Sentinel Case Research Articles

Do pediatricians recognize fetal alcohol spectrum disorders in children with developmental and behavioral problems?

Limited studies have examined pediatricians' knowledge, attitudes, and practice about fetal alcohol spectrum disorders (FASDs), and none have examined alcohol-related neurodevelopmental disabilities (ARND). This study examined whether pediatricians consider FASDs in children with developmental and behavioral problems. All 149 pediatricians, 55 males and 94 females, in New Haven County, CT, were contacted to complete a web-based survey. They were given cases of preschool boys with (1) fetal alcohol syndrome (FAS), (2) ARND, and (3) Williams Syndrome (WS) and asked to provide a diagnosis and rate their confidence in this. They could access up to 7 additional pieces of information. Sixty-six pediatricians responded (44.3%), and 46 had complete data (30.9%). Eight (17.4%) correctly identified FAS and 29 (63.1%) ARND. Significantly fewer pediatricians diagnosed FAS versus ARND and WS (p < .001), and they were less confident in identifying FAS and ARND than WS (10.9 % and 45.7% vs. 73.9%, p < .01). After viewing the photographs with sentinel dysmorphology and case description, respondents were more likely to diagnose WS (37%) versus FAS (19.6%) (p = .064), less confident in their diagnosis (p = .009), and required more information to make an FAS diagnosis (p = .002). Pediatricians underrecognize FASDs, lack confidence in making this diagnosis, and are unfamiliar with the diagnostic criteria. They need more training to consider the possibility of an FASD when seeing children with developmental and behavioral problems.

High toxicity and carcinogenesis of occupational exposure to 4, 4’-methylenebis (2-chloroaniline) (MBOCA)

4,4 -Methylenebis (2-chloroaniline) (MBOCA) is an aromatic diamine used widely as a curing agent for polyurethane and epoxy resins. The most notable risk factor for the development of lower urinary tract cancers is occupational exposure to aromatic amines, first noted in England in 1895 [1]. A sentinel case of transitional cell carcinoma of the urinary bladder was diagnosed in an MBOCA manufacturing factory in Taiwan in 2005 [2]. There is also no information regarding the daily dose of MBOCA to which workers were exposed or the route of exposure [3]. However, it remains unclear whether MBOCA causes malignancy.

Risk Assessment for Healthcare Workers After a Sentinel Case of Rabies and Review of the Literature

After a case of rabies, healthcare workers (HCWs) had fear of contagion from the infected patient. Although transmission of rabies to HCWs has never been documented, high-risk exposures theoretically include direct contact of broken skin and/or mucosa with saliva, tears, oropharyngeal secretions, cerebrospinal fluid, and neural tissue. Urine/kidney exposure posed a concern, as our patient's renal transplant was identified as the infection source. Our risk assessment included (1) identification of exposed HCWs; (2) notification of HCWs; (3) risk assessment using a tool from the local health department; (4) supplemental screening for urine/kidney exposure; and (5) postexposure prophylaxis (PEP) when indicated. A total of 222 HCWs including diverse hospital staff and medical trainees from university affiliates were evaluated. Risk screening was initiated within 2 hours of rabies confirmation, and 95% of HCWs were assessed within the first 8 days. There were 8 high-risk exposures related to broken skin contact or mucosal splash with the patient's secretions, and 1 person without high-risk contact sought and received PEP outside our hospital. Nine HCWs (4%) received PEP with good tolerance. Due to fear of rabies transmission, additional HCWs without direct patient contact required counseling. There have been no secondary cases after our sentinel rabies patient. Rabies exposure represents a major concern for HCWs and requires rapid, comprehensive risk screening and counseling of staff and timely PEP. Given the lack of human-to-human rabies transmission from our own experience and the literature, a conservative approach seems appropriate for providing PEP to HCWs.

A workplace tuberculosis case investigation in the presence of immigrant contacts from high prevalence countries.

The highest prevalence of tuberculosis (TB) occurs in foreign born immigrants in the United States. Contact investigations at work sites with mostly immigrant workers present multiple practical problems. Recently 402 contacts were investigated at a meat packing plant in rural Texas by the Texas Department of State Health Services (DSHS). Our objective was to study the approach and effectiveness of this intensive investigation. We reviewed information, including symptoms, BCG status, TB history, X-rays, and treatment, on the sentinel case and 47 contacts managed by the Texas DSHS TB Division in Lubbock, TX. We used a gamma interferon release assay (T-SPOT.TB) to identify contacts with TB infection. The sentinel case was foreign born and had cavitary TB with acid-fast positive smears. Forty-two work site contacts were foreign born, and five were US born. The foreign born contacts were from Sudan, Somalia, Mexico, Burma, and Haiti; 18 contacts had a history of BCG vaccination. T-SPOT.TB tests were positive in 20 contacts, borderline in four, and negative in 23. Contacts with borderline results had negative repeat tests. Twenty-three contacts with negative T-SPOT.TB tests were scheduled for repeat tests in 4 weeks, but only four returned for this testing. Chest X-rays were abnormal in two contacts who were started on treatment. Sputum was collected in three individuals; one was culture positive for pan-sensitive Mycobacterium tuberculosis. Twelve contacts were treated for latent TB. Our investigation established an infection rate of 42.5% in this work site contact cohort, which is similar to the 39% prevalence reported by the Center for Disease Control. The use of T-SPOT.TB assays simplified testing in immigrants with high rates of BCG vaccination. Our investigation was complicated by language barriers, varying and uncertain levels of exposure, and a high rate of drop outs in the negative T-SPOT.TB contacts. This concerted effort provides a model for investigating work site contacts, especially with numerous immigrants, and illustrates the problems associated with these investigations.

Focal screening and treatment for malaria: defining the sentinel population

Background Mass screening and treatment campaigns have had limited success in curbing malaria transmission, possibly as a consequence of the high prevalence of subpatent infections that are missed using the currently available field based diagnostic tools. It has been shown that subpatent malaria infections are more likely to occur in households where patent infections are identified suggesting that it may be possible to employ a more focal approach to treatment campaigns using sentinel cases as markers for the presence of a subpatent reservoir. However, it is not known which definition of sentinel case to rely on for initiation of treatment would provide optimal coverage of the parasite reservoir.

Expansion of acute flaccid paralysis surveillance: beyond poliomyelitis

Acute flaccid paralysis (AFP) is the relatively sudden onset of weakness involving one or more limbs with accompanying reduction in muscle tone and deep tendon reflexes. AFP encompasses a range of infectious, autoimmune and acquired etiologies. The epidemiology and actions required to address the major causes of AFP in childhood are, however, unknown in spite of active surveillance to detect poliomyelitis in more than 150 countries. In 2012, there were 223 reported wildtype cases of poliomyelitis (Anonymous 2012). More than 47 000 cases of AFP were reported globally to detect these cases. AFP cases are reported as ‘polio’ or ‘non-polio’ to national surveillance units. The other important leading causes of AFP require renewed attention. Data and efforts to combat the major vaccine-preventable causes of AFP – diphtheria, tetanus and rabies – lag behind those of poliomyelitis. The last available reporting year for diphtheria deaths was 2004, when 5000 deaths were reported by WHO. Between 2007 and 2011, there were more than 20 000 reported cases of diphtheria, including nearly 18 000 cases in India (WHO 2013a). Currently, only 29% of all countries report more than 80% coverage of the diphtheria-tetanus-pertussis (DTP3) vaccine (WHO 2013b). Deaths from rabies total approximately 50 000 people per year with post-exposure prophylaxis for rabies offered to an estimated 15 million people globally (WHO 2013c). Sentinel case surveillance could lead to targeted vaccinations in locations with children at highest risk. Although rabies presents as both paralytic (dumb) and encephalitic (furious) forms, paralysis due to rabies is fatal and preventable. As 40% of rabies cases are in children, surveillance efforts could employ similar age ranges as applied to poliomyelitis. Children and dogs could be vaccinated in highly endemic regions. In India, even during the last years of continued, uninterrupted transmission of wildtype poliovirus, traumatic neuropathy was a leading cause of paralysis in childhood, often the result of injections by local healthcare providers that cause neuropathic damage. Such injections are given when children become febrile from various causes and are non-therapeutic. Guillain-Barré syndrome, traumatic neuritis and hemiplegia are currently the most common causes of AFP in polio-endemic Pakistan. In most other locations, including throughout the African continent, the range of etiologies for paralysis – from infections to birth-related injuries – remain unclear. Active surveillance of AFP has been highly effective in the push towards eradication of poliomyelitis globally as witnessed by the 99% reduction in poliomyelitis cases through targeted vaccination programmes (Polio Eradication Initiative 2013). The frontline surveillance effort is predominantly clinical, requiring several thousands of healthcare workers in multiple low-income settings. Trained surveillance officers monitor and report AFP through large networks based on interactions with local healthcare providers and traditional healers. Cases of paralysis that fit standard definitions of AFP are examined, encompassing various presentations of poliomyelitis, including single-limb, multiple-limb and facial weakness in children younger than 15 years. Formal case histories are reported to a national polio surveillance centre, and stool samples are serotyped for poliovirus. A small proportion of all detected cases of AFP is due to poliomyelitis (Marx et al. 2000), even in poliomyelitis-endemic countries (WHO 2013d) (Table 1). Those cases that are ultimately diagnosed as poliomyelitis are reported weekly (WHO 2013e). Cases of AFP that are not due to poliomyelitis, the vast majority, are currently discarded and not officially reported or scrutinised. As the remaining countries eradicate poliomyelitis, surveillance personnel, laboratories and data reporting infrastructure are valuable for addressing other infectious and paralytic diseases. In some cases, expansion to measles and meningitis has been performed (Anonymous 2012). However, the existing infrastructure is also well suited to validate case definitions of AFP, address AFP-related fatality and disability, and consider leading causes of AFP that are not infectious but rather iatrogenic. Vertical programming can be expanded with limited efforts to diphtheritic polyneuropathy and eventually rabies, Guillain-Barré syndrome, and traumatic neuropathies. The clinical overlap and high amount of otherwise discarded data could reduce mortality. Although poliomyelitis can be severely disabling, it is less often fatal than many other paralytic disorders. Twenty-five years ago, the exclusivity of poliomyelitis eradication initiatives was prompted by international ‘lameness’ surveys which reported the higher than expected prevalence of preventable polio-related AFP in low-income settings. Today, poliomyelitis eradication campaigns reveal an unmet opportunity to remove the scourge of several other preventable causes of AFP in low-income settings. The disease surveillance approach that assisted poliomyelitis eradication can now also inform efforts to control other causes of childhood paralysis.

Prognostic Significance of β-Human Chorionic Gonadotropin and PAX8 Expression in Anaplastic Thyroid Carcinoma

Anaplastic thyroid carcinoma (ATC) is a rare, aggressive malignancy with a median survival of five months. Multimodality treatment is associated with some improvement in survival, but patients are only infrequently curable. Although β-hCG secretion has been reported in many neoplasms, it has never been described in ATC. The objectives of this study were to report a case of β-hCG-secreting ATC and to study the expression and significance of β-hCG and PAX8 in an institutional cohort of ATC. The sentinel case was characterized and then immunohistochemistry was performed for β-hCG and PAX8 on 30 ATC patients. Clinical follow-up was obtained by chart review. The sentinel patient with β-hCG-secreting ATC had a dramatic response to chemotherapy and radiation. After surgical excision of residual disease, the patient developed a regional recurrence of differentiated thyroid carcinoma at 18 months. However, she is now, 30 months after initial therapy, with no evidence of disease and no detectable serum β-hCG or thyroglobulin. Five of the 30 (17%) total ATCs were positive for β-hCG and 18 (60%) for PAX8. Outcomes for the β-hCG-positive cases were not significantly different from those for negative ones. However, none of the other four β-hCG-positive ATC patients received treatment with either chemotherapy or radiation. Interestingly, PAX8 positivity correlated with statistically significantly better overall survival (p=0.019). β-hCG is expressed in a minority of ATCs. Although only a single case in the study had diffuse immunohistochemical expression, the response it showed to aggressive multimodality therapy and the resulting favorable outcome suggest that β-hCG-positive ATC may be a unique tumor subtype, or possibly even a unique entity. PAX8 is a useful marker of ATC and may be helpful in the differential diagnosis with other malignant neoplasms.

Wire-related Pulmonary Artery Injury during Pediatric and Adult Congenital Interventional Cardiac Catheterization

Guidewires used in pediatric catheterization are typically floppy, soft, or J-tipped, and are generally assumed to be atraumatic. A recent sentinel case suggested that such wires may cause clinically significant pulmonary artery (PA) injury. We sought to determine the incidence of wire-related PA injury as a cause of "idiopathic" airway bleeding (endobronchial blood) during interventional cardiac catheterization in patients with congenital heart disease. The Children's Hospital Boston database of cardiac catheterizations was reviewed for adverse events (AEs) indicating possible PA injury occurring between September 2006 and August 2011. Procedure notes were reviewed, and when the clinical scenario was suggestive of wire injury or was not clear, relevant angiograms were reviewed. One thousand forty-seven cases involving PA dilation were performed in the period of interest. Five cases of probable wire injury were identified, suggesting an incidence of approximately 0.5 per 100 cases. Of these five cases, trauma was judged due to floppy-tipped wires in two, soft-tipped wires in two, and a J-tipped wire in one. In three cases, the distal wire was looped such that the leading segment was stiffer than the wire tip. Clinical manifestations of wire injury comprised contrast within the airway, vessel aneurysm/tear, obstructive intimal flap, blood from the endotracheal tube, hemothorax, and wedge defect on lung scan. These injuries were relatively benign and did not result in instability or prolonged bleeding. Wire injury to the PAs is relatively uncommon, although possible with even floppy-tipped wires. The mechanism and implications of such injuries are markedly different than balloon-mediated vascular tears.

Why the FBI Can't Build a Case Management System

A review of the problems that haunted the FBI's Virtual Case File and Sentinel case management programs and an examination of the technical reasons for these failures provide the basis for recommendations to help avoid their repetition.

D6 Estimation and Projection of HIV Epidemic Among High-Risk Populations in Jilin Province, China

Background National HIV estimates for China are conflicting. Current estimates are 0.057% (Chinese government), 0.1% (UNAIDS). Objective: To estimate the number of people living with HIV/AIDS (PLWHA) in Jilin province, China, in 2009 and to analyze and project the HIV epidemic trend in the next five years (2010–2015), thereby providing evidence for targeted HIV prevention and control measures. Method Workbook method, Estimation and Projection Package and Asia Epidemic Model were used to estimate the number of individuals with HIV/AIDS and to project the HIV epidemic trend from 2010 to 2015 using data from sentinel surveillance, case reports, epidemiological surveys and scientific lectures. Results By the end of 2009, there were 4388 PLWHA in Jilin Province, with a provincial HIV prevalence rate of 0.024%. Over 50% of PLWHA were men who have sex with men (MSM). From 2010 to 2015, the HIV epidemic will rise markedly among MSM [from 2.96% (2010) to 7.45 (2015)], relatively rise slowly among injecting drug users (IDU) [4.75% (2010) to 6.40 (2015)], and slow down among female sex workers (FSW) [0.66% (2010) to 1.62 (2015)] and their clients [1.05% (2010) to 2.62 (2015)]. Conclusions The number of PLWHA in Jilin province (and China) will rise quickly in the next five years if intervention efforts are not intensified to thwart the spread of HIV and if stigma and discrimination against MSM is not stopped. There is need for targeted preventive interventions. There is need to sensitize health care workers and health care administrators on the importance of accurate reporting of HIV cases.

Writing From the Wards

Published articles share information and ideas across fields and can be a part of educational and career development. Academic and personal interests are the typical motivators, but many residents have trouble with the logistics of writing and the simple act of getting started. The following article gives concrete advice, structural recommendations and addresses logistical concerns in writing manuscripts, focusing on case reports. The process of writing a paper results in self-teaching, while striving to teach others. Working on case reports often produces posters and presentations on the way to writing the manuscript. This article reviews different types of case reports: from the classic sentinel case, to case series, and video submissions, to teaching cases. A "how to" strategy is presented in the writing process, from idea, to data, to writing itself. Aspects such as choosing your audience and journal are discussed, as well as employing coauthors and working together to produce a polished manuscript. Residents and fellows are immersed in clinical medicine but may not possess experience in writing journal articles. Presented is advice on and logistics of writing manuscripts that are based on clinical data and clinical experience. Through utilizing a structured approach and understanding the practicalities involved, more physicians in training can write from the wards.

Chronic traumatic encephalopathy in an Iraqi war veteran with posttraumatic stress disorder who committed suicide

Following his discovery of chronic traumatic encephalopathy (CTE) in football players in 2002, Dr. Bennet Omalu hypothesized that posttraumatic stress disorder (PTSD) in military veterans may belong to the CTE spectrum of diseases. The CTE surveillance at the Brain Injury Research Institute was therefore expanded to include deceased military veterans diagnosed with PTSD. The authors report the case of a 27-year-old United States Marine Corps (USMC) Iraqi war veteran, an amphibious assault vehicle crewman, who committed suicide by hanging after two deployments to Fallujah and Ramadi. He experienced combat and was exposed to mortar blasts and improvised explosive device blasts less than 50 m away. Following his second deployment he developed a progressive history of cognitive impairment, impaired memory, behavioral and mood disorders, and alcohol abuse. Neuropsychiatric assessment revealed a diagnosis of PTSD with hyperarousal (irritability and insomnia) and numbing. He committed suicide approximately 8 months after his honorable discharge from the USMC. His brain at autopsy appeared grossly unremarkable except for congestive brain swelling. There was no atrophy or remote focal traumatic brain injury such as contusional necrosis or hemorrhage. Histochemical and immunohistochemical brain tissue analysis revealed CTE changes comprising multifocal, neocortical, and subcortical neurofibrillary tangles and neuritic threads (ranging from none, to sparse, to frequent) with the skip phenomenon, accentuated in the depths of sulci and in the frontal cortex. The subcortical white matter showed mild rarefaction, sparse perivascular and neuropil infiltration by histiocytes, and mild fibrillary astrogliosis. Apolipoprotein E genotype was 3/4. The authors report this case as a sentinel case of CTE in an Iraqi war veteran diagnosed with PTSD to possibly stimulate new lines of thought and research in the possible pathoetiology and pathogenesis of PTSD in military veterans as part of the CTE spectrum of diseases, and as chronic sequelae and outcomes of repetitive traumatic brain injuries.

A SENTINEL CASE SERIES OF CANCER PATIENTS WITH OCCUPATIONAL EXPOSURES TO ELECTROMAGNETIC NON-IONIZING RADIATION WITH SHORT LATENT PERIODS

Background and Aims: We have reported groups of workrers with high exposures to Non-Ionizing Radiation and short latent periods for cancer. We present a sentinel case series (n=47, 40M, 7F) of self-referred cancer patients with occupational exposures to EMF.Our aim was to report ages of first diagnosis/latency and tumor type and exposures Methods: We categorized patients with regard to types of radiation, far or near field exposure and direct body contact, age of diagnosis and latency. For some we had data on frequencies, for others we provided assessments Results: 15 patients developed cancer with latent periods &lt; 5y and 12 patients with latent periods between 5y and 10y. The remaining 20 patients had longer latent periods In the &lt;5y latency group there were 8 hematolymphatic cancers and 9 solid tumours – testis, head &amp; neck (including brain) and GI tract. In both the &lt;5y and 5-9y latency groups there were patients exposed to intense levels of EMF, to several frequencies of EMF, or to EMF in combination with IR or other exposures. There were patients with direct body contact, or were in direct line of focus from point sources, or worked in small, electronically dense environments. In the &gt;10y latency group there were more patients with intermittent exposures or exposures at older ages. Conclusions: The data suggest that cancer in young workers may be associated with intense severe exposures to EMF and short latent periods, especially for hematolymphatic cancers. The findings state the case for (1) more careful modelling of exposure sources and penetration into the body, (2) preventive and protective measures based on control of exposure at source, barriers, and personal protection and (3) exploring low-exposure-low risk relationships for latent periods &lt;10 y

Sentinel Case of Group A Beta-Hemolytic Streptococcus Causing Constrictive Pericarditis Presenting as Hypogammaglobulinemia

This is a unique case of a previously healthy 7-year-old boy, which highlights the importance of considering immunodeficiency when a rare infection occurs. In the following case report, the patient develops constrictive pericarditis secondary to group A beta-hemolytic streptococcal infection. As a result of this infection, we speculate that he develops hypogammaglobulinemia secondary to the documented association between constrictive pericarditis and intestinal lymphangiectasia because an extensive work-up for a primary immunodeficiency was negative. This is the first case ever to present constrictive pericarditis because of group A beta-hemolytic streptococcal infection.

When ordinary days become extraordinary: The response to H1N1 at the Izaak Walton Killam Health Centre

In April 2009, the H1N1 swine flu virus entered Canada with a sentinel case presenting in a private school in Windsor, Nova Scotia, signaling the beginning of wave 1 of a pandemic. By June, the World Health Organization raised the alert level to 6. Wave 2 was expected in 4 to 6 months. Between waves, the IWK took the opportunity to revise pandemic plans that had been prepared for the H5N1 avian influenza virus to ensure that the organization would be prepared for the emergency response that would be required to manage large numbers of ill people seeking healthcare services for the pending second wave of the swine flu.

Pregnancy Complicated by Cyclic Vomiting Syndrome

Cyclic vomiting syndrome is a condition that consists of recurrent episodes of vomiting occurring between periods of normal health, with no apparent organic cause of vomiting. We report the sentinel case of pregnancy complicated by preexisting cyclic vomiting syndrome. A primigravida presented at 8 weeks of gestation with a complaint of protracted vomiting. She had been diagnosed previously with cyclic vomiting syndrome. An extensive workup was performed, and she was admitted for therapy numerous times during her pregnancy. She underwent an indicated preterm delivery for fetal growth restriction, oligohydramnios, and nonreassuring fetal testing. The neonate was discharged to home in stable condition. Cyclic vomiting syndrome can complicate pregnancy, and the gravida with cyclic vomiting syndrome may be at risk for pregnancy complications. Increased surveillance may be warranted.

Transmission and expansion of HOXB4-induced leukemia in two immunosuppressed dogs: Implications for a new canine leukemia model

There are currently no large animal models to study the biology of leukemia and development of novel antileukemia therapies. We have previously shown that dogs transplanted with homeobox B4 (HOXB4)-transduced autologous CD34(+) cells developed myeloid leukemia associated with HOXB4 overexpression. Here we describe the transmission, engraftment, and expansion of these canine leukemia cells into two genetically unrelated, immunosuppressed dogs. Two dogs immunosuppressed after major histocompatibility complex-haploidentical hematopoietic cell transplantation and exhibiting mixed donor-host chimerism were accidentally infused trace amounts of HOXB4-overexpressing leukemia cells from a third-party dog. Six weeks after infusion of HOXB4-overexpressing leukemia cells, these two dogs rapidly developed myeloid leukemia consisting of marrow and organ infiltration, circulating blasts, and, in one dog, chloromatous masses. Despite neither of these dogs sharing any dog leukocyte antigen haplotypes with the sentinel case, the HOXB4-transduced clones engrafted and proliferated without difficulty in the presence of immunosuppression. Chimerism studies in both dogs confirmed that donor and, in one case, host hematopoietic cell engraftment was lost and replaced by third-party HOXB4 cells. The engraftment and expansion of these leukemia cells in dogs will allow studies into the biology of leukemia and development and evaluation of novel antileukemia therapies in a clinically relevant large animal model.

GS11 SEEING IS BELIEVING: A NEW WAY OF LOOKING AT HISTOPATHOLOGY RESULTS

Purpose: A sentinel case of missed rectal malignancy resulting in a poor outcome for a patient prompted a search for a process that ensures adequate follow up of all significant histopathology results. This paper aims to quantify the problem of inadequate histopathology follow up and develop an electronic tool and review process to ensure the patient's results are acted upon appropriately.Methodology: A Histopathology audit was undertaken at the Geelong Hospital between 2002 and 2006. Patients where inadequate follow up had occurred were identified. The situation for these patients was rectified and the risk quantified. An integrated electronic tool was then developed including a minimum data set. A review process was then tested to ensure adequacy of future follow up.Results: 6.3% (120/1912) of histopathology results in a 5 year period had been inadequately followed up. No further adverse outcomes were identified but each case was a potential time bomb for the patients who were not scheduled for clinical review (3.8%) or a recommended procedure (2.5%). A process of follow up has now been implemented and a minimum data set, procedure and electronic audit tool developed to assist with this process.Conclusion: Failure of adequate follow up of histopathology is a potential pitfall in any large health system. One such failure led to a disastrous outcome and a comprehensive audit suggested 6.3% of patients in the last 5 years were also at risk. We have established a review process we believe is reliable and developed an electronic tool to facilitate this process.

Respiratory Disease in Army Recruits: Surveillance Program Overview, 1995–2006

Since 1966, the U.S. Army has had in place a comprehensive surveillance system for acute respiratory disease (ARD) because of its continued high incidence in the recruit population. A retrospective review of the program from 1995 to 2006, a continuation of an earlier analysis from 1985-1994, was performed to describe the program and to summarize group A streptococcal (GAS) outbreaks identified through this program. Weekly incidence data and daily sentinel case data collected as part of the ARD surveillance program were analyzed in 2007 to report rates of ARD and GAS outbreaks over this 12-year period (1995-2006) for five participating Army sites. Average ARD rates were consistently higher from 2000 to 2006 than from 1995 to 1999. Rate ratios of winter rates to summer rates were greater than 1.0 prior to 2000, but from 2000 to 2006, ratios were consistently near 1.0. Rheumatogenic M types were available for three of five outbreaks. Continuing high incidence of ARD in the military, re-emerging rheumatogenic M types, and a highly mobile military underscore the need for continued surveillance efforts. The continued employment of interventions with demonstrated effectiveness, such as chemoprophylaxis and basic preventive measures, is essential to reducing the burden of ARD.

A Process for Sentinel Case Review to Assess Causal Relationships between Smallpox Vaccination and Adverse Outcomes, 2003–2004

The US Department of Defense requested that the Advisory Committee on Immunization Practices-Armed Forces Epidemiological Board joint Smallpox Vaccine Safety Working Group define the likelihood that smallpox vaccination played a causal role in the fatal illness of an Army reservist. Reported serious adverse events for which there was no a priori reason to discount the existence of a causal association with smallpox vaccine were reviewed to assess whether they were signals of constellations of vaccine-associated adverse events. A causal relationship between the immunization experience and the index patient's death was favored, but the implication of an individual vaccine was precluded. No new smallpox vaccine-associated clinical syndromes were identified. The data supported neutrality regarding the hypothesis that dilated cardiomyopathy was causally associated with smallpox vaccine-induced myocarditis. This review of sentinel cases augmented the ongoing safety review process and was transparent, but it shares limitations with other case-based causality-assessment methods.