Goldmann D A, Dixon R E, Fulkerson C C, Maki D G, Martin S M, Bennett J V
Am J Epidemiol. 1978 Sep;108(3):207-13. doi: 10.1093/oxfordjournals.aje.a112613.
Since January, 1970, the Center for Disease Control (CDC) has corridnated surveillance of nosocomial infections in a group of voluntarily cooperating hispitals in the United States. In 1970, this surveillance system failed to realize one of its major goals: detection of a nationwide epidemic of septicemia caused by contaminated intravenous products. However, retrospective review of infections reported to CDC revealed that the data received were sufficient for the outbreak to have been recognized. Beginning in July, 1970, one month after the contaminated products were first distributed and five months before the outbreak was actually detected. CDC data showed a persistent increase in the incidence of Enterobacter and Erwinia (presently designated Enterobacter agglomerans) bacteremia. Furthermore, monthly rates of cases of bacteremia caused by these organisms were higher in hospitals using the contaminated intravenous products than for hospitals not using them. Failure to detect this outbreak at the time of its occurrence was due to delays in data processing and insufficiently sophisticated data analysis. Based on this experience, CDC has modified the surveillance system to aid recognition of future outbreaks.
自1970年1月以来，美国疾病控制中心（CDC）一直在协调对一组自愿合作的医院中的医院感染进行监测。1970年，该监测系统未能实现其主要目标之一：发现由受污染静脉注射产品引起的全国性败血症流行。然而，对向疾病预防控制中心报告的感染情况进行回顾性审查发现，收到的数据足以识别此次疫情。从1970年7月开始，即受污染产品首次分发后的一个月，也是疫情实际被发现前的五个月。疾病预防控制中心的数据显示，肠杆菌属和欧文氏菌属（现称为成团泛菌）菌血症的发病率持续上升。此外，使用受污染静脉注射产品的医院中，由这些微生物引起的菌血症病例月发病率高于未使用该产品的医院。此次疫情发生时未能被发现，是由于数据处理延迟和数据分析不够精细。基于这一经验，疾病预防控制中心对监测系统进行了改进，以帮助识别未来的疫情。
