More than 10 years of unrecognized nosocomial transmission of legionnaires' disease among transplant patients

OBJECTIVE: To investigate a cluster of cases of legionnaires' disease among patients at a hospital. SETTING: A university hospital that is a regional transplant center. DESIGN: Retrospective review of microbiology and serology data from the hospital laboratories and prospective surveillance via the radiology department; a case-control study and environmental sampling within the hospital and from nearby cooling towers. RESULTS: Diagnosis of seven cases of legionnaires' disease in the first 9 months of 1996 led to recognition of a nosocomial outbreak that may have begun as early as 1979. Review of charts from 1987 through September 1996 identified 25 culture-confirmed cases of nosocomial or possibly nosocomial legionnaires' disease, including 18 in bone marrow and heart transplant patients. Twelve patients (48%) died. During the first 9 months of 1996, the attack rate was 6% among cardiac and bone marrow transplant patients. For cases that occurred before 1996, intubation was associated with increased risk for disease. High-dose corticosteroid medication was strongly associated with the risk for disease, but other immunosuppressive therapy or cancer chemotherapy was not. Several species and serogroups of Legionella were isolated from numerous sites in the hospital's potable water system. Six of seven available clinical isolates were identical and were indistinguishable from environmental isolates by pulsed-field gel electrophoresis. Initial infection control measures failed to interrupt nosocomial acquisition of infection. After extensive modifications to the water system, closely monitored repeated hyperchlorinations, and reduction of patient exposures to aerosols, transmission was interrupted. No cases have been identified since September 1996. CONCLUSIONS: Legionella can colonize hospital potable water systems for long periods of time, resulting in an ongoing risk for patients, especially those who are immunocompromised. In this hospital, nosocomial transmission possibly occurred for more than 17 years and was interrupted in 1996, after a sudden increase in incidence led to its recognition. Hospitals specializing in the care of immunocompromised patients (eg, transplant centers) should prioritize surveillance for cases of legionnaires' disease. Aggressive control measures can interrupt transmission of this disease successfully.     

Temperature Dependence of the Hall and Longitudinal Resistances in a Quantum Hall Resistance Standard

We present detailed measurements of the temperature dependence of the Hall and longitudinal resistances on a quantum Hall device [(GaAs(7)] which has been used as a resistance standard at NIST. We find a simple power law relationship between the change in Hall resistance and the longitudinal resistance as the temperature is varied between 1.4 K and 36 K. This power law holds over seven orders of magnitude change in the Hall resistance. We fit the temperature dependence above about 4 K to thermal activation, and extract the energy gap and the effective g-factor.     

Dependence of Quantized Hall Effect Breakdown Voltage on Magnetic Field and Current

When large currents are passed through a high-quality quantized Hall resistance device the voltage drop along the device is observed to assume discrete, quantized states if the voltage is plotted versus the magnetic field. These quantized dissipative voltage states are interpreted as occurring when electrons are excited to higher Landau levels and then return to the original Landau level. The quantization is found to be, in general, both a function of magnetic field and current. Consequently, it can be more difficult to verify and determine dissipative voltage quantization than previously suspected.     

Quantized dissipation of the quantum Hall effect at high currents

Quantized dissipative voltage states are observed when large currents are passed through a high-quality quantized Hall resistance device. These dissipative states are interpreted as occurring when electrons are excited to higher Landau levels and then return to the original Landau level. The author shows that the quantization is more complicated than previously thought. For example, the quantization can be a function of magnetic field. Therefore, the dissipative voltage quantization can, in general, be difficult to verify and determine     

Precision Tests of a Quantum Hall Effect Device DC Equivalent Circuit Using Double-Series and Triple-Series Connections

Precision tests verify the dc equivalent circuit used by Ricketts and Kemeny to describe a quantum Hall effect device in terms of electrical circuit elements. The tests employ the use of cryogenic current comparators and the double-series and triple-series connection techniques of Delahaye. Verification of the dc equivalent circuit in double-series and triple-series connections is a necessary step in developing the ac quantum Hall effect as an intrinsic standard of resistance.     

Equivalent Electrical Circuit Representations of AC Quantized Hall Resistance Standards

We use equivalent electrical circuits to analyze the effects of large parasitic impedances existing in all sample probes on four-terminal-pair measurements of the ac quantized Hall resistance R_H. The circuit components include the externally measurable parasitic capacitances, inductances, lead resistances, and leakage resistances of ac quantized Hall resistance standards, as well as components that represent the electrical characteristics of the quantum Hall effect device (QHE). Two kinds of electrical circuit connections to the QHE are described and considered: single-series “offset” and quadruple-series. (We eliminated other connections in earlier analyses because they did not provide the desired accuracy with all sample probe leads attached at the device.) Exact, but complicated, algebraic equations are derived for the currents and measured quantized Hall voltages for these two circuits. Only the quadruple-series connection circuit meets our desired goal of measuring R_H for both ac and dc currents with a one-standard-deviation uncertainty of 10⁻⁸ R_H or less during the same cool-down with all leads attached at the device. The single-series “offset” connection circuit meets our other desired goal of also measuring the longitudinal resistance R_x for both ac and dc currents during that same cool-down. We will use these predictions to apply small measurable corrections, and uncertainties of the corrections, to ac measurements of R_H in order to realize an intrinsic ac quantized Hall resistance standard of 10⁻⁸ R_H uncertainty or less.     

A Problem in AC Quantized Hall Resistance Measurements and a Proposed Solution

In all experiments reported to date the measured values of the ac quantized Hall resistances R_H varied with the frequency of the applied current, and differed significantly from the dc values of R_H, making it difficult to use the ac quantum Hall effect as an absolute impedance standard. We analyze the effects due to the large capacitances-to-shields existing in the sample probes on measurements of R_H to see if this is the source of the problem. Equivalent electrical circuits are utilized; they contain capacitances and leakage resistances to the sample probe shields, longitudinal resistances within the quantized Hall effect devices, and multiple connections to the devices. The algebraic solutions for the R_H values in these circuits reveal large out-of-phase contributions to the quantized Hall voltages V_H that would make it difficult to do accurate measurements with high precision ac bridges. These large out-of-phase contributions could introduce the linear frequency dependences observed in previous R_H measurements. We predict, however, that quadruple-series connections to the quantum Hall devices yield only small out-of-phase contributions to V_H which may allow accurate measurements of the quantity R_H − R_x, where R_x is the longitudinal resistance along the device.     

Observation and an Explanation of Breakdown of the Quantum Hall Effect

We observe a spatially localized breakdown of the nearly dissipationless quantum Hall effect into a set of discrete dissipative states in wide, high-quality GaAs/AlGaAs samples. The phenomenon can be explained by an extension of the quasi-elastic inter-Landau level scattering model of Eaves and Sheard.