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1.  Trends in Invasive Infection with Methicillin-Resistant Staphylococcus aureus, Connecticut, USA, 2001–2010 
Emerging Infectious Diseases  2012;18(6):917-924.
Decreases in health care–related isolates accounted for all reductions in MRSA during 2007–2010.
PMCID: PMC3358174  PMID: 22607942
methicillin-resistant Staphylococcus aureus; MRSA; community-associated; hospital onset; health care–associated; invasive infection; trends; bacteria; antimicrobial resistance; Connecticut; United States; USA
2.  Socioeconomic Status and Campylobacteriosis, Connecticut, USA, 1999–2009 
Emerging Infectious Diseases  2014;20(7):1240-1242.
PMCID: PMC4073850  PMID: 24964129
Campylobacter; GIS; socioeconomic status; poverty; campylobacteriosis; Connecticut; bacteria; Suggested citation for this article: Bemis K; Marcus R; Hadler JL.Socioeconomic status and campylobacteriosis; Connecticut; USA; 1999–2009 [letter].Emerg Infect Dis [Internet]. 2014 Jul [date cited].
3.  Influenza-related hospitalization of adults associated with low census tract socioeconomic status and female sex in New Haven County, Connecticut, 2007-2011 
To help guide universal influenza vaccination efforts in the United States, it is important to know which demographic groups are currently at highest risk of costly complications of influenza infection. Few studies have examined the relationship between hospitalization with influenza and either socioeconomic status (SES) or sex. We examined associations between census tract-level SES and sex and incidence of influenza-related hospitalizations among adults.
Descriptive analysis of data collected by active population-based surveillance for persons >18 years old hospitalized with laboratory confirmed influenza during the 2007–2008 through 2010–2011 influenza seasons. Case residential addresses were geocoded and linked to data from the 2006–2010 American Community Survey to obtain census-tract level (neighborhood) SES measures. Census-tract level SES variables included measures of poverty, education, crowding, primary language, and median income. Four levels were created for each.
New Haven, County, Connecticut.
Entire New Haven County population >18 years old.
Main Outcome Measures
Age-adjusted incidence of influenza hospitalizations and relative risk by sex and by each of five SES measures.
Crude and age-adjusted incidence progressively increased with decreasing neighborhood SES for each measure both overall and for each influenza season. Female incidence was higher than male for each age group, and female age-adjusted incidence was higher for each SES level and influenza season.
Female sex and lower neighborhood SES were independently and consistently associated with higher incidence of hospitalization of adults with influenza. If this is more broadly the case, these findings have implications for future influenza vaccination efforts. Analysis using census tract SES measures can provide additional perspective on health disparities.
PMCID: PMC4181475  PMID: 24382111
Disparities; female; hospitalization; Influenza; sex; socioeconomic status
4.  Gram-positive Rod Surveillance for Early Anthrax Detection 
Emerging Infectious Diseases  2005;11(9):1483-1486.
Connecticut established telephone-based gram-positive rod (GPR) reporting primarily to detect inhalational anthrax cases more quickly. From March to December 2003, annualized incidence of blood isolates was 21.3/100,000 persons; reports included 293 Corynebacterium spp., 193 Bacillus spp., 73 Clostridium spp., 26 Lactobacillus spp., and 49 other genera. Around-the-clock GPR reporting has described GPR epidemiology and enhanced rapid communication with clinical laboratories.
PMCID: PMC3310606  PMID: 16229790
population surveillance; gram-positive rods; anthrax; clostridium infections; sepsis; disease notification; dispatch
5.  Impact of 2-Dose Vaccination on Varicella Epidemiology: Connecticut—2005–2008 
The Journal of Infectious Diseases  2011;203(4):509-512.
In 2006, the Advisory Committee on Immunization Practices recommended that children routinely receive 2 varicella vaccine doses in place of the 1 dose previously recommended. This recommendation’s initial impact on varicella epidemiology in Connecticut was assessed. Reported incidence and case-specific data were compared for 2005 and 2008. Varicella incidence decreased from 48.7 cases/100,000 persons in 2005 to 24.5 in 2008. Age-specific incidence decreased significantly (P < .05) among children aged 1–14 years. Reported varicella incidence has declined in Connecticut after implementation of routine 2-dose varicella vaccination for children. Continued surveillance is needed to determine the recommendation’s full impact.
PMCID: PMC3071238  PMID: 21199882
6.  Changing Disparities in Invasive Pneumococcal Disease by Socioeconomic Status and Race/ Ethnicity in Connecticut, 1998–2008 
Public Health Reports  2011;126(Suppl 3):81-88.
We compared invasive pneumococcal disease (IPD) incidence by race/ethnicity and neighborhood poverty level and assessed their relative utility to describe disparities in IPD in 1998–1999 and again in 2007–2008, after introduction of the 7-valent pneumococcal conjugate vaccine (PCV7).
We conducted laboratory surveillance for pneumococcal isolates from sterile body sites and serotyped the isolates. Home address was geocoded to the census-tract level. Census-tract data on the percentage of people below poverty were grouped into three categories. The difference in the magnitude of incidence by race/ethnicity and by census-tract socioeconomic status (SES) (high poverty minus low poverty) was compared for 1998–1999 and 2007–2008 for PCV7 and non-PCV7 serotypes.
In 1998–1999, incidence difference (all per 100,000 population) for PCV7 serotypes for black people compared with white people was 14.3 and by poverty level was 13.9. The highest rate was among white people in high-poverty tracts (77.3). By 2007–2008, there were only slight differences between rates for black and white people (0.7) and SES (1.4). In 1998–1999, the incidence difference for non-PCV7 serotypes was 4.7 between black and white people and 6.0 by SES. By 2007–2008, the differences were 11.6 and 11.7, respectively. Among those living in the highest-poverty tracts, white people had the highest rate (42.9).
In the absence of vaccine, IPD incidence is higher among people living in higher-poverty census tracts and among black people. Emerging serotypes also follow this trend. Differences in neighborhood poverty levels reveal disparities in rates of IPD as large as those seen by race/ethnicity and could be used to routinely describe disparities and target prevention.
PMCID: PMC3150133  PMID: 21836741
7.  Case Fatality Rates Based on Population Estimates of Influenza-Like Illness Due to Novel H1N1 Influenza: New York City, May–June 2009 
PLoS ONE  2010;5(7):e11677.
The public health response to pandemic influenza is contingent on the pandemic strain's severity. In late April 2009, a potentially pandemic novel H1N1 influenza strain (nH1N1) was recognized. New York City (NYC) experienced an intensive initial outbreak that peaked in late May, providing the need and opportunity to rapidly quantify the severity of nH1N1.
Methods and Findings
Telephone surveys using rapid polling methods of approximately 1,000 households each were conducted May 20–27 and June 15–19, 2009. Respondents were asked about the occurrence of influenza-like illness (ILI, fever with either cough or sore throat) for each household member from May 1–27 (survey 1) or the preceding 30 days (survey 2). For the overlap period, prevalence data were combined by weighting the survey-specific contribution based on a Serfling model using data from the NYC syndromic surveillance system. Total and age-specific prevalence of ILI attributed to nH1N1 were estimated using two approaches to adjust for background ILI: discounting by ILI prevalence in less affected NYC boroughs and by ILI measured in syndromic surveillance data from 2004–2008. Deaths, hospitalizations and intensive care unit (ICU) admissions were determined from enhanced surveillance including nH1N1-specific testing. Combined ILI prevalence for the 50-day period was 15.8% (95% CI:13.2%–19.0%). The two methods of adjustment yielded point estimates of nH1N1-associated ILI of 7.8% and 12.2%. Overall case-fatality (CFR) estimates ranged from 0.054–0.086 per 1000 persons with nH1N1-associated ILI and were highest for persons ≥65 years (0.094–0.147 per 1000) and lowest for those 0–17 (0.008–0.012). Hospitalization rates ranged from 0.84–1.34 and ICU admission rates from 0.21–0.34 per 1000, with little variation in either by age-group.
ILI prevalence can be quickly estimated using rapid telephone surveys, using syndromic surveillance data to determine expected “background” ILI proportion. Risk of severe illness due to nH1N1 was similar to seasonal influenza, enabling NYC to emphasize preventing severe morbidity rather than employing aggressive community mitigation measures.
PMCID: PMC2908148  PMID: 20657738
8.  Two Tuberculosis Genotyping Clusters, One Preventable Outbreak 
Public Health Reports  2009;124(4):490-494.
In 2006, eight community tuberculosis (TB) cases and a ninth incarceration-related case were identified during an outbreak investigation, which included genotyping of all Mycobacterium tuberculosis isolates. In 1996, the source patient had pulmonary TB but completed only two weeks of treatment. From February 2005 to May 2006, the source patient lived in four different locations while contagious. The outbreak cases had matching isolate spoligotypes; however, the mycobacterial interspersed repetitive unit (MIRU) patterns from isolates from two secondary cases differed by one tandem repeat at a single MIRU locus. The source patient's isolates showed a mixed mycobacterial population with both MIRU patterns. Traditional and molecular epidemiologic methods linked eight secondary TB cases to a single source patient whose incomplete initial treatment, incarceration, delayed diagnosis, and housing instability resulted in extensive transmission. Adequate treatment of the source patient's initial TB or early diagnosis of recurrent TB could have prevented this outbreak.
PMCID: PMC2693162  PMID: 19618785
9.  Public health strategies for distribution of influenza vaccine during an influenza pandemic. 
In order to consider the ethical issues around vaccine distribution during an influenza pandemic, it is critical to have an understanding of the role of influenza vaccine in a pandemic, the rate at which vaccine is likely to be come available, who will likely produce and "own" the vaccine, how vaccine distribution and administration might be accomplished, and which are the groups that might be deemed highest priority to be vaccinated against influenza. The United States and Connecticut have been considering the more challenging of these issues and have learned from Canada, which previously discussed and made decisions on the challenges related to vaccine distribution. Although there is still some critical advance thinking that needs to be done, planning for the response to an influenza pandemic is now at an advanced stage. The keys to preparedness at this stage are to be aware of the vaccine distribution options, to know the benefits and limitations of each option, and to be flexible but nimble in dealing with a real pandemic.
PMCID: PMC2259167  PMID: 17132334
10.  Consumer Attitudes and Use of Antibiotics 
Emerging Infectious Diseases  2003;9(9):1128-1135.
Recent antibiotic use is a risk factor for infection or colonization with resistant bacterial pathogens. Demand for antibiotics can be affected by consumers’ knowledge, attitudes, and practices. In 1998–1999, the Foodborne Diseases Active Surveillance Network (FoodNet) conducted a population-based, random-digit dialing telephone survey, including questions regarding respondents’ knowledge, attitudes, and practices of antibiotic use. Twelve percent had recently taken antibiotics; 27% believed that taking antibiotics when they had a cold made them better more quickly, 32% believed that taking antibiotics when they had a cold prevented more serious illness, and 48% expected a prescription for antibiotics when they were ill enough from a cold to seek medical attention. These misguided beliefs and expectations were associated with a lack of awareness of the dangers of antibiotic use; 58% of patients were not aware of the possible health dangers. National educational efforts are needed to address these issues if patient demand for antibiotics is to be reduced.
PMCID: PMC3016767  PMID: 14519251
antibiotic use; antimicrobial resistance; KAP survey
11.  Bioterrorism-related Inhalational Anthrax in an Elderly Woman, Connecticut, 2001 
Emerging Infectious Diseases  2003;9(6):681-688.
On November 20, 2001, inhalational anthrax was confirmed in an elderly woman from rural Connecticut. To determine her exposure source, we conducted an extensive epidemiologic, environmental, and laboratory investigation. Molecular subtyping showed that her isolate was indistinguishable from isolates associated with intentionally contaminated letters. No samples from her home or community yielded Bacillus anthracis, and she received no first-class letters from facilities known to have processed intentionally contaminated letters. Environmental sampling in the regional Connecticut postal facility yielded B. anthracis spores from 4 (31%) of 13 sorting machines. One extensively contaminated machine primarily processes bulk mail. A second machine that does final sorting of bulk mail for her zip code yielded B. anthracis on the column of bins for her carrier route. The evidence suggests she was exposed through a cross-contaminated bulk mail letter. Such cross-contamination of letters and postal facilities has implications for managing the response to future B. anthracis–contaminated mailings.
PMCID: PMC3000148  PMID: 12781007
Bacillus anthracis; inhalational anthrax; bioterrorism; postal facilities; research
12.  Anthrax Postexposure Prophylaxis in Postal Workers, Connecticut, 2001 
Emerging Infectious Diseases  2002;8(10):1133-1137.
After inhalational anthrax was diagnosed in a Connecticut woman on November 20, 2001, postexposure prophylaxis was recommended for postal workers at the regional mail facility serving the patient’s area. Although environmental testing at the facility yielded negative results, subsequent testing confirmed the presence of Bacillus anthracis. We distributed questionnaires to 100 randomly selected postal workers within 20 days of initial prophylaxis. Ninety-four workers obtained antibiotics, 68 of whom started postexposure prophylaxis and 21 discontinued. Postal workers who stopped or never started taking prophylaxis cited as reasons disbelief regarding anthrax exposure, problems with adverse events, and initial reports of negative cultures. Postal workers with adverse events reported predominant symptoms of gastrointestinal distress and headache. The influence of these concerns on adherence suggests that communication about risks of acquiring anthrax, education about adverse events, and careful management of adverse events are essential elements in increasing adherence.
PMCID: PMC2730305  PMID: 12396928
Anthrax; Bacillus anthracis; prophylaxis; adverse effects; ciprofloxacin; doxycycline; patient noncompliance; Connecticut
13.  Bioterrorism-Related Anthrax Surveillance, Connecticut, September–December, 2001 
Emerging Infectious Diseases  2002;8(10):1078-1082.
On November 19, 2001, a case of inhalational anthrax was identified in a 94-year-old Connecticut woman, who later died. We conducted intensive surveillance for additional anthrax cases, which included collecting data from hospitals, emergency departments, private practitioners, death certificates, postal facilities, veterinarians, and the state medical examiner. No additional cases of anthrax were identified. The absence of additional anthrax cases argued against an intentional environmental release of Bacillus anthracis in Connecticut and suggested that, if the source of anthrax had been cross-contaminated mail, the risk for anthrax in this setting was very low. This surveillance system provides a model that can be adapted for use in similar emergency settings.
PMCID: PMC2730303  PMID: 12396919
14.  Investigation of Bioterrorism-Related Anthrax, United States, 2001: Epidemiologic Findings 
Emerging Infectious Diseases  2002;8(10):1019-1028.
In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.
PMCID: PMC2730292  PMID: 12396909
15.  Environmental Sampling for Spores of Bacillus anthracis 
Emerging Infectious Diseases  2002;8(10):1083-1087.
On November 11, 2001, following the bioterrorism-related anthrax attacks, the U.S. Postal Service collected samples at the Southern Connecticut Processing and Distribution Center; all samples were negative for Bacillus anthracis. After a patient in Connecticut died from inhalational anthrax on November 19, the center was sampled again on November 21 and 25 by using dry and wet swabs. All samples were again negative for B. anthracis. On November 28, guided by information from epidemiologic investigation, we sampled the site extensively with wet wipes and surface vacuum sock samples (using HEPA vacuum). Of 212 samples, 6 (3%) were positive, including one from a highly contaminated sorter. Subsequently B. anthracis was also detected in mail-sorting bins used for the patient’s carrier route. These results suggest cross-contaminated mail as a possible source of anthrax for the inhalational anthrax patient in Connecticut. In future such investigations, extensive sampling guided by epidemiologic data is imperative.
PMCID: PMC2730287  PMID: 12396920
Bacillus anthracis; anthrax; environmental sampling; postal facility; surface sampling; HEPA vacuum sock; swabs; wipes

Results 1-15 (15)