Lyme, Lyme, and East Haddam, Connecticut, was compared with the incidence of reported human Lyme disease in the 12-town area around the Connecticut River and the State of Connecticut for the period 1989 to 1996. Ticks were sampled from lawns and woodlands by dragging flannel over the vegetation and examined for the presence of B. burgdorferi by indirect fluorescent antibody staining. The infection rate of the nymphal ticks by B. burgdorferi during the 9-year period was 14.3% (of 3,866), ranging from 8.6% (1993) to 24.4% (1996). The incidence of Lyme disease was positively correlated with tick abundance in the 12 town area (r = 0.828) and the State of Connecticut (r = 0.741). An entomological risk index based upon the number of I. scapularis ticks infected by B. burgdorferi was highest in 1992, 1994, and 1996 and was highly correlated with the incidence of Lyme disease in Connecticut (r = 0.944). The number of Lyme disease cases has been influenced, in part, by annual changes in population densities of I. scapularis and, presumably, a corresponding change in the risk of contact with infected ticks. Based upon tick activity and spirochetal infection rates, epidemiologically based Lyme disease case reports on a regional scale appear to reflect real trends in disease.

Animals↗

PubMed1998

Rabies prophylaxis following the feeding of a rabid pony.

A survey was performed to identify people who were exposed to a rabid pony and determine whether or not they received rabies postexposure prophylaxis (PEP). Sixty-one visitors who came in contact with the rabid pony were identified. These visitors heard about the rabid pony via the news media. Forty-five visitors were exposed during the 2 weeks before the pony died. Thirty-two of these 45 visitors received PEP. Thirty-one visitors had or may have had saliva contact to an open wound or mucosa and all 31 received PEP. Fourteen visitors had no saliva contact to a wound or mucosa and one received PEP. Sixteen visitors were exposed before the pony was potentially shedding rabies virus and one received PEP. No visitor was bitten by the pony. Most of the persons 31/33 (94%) who received PEP had an exposure for which PEP was indicated. Nonbite transmission of rabies is discussed.

Animals↗

PubMed1998

A recurrent outbreak of nosocomial legionnaires' disease detected by urinary antigen testing: evidence for long-term colonization of a hospital plumbing system.

BACKGROUND: In 1994, a hospital reported an increase in nosocomial legionnaires' disease after implementing use of a rapid urinary antigen test for Legionella pneumophila serogroup 1 (Lp-1). This hospital was the site of a previous nosocomial legionnaires' disease outbreak during 1980 to 1982. METHODS: Infection control records were reviewed to compare rates of nosocomial pneumonia and the proportion of cases attributable to legionnaires' disease during the 1994 outbreak period with those during the same period in 1993. Water samples were collected for Legionella culture from the hospital's potable water system and cooling towers, and isolates were subtyped by monoclonal antibody (MAb) testing and arbitrarily primed polymerase chain reaction (AP-PCR). RESULTS: Nosocomial pneumonia rates were similar from April through October 1993 and April through October 1994: 5.9 and 6.6 per 1,000 admissions, respectively (rate ratio [RR], 1.1; P=.56); however, 3.2% of nosocomial pneumonias were diagnosed as legionnaires' disease in 1993, compared with 23.9% in 1994 (RR, 9.4; P<.001). In 1994, most legionnaires' disease cases were detected by the urinary antigen testing alone. MAb testing and AP-PCR demonstrated identical patterns among Lp-1 isolates recovered from a patient's respiratory secretions, the hospital potable water system, and stored potable water isolates from the 1980 to 1982 outbreak. CONCLUSIONS: There may have been persistent transmission of nosocomial legionnaires' disease at this hospital that went undiscovered for many years because there was no active surveillance for legionnaires' disease. Introduction of a rapid urinary antigen test improved case ascertainment. Legionella species can be established in colonized plumbing systems and may pose a risk for infection over prolonged periods.

Connecticut↗

PubMed1997

Predisposing factors for individuals' Lyme disease prevention practices: Connecticut, Maine, and Montana.

OBJECTIVES: This study examined factors that predispose individuals to protect against Lyme disease. METHODS: Knowledge, attitude, and practice questions concerning Lyme disease prevention were included in the Behavioral Risk Factor Surveillance surveys in Connecticut, Maine, and Montana. A total of 4246 persons were interviewed. RESULTS: Perceived risk of acquiring Lyme disease, knowing anyone with Lyme disease, knowledge about Lyme disease, and believing Lyme disease to be a common problem were significantly associated with prevention practices. CONCLUSIONS: Predisposing factors differ substantially between states and appear related to disease incidence. Personal risk, knowing someone with Lyme disease, and cognizance about Lyme disease and acting on this information are consistent with social learning theories.

Adult↗

PubMed1997

Emergence of raccoon rabies in Connecticut, 1991-1994: spatial and temporal characteristics of animal infection and human contact.

The North American raccoon rabies epizootic continues to expand, now affecting most of New England. In 1990, raccoons became the vertebrate most often reported rabid in the United States. Emergence of this zoonosis poses increasing, but poorly defined risks to humans. This study analyzed various demographic, environmental, and behavioral factors associated with animal infection and human exposure before and during the epizootic in Connecticut. Rabies virus infections among terrestrial vertebrates were analyzed from 1985 through 1994. From March 1991, when the first case was diagnosed, through December 1994, 2,522 of 13,147 animals tested were found positive for rabies viral antigen. Forty-seven percent of the raccoons tested were infected, representing 88.0% of all animals found positive. Domestic animals constituted only 1.7% of positive test results, but 40.6% of the tests performed. The epizootic wave of transmission advanced approximately 30 km/year. Most rabies-positive wild animals were taken from private properties, usually near houses. Possible human exposures involved 939 people on 556 occasions through direct contact (20.7%) or indirectly through another animal (79.3%). Of 3,239 domestic animals exposed to rabies-positive wild animals, 18.4% lacked vaccination. Rabies has become enzootic in Connecticut and risk to humans and animals persists. The public health burden is considerable, yet knowledge is lacking to develop sustainable prevention strategies.

Animals↗

PubMed1996

Meat grinders and molecular epidemiology: two supermarket outbreaks of Escherichia coli O157:H7 infection.

Between 23 June and 15 July 1994, 21 cases (19 primary and 2 secondary) of Escherichia coli O157:H7 infection were identified in the Bethel, Connecticut, area. Three pulsed-field gel electrophoresis (PFGE) patterns from 15 isolates (I, n = 13; II, n = 2; and III, n = 1) were observed. A case-control study that excluded secondary cases and patients with PFGE II and III patterns (n = 16) demonstrated that consumption of food from one supermarket was associated with illness (15/16 cases vs. 31/47 geographically matched controls, odds ratio [OR] undefined, lower 95% confidence interval OR = 1.45, P = .018). No one food was associated with illness. Inspection of the supermarket revealed deficiencies in hygiene and meat handling practices. The 2 cases with PFGE II ate raw beef and raw lamb from a second supermarket. These outbreaks demonstrate the value of PFGE in supporting epidemiologic investigations and the potential for outbreaks arising from retail outlets.

Adolescent↗

PubMed1996

Underreporting of Lyme disease by Connecticut physicians, 1992.

To determine the magnitude of underreporting of Lyme disease, a random sample of Connecticut physicians was surveyed in 1993. The magnitude of underreporting was assessed by comparing physician estimates of Lyme disease diagnoses with reports of Lyme disease sent by physicians to the Connecticut Lyme disease surveillance system. Complete questionnaires were returned by 59 percent (412/698) of those surveyed. Of the 224 respondents who indicated that they had made a diagnosis of Lyme disease in 1992, only 56 (25 percent) reported a case of Lyme disease that year. Survey results suggested that, at best, only 16 percent of Lyme disease cases were reported in 1992. Physician underreporting of Lyme disease underestimates the public health impact of Lyme disease.

Connecticut↗

PubMed1996

A meningococcal vaccination campaign on a university campus: vaccination rates and factors in nonparticipation.

OBJECTIVES: This study was undertaken to determine an accurate vaccination rate and identify factors influencing nonvaccination in a meningococcal vaccination campaign on a Connecticut university campus in May 1993. METHODS: Vaccination and student data were merged to determine demographic factors associated with nonvaccination. A case-control study examined reasons for nonvaccination. RESULTS: The estimated vaccination rate for students returning to the campus was 93%. Lower rates occurred among older students, students living off campus, graduate and nondegree students, and married students. Perceived poor access to the vaccination center was the strongest predictor of nonvaccination. CONCLUSIONS: Higher vaccination rates may be achieved by specifically targeting students who live off campus and by providing multiple vaccination sites with extended hours.

Adolescent↗

PubMed1995

The role of heightened surveillance in an outbreak of Escherichia coli O157.H7.

After instituting laboratory screening for Escherichia coli O157.H7, a Connecticut hospital isolated the organism from four persons in September 1993. As a result, an outbreak of E. coli O157.H7 associated with a country club was detected. The club had served hamburger from the same shipment at two picnics. Attendees of two picnics were interviewed, stool cultures were obtained from symptomatic persons, and the remaining hamburger was cultured. Twenty (22%) of 89 persons who ate hamburger became ill, compared with 1 of 60 who did not eat hamburger (relative risk = 13.5, 95% confidence interval 3.2-56.3). Among persons who ate hamburgers, illness was strongly associated with eating hamburger that was not thoroughly cooked (P < 0.001). All 20 samples from 5 remaining boxes of patties yielded E. coli O157.H7. Isolates from hamburger and case-patients were indistinguishable by pulsed-field gel electrophoresis. Heightened surveillance can rapidly identify outbreaks and may mitigate their impact. However, continued review of food safety issues is necessary if E. coli O157.H7 outbreaks are to be prevented.

Adolescent↗

PubMed1995

Prospective assessment of Lyme disease in a school-aged population in Connecticut.

To determine the incidence and cumulative frequency of Lyme disease in a school-aged population in an area in which Lyme disease is endemic, serum specimens were obtained before and after the 1990-1992 tick seasons from 410 middle and high school students in southeastern Connecticut. Sera were tested for serologic evidence of infection with Borrelia burgdorferi, and students were questioned about physician-confirmed episodes of clinical Lyme disease. At enrollment, 29 (7%) students had a history of Lyme disease, and of these, 12 (41%) were seropositive for B. burgdorferi infection. Seronegative students (397) were followed prospectively over a total of 796 person years. At enrollment, 381 students (93%) had no history of Lyme disease, and of these, 1 (0.3%) was seropositive. During this period, 8 students developed clinical Lyme disease and 3 had asymptomatic infections with B. burgdorferi. The incidences of clinical Lyme disease and asymptomatic B. burgdorferi infection were 10.1 and 3.8 cases/1000 person-years, respectively. Lyme disease is an important health problem in school-aged children living in southeastern Connecticut.

Adolescent↗