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1.  The Effect of Age on Transmission of 2009 Pandemic Influenza A (H1N1) in a Camp and Associated Households 
Epidemiology (Cambridge, Mass.)  2011;22(2):10.1097/EDE.0b013e3182060ca5.
A major portion of influenza disease burden during the 2009 pandemic was observed among young people.
We examined the effect of age on the transmission of influenza-like illness associated with the 2009 pandemic influenza A (H1N1) virus (pH1N1) for an April–May 2009 outbreak among youth-camp participants and household contacts in Washington State.
An influenza-like illness attack rate of 51% was found among 96 camp participants. We observed a cabin secondary attack rate of 42% (95% confidence interval = 21%–66%) and a camp local reproductive number of 2.7 (1.7–4.1) for influenza-like illness among children (less than 18 years old). Among the 136 contacts in the 41 households with an influenza-like illness index case who attended the camp, the influenza-like illness secondary attack rate was 11% for children (5%–21%) and 4% for adults (2%–8%). The odds ratio for influenza-like illness among children versus adults was 3.1 (1.3–7.3).
The strong age effect, combined with the low number of susceptible children per household (1.2), plausibly explains the lower-than-expected household secondary attack rate for influenza-like illness, illustrating the importance of other venues where children congregate for sustaining community transmission. Quantifying the effects of age on pH1N1 transmission is important for informing effective intervention strategies.
PMCID: PMC3755879  PMID: 21233714
2.  Public health communications and alert fatigue 
Health care providers play a significant role in large scale health emergency planning, detection, response, recovery and communication with the public. The effectiveness of health care providers in emergency preparedness and response roles depends, in part, on public health agencies communicating information in a way that maximizes the likelihood that the message is delivered, received, deemed credible and, when appropriate, acted on. However, during an emergency, health care providers can become inundated with alerts and advisories through numerous national, state, local and professional communication channels. We conducted an alert fatigue study as a sub-study of a larger randomized controlled trial which aimed to identify the most effective methods of communicating public health messages between public health agencies and providers. We report an analysis of the effects of public health message volume/frequency on recall of specific message content and effect of rate of message communications on health care provider alert fatigue.
Health care providers enrolled in the larger study (n=528) were randomized to receive public health messages via email, fax, short message service (SMS or cell phone text messaging) or to a control group that did not receive messages. For 12 months, study messages based on real events of public health significance were sent quarterly with follow-up telephone interviews regarding message receipt and topic recall conducted 5–10 days after the message delivery date. During a pandemic when numerous messages are sent, alert fatigue may impact ability to recall whether a specific message has been received due to the “noise” created by the higher number of messages. To determine the impact of “noise” when study messages were sent, we compared health care provider recall of the study message topic to the number of local public health messages sent to health care providers.
We calculated the mean number of messages that each provider received from local public health during the time period around each study message and provider recall of study message content. We found that recall rates were inversely proportional to the mean number of messages received per week: Every increase of one local public health message per week resulted in a statistically significant 41.2% decrease (p < 0.01), 95% CI [0.39, .87] in the odds of recalling the content of the study message.
To our knowledge, this is the first study to document the effects of alert fatigue on health care providers’ recall of information. Our results suggest that information delivered too frequently and/or repetitively through numerous communication channels may have a negative effect on the ability of health care providers to effectively recall emergency information. Keeping health care providers and other first-line responders informed during an emergency is critical. Better coordination between organizations disseminating alerts, advisories and other messages may improve the ability of health care providers to recall public health emergency messages, potentially impacting effective response to public health emergency messages.
PMCID: PMC3751004  PMID: 23915324
3.  Diarrhetic Shellfish Poisoning, Washington, USA, 2011 
Emerging Infectious Diseases  2013;19(8):1314-1316.
Diarrhetic shellfish poisoning is a gastrointestinal illness caused by consumption of bivalves contaminated with dinophysistoxins. We report an illness cluster in the United States in which toxins were confirmed in shellfish from a commercial harvest area, leading to product recall. Ongoing surveillance is needed to prevent similar illness outbreaks.
PMCID: PMC3739508  PMID: 23876232
Diarrhetic shellfish poisoning; shellfish; toxins; DSP; dinophysistoxins; marine biotoxins; Dinophysis spp.; Washington; United States; enteric infections
4.  Tattoo-associated Mycobacterium haemophilum Skin Infection in Immunocompetent Adult, 2009 
Emerging Infectious Diseases  2011;17(9):1734-1736.
After a laboratory-confirmed case of Mycobacterium haemophilum skin infection in a recently tattooed immunocompetent adult was reported, we investigated to identify the infection source and additional cases. We found 1 laboratory-confirmed and 1 suspected case among immunocompetent adults who had been tattooed at the same parlor.
PMCID: PMC3322073  PMID: 21888807
Mycobacterium haemophilum; tattoo; skin infection; immunocompetent; tuberculosis and other mycobacteria; dispatch
5.  Public Health Emergency Preparedness and Response Communications with Health Care Providers: A Literature Review 
BMC Public Health  2011;11:337.
Health care providers (HCPs) play an important role in public health emergency preparedness and response (PHEPR) so need to be aware of public health threats and emergencies. To inform HCPs, public health issues PHEPR messages that provide guidelines and updates, and facilitate surveillance so HCPs will recognize and control communicable diseases, prevent excess deaths and mitigate suffering. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. We conducted a literature review to investigate the systems and tools used by public health to generate PHEPR communications to HCPs, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective PHEPR communications.
A systematic review of peer- and non-peer-reviewed literature focused on the following questions: 1) What public health systems exist for communicating PHEPR messages from public health agencies to HCPs? 2) Have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? 3) What have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate PHEPR messages to HCPs?
We identified 25 systems or tools for communicating PHEPR messages from public health agencies to HCPs. Few articles assessed PHEPR communication systems or messaging methods or outcomes. Only one study compared the effectiveness of the delivery format, device or message itself. We also discovered that the potential is high for HCPs to experience "message overload" given redundancy of PHEPR messaging in multiple formats and/or through different delivery systems.
We found that detailed descriptions of PHEPR messaging from public health to HCPs are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. To meet present-day and future information needs for emergency preparedness, more attention needs to be given to evaluating the effectiveness of these systems in a scientifically rigorous manner.
PMCID: PMC3121631  PMID: 21592390
6.  Shedding of Pandemic (H1N1) 2009 Virus among Health Care Personnel, Seattle, Washington, USA 
Emerging Infectious Diseases  2011;17(4):639-644.
The Centers for Disease Control and Prevention (CDC) recommends that health care personnel (HCP) infected with pandemic influenza (H1N1) 2009 virus not work until 24 hours after fever subsides without the use of antipyretics. During an influenza outbreak, we examined the association between viral shedding and fever among infected HCP. Participants recorded temperatures daily and provided nasal wash specimens for 2 weeks after symptom onset. Specimens were tested by using PCR and culture. When they met CDC criteria for returning to work, 12 of 16 HCP (75%) (95% confidence interval 48%–93%) had virus detected by PCR, and 9 (56%) (95% confidence interval 30%–80%) had virus detected by culture. Fever was not associated with shedding duration (p = 0.65). HCP might shed virus even when meeting CDC exclusion guidelines. Further research is needed to clarify the association between viral shedding, symptoms, and infectiousness.
PMCID: PMC3377395  PMID: 21470453
Influenza; virus shedding; pandemic (H1N1) 2009; viruses; PCR; health care personnel; outbreak; Washington; research
7.  Tri-county comprehensive assessment of risk factors for sporadic reportable bacterial enteric infection in children 
The Journal of Infectious Diseases  2009;199(4):467-476.
Background. The aim of this study was to determine risk factors for childhood sporadic reportable enteric infection (REI) caused by bacteria, specifically Campylobacter, Salmonella, Escherichia coli O157, or Shigella (REI-B).
Methods. Matched case-control study. Case patients aged <19 years who were reported to 3 Washington State county health departments and matched control subjects were interviewed from November 2003–November 2005. Matched odds ratios (ORs) were calculated by using conditional logistic regression. Population attributable risk percentages were calculated for exposures associated with infection.
Results. Two hundred ninety-six case patients were matched to 580 control subjects. Aquatic recreation was the most important factor associated with all REI-Bs studied (beach water exposure [OR for Salmonella infection, 28.3 {CI, 7.2–112.2}; OR for Shigella infection, 14.5 {CI 1.5–141.0} or any recreational water exposure [OR for Campylobacter infection, 2.7 {CI, 1.5–4.8}; OR for Escherichia coli O157 infection, 7.4 {CI, 2.1–26.1}]). Suboptimal kitchen hygiene after preparation of raw meat or chicken (OR, 7.1 [CI, 2.1–24.1]) and consumption of food from restaurants were additional risks for Campylobacter infection. Infection with Salmonella was associated with the use of private wells as sources of drinking water (OR, 6.5 [CI, 1.4–29.7]), and the use of residential septic systems was a risk for both Salmonella (OR, 3.2 [CI, 1.3–7.8]) and E. coli (OR, 5.7 [CI, 1.2–27.2]) O157 infection.
Conclusions. Overall, non-food exposures were as important as food-related exposures with regard to their contributions to the proportion of cases. Infection prevention efforts should address kitchen hygiene practices and non-food exposures, such as recreational water exposure, in addition to food-consumption risks.
PMCID: PMC3693595  PMID: 19281302
8.  Syndromic surveillance using automated collection of computerized discharge diagnoses 
The Syndromic Surveillance Information Collection (SSIC) system aims to facilitate early detection of bioterrorism attacks (with such agents as anthrax, brucellosis, plague, Q fever, tularemia, smallpox, viral encephalitides, hemorrhagic fever, botulism toxins, staphylococcal enterotoxin B, etc.) and early detection of naturally occurring disease outbreaks, including large foodborne disease outbreaks, emerging infections, and pandemic influenza. This is accomplished using automated data collection of visit-level discharge diagnoses from heterogeneous clinical information systems, integrating those data into a common XML (Extensible Markup Language) form, and monitoring the results to detect unusual patterns of illness in the population. The system, operational since January 2001, collects, integrates, and displays data from three emergency department and urgent care (ED/UC) departments and nine primary care clinics by automatically mining data from the information systems of those facilities. With continued development, this system will constitute the foundation of a population-based surveillance system that will facilitate targeted investigation of clinical syndromes under surveillance and allow early detection of unusual clusters of illness compatible with bioterrorism or disease outbreaks.
PMCID: PMC3456541  PMID: 12791784
Biological warfare; Bioterrorism; Data collection; Database; Informatics; Information systems; Sentinel surveillance
10.  Case-reporting of acute hepatitis B and C among injection drug users 
Although public health surveillance system data are widely used to describe the epidemiology of communicable disease, occurrence of hepatitis B and C virus (HBV and HCV, respectively) infections may be misrepresented by under-reporting in injection drug users (IDUs). This study was carried out to examine the relationship between HBV and HCV incidence and case-reporting of hepatitis B and C in Seattle IDUs. Names of participants in a Seattle IDU cohort study who acquired HBV or HCV infection over a 12-month follow-up period were compared to a database of persons with acute bepatitis B and C reported to the bealth department surveillance unit over the same period. Of 2,208 IDUs enrolled in the cohort who completed a follow-up visit, 63/759 acquired HBV infection, 53/317 acquired HCV infection, and 3 subjects acquired both HBV and HCV. Of 113 cohort subjects who acquired HBV or HCV, only 2 (1.5%) cases were reported; both bad acute bepatitis B. The upper 95% confidence limit for case-reporting of bepatitis C in the cohort was 5.7%, and for hepatitis B, it was 7.5%. In this study, reporting of acute bepatitis in IDUs was extremely low, raising questions regarding the use of community surveillance data to estimate underlying incidence in that population group.
PMCID: PMC3456717  PMID: 12468677
Hepatitis B; Hepatitis C; Substance use; Surveillance
11.  Genetic Diversity of Pneumocystis carinii f. sp. hominis Based on Variations in Nucleotide Sequences of Internal Transcribed Spacers of rRNA Genes 
Journal of Clinical Microbiology  2002;40(4):1146-1151.
A variety of genes have been used to type Pneumocystis carinii. In the present study, nucleotide sequence variations in the ITS1 and ITS2 internal transcribed spacer (ITS) regions of the rRNA genes were used to type Pneumocystis carinii f. sp. hominis DNA obtained from the lungs of 60 human immunodeficiency virus-infected individuals. These regions were amplified by PCR, cloned, and sequenced. Multibase polymorphisms were identified among samples. Several new genotypes are reported on the basis of the nucleotide sequence variations at previously unreported positions of both the ITS1 and the ITS2 regions. Twelve new ITS1 sequences were observed, in addition to the nine sequence types reported previously. The most common was type E, which was observed in 60.5% of the samples. The sequence variations in the ITS1 region were mainly located at positions 5, 12, 23, 24, 45, 53, and 54. Sixteen new ITS2 types were also identified, in addition to the 13 types reported previously. The most common was type g (26.6%). The sequences of the ITS2 regions in most specimens were different from the previously published sequence at bases 120 and 166 through 183. The most common variations observed were deletions at positions 177 through 183. The presence of more than one sequence type in some patients (60%) suggested the occurrence of coinfection with multiple P. carinii strains. The genetic polymorphism observed demonstrates the degree of diversity of Pneumocystis strains that infect humans. Furthermore, the high degree of polymorphism suggests that these genes are evolving faster than other genes. Consequently, the sequence information derived is useful for purposes such as examination of the potential of person-to-person transmission and recurrent infections but perhaps not for other genotyping applications that rely on more stable genetic loci.
PMCID: PMC140386  PMID: 11923323

Results 1-11 (11)