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Volume 12, Number 11—November 2006

Volume 12, Number 11—November 2006   PDF Version [PDF - 7.81 MB - 187 pages]

Perspective

  • Prophylaxis and Treatment of Pregnant Women for Emerging Infections and Bioterrorism Emergencies PDF Version [PDF - 182 KB - 7 pages]
    J. Cono et al.
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    Infectious disease emergency preparedness planners should consider the special medical issues of pregnant women.

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    Emerging infectious disease outbreaks and bioterrorism attacks warrant urgent public health and medical responses. Response plans for these events may include use of medications and vaccines for which the effects on pregnant women and fetuses are unknown. Healthcare providers must be able to discuss the benefits and risks of these interventions with their pregnant patients. Recent experiences with outbreaks of severe acute respiratory syndrome, monkeypox, and anthrax, as well as response planning for bioterrorism and pandemic influenza, illustrate the challenges of making recommendations about treatment and prophylaxis for pregnant women. Understanding the physiology of pregnancy, the factors that influence the teratogenic potential of medications and vaccines, and the infection control measures that may stop an outbreak will aid planners in making recommendations for care of pregnant women during large-scale infectious disease emergencies.

  • Emerging Infections and Pregnancy PDF Version [PDF - 145 KB - 6 pages]
    D. J. Jamieson et al.
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    Immunologic changes of pregnancy may increase susceptibility to certain intracellular pathogens.

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    A key component of the response to emerging infections is consideration of special populations, including pregnant women. Successful pregnancy depends on adaptation of the woman's immune system to tolerate a genetically foreign fetus. Although the immune system changes are not well understood, a shift from cell-mediated immunity toward humoral immunity is believed to occur. These immunologic changes may alter susceptibility to and severity of infectious diseases in pregnant women. For example, pregnancy may increase susceptibility to toxoplasmosis and listeriosis and may increase severity of illness and increase mortality rates from influenza and varicella. Compared with information about more conventional disease threats, information about emerging infectious diseases is quite limited. Pregnant women's altered response to infectious diseases should be considered when planning a response to emerging infectious disease threats.

  • Health Consequences of Child Marriage in Africa PDF Version [PDF - 114 KB - 6 pages]
    N. M. Nour
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    Comprehensive, multifaceted policies are needed to end child marriage and protect girls and their offspring.

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    Despite international agreements and national laws, marriage of girls <18 years of age is common worldwide and affects millions. Child marriage is a human rights violation that prevents girls from obtaining an education, enjoying optimal health, bonding with others their own age, maturing, and ultimately choosing their own life partners. Child marriage is driven by poverty and has many effects on girls' health: increased risk for sexually transmitted diseases, cervical cancer, malaria, death during childbirth, and obstetric fistulas. Girls' offspring are at increased risk for premature birth and death as neonates, infants, or children. To stop child marriage, policies and programs must educate communities, raise awareness, engage local and religious leaders, involve parents, and empower girls through education and employment.

  • Anatidae Migration in the Western Palearctic and Spread of Highly Pathogenic Avian Influenza H5N1 Virus PDF Version [PDF - 317 KB - 7 pages]
    M. Gilbert et al.
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    Anatids may have spread the virus along their autumn migration routes.

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    During the second half of 2005, highly pathogenic avian influenza (HPAI) H5N1 virus spread rapidly from central Asia to eastern Europe. The relative roles of wild migratory birds and the poultry trade are still unclear, given that little is yet known about the range of virus hosts, precise movements of migratory birds, or routes of illegal poultry trade. We document and discuss the spread of the HPAI H5N1 virus in relation to species-specific flyways of Anatidae species (ducks, geese, and swans) and climate. We conclude that the spread of HPAI H5N1 virus from Russia and Kazakhstan to the Black Sea basin is consistent in space and time with the hypothesis that birds in the Anatidae family have seeded the virus along their autumn migration routes.

  • Review of Aerosol Transmission of Influenza A Virus PDF Version [PDF - 179 KB - 6 pages]
    R. Tellier
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    Extensive evidence indicates that aerosol transmission of influenza occurs and should be taken into account for pandemic planning.

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    In theory, influenza viruses can be transmitted through aerosols, large droplets, or direct contact with secretions (or fomites). These 3 modes are not mutually exclusive. Published findings that support the occurrence of aerosol transmission were reviewed to assess the importance of this mode of transmission. Published evidence indicates that aerosol transmission of influenza can be an important mode of transmission, which has obvious implications for pandemic influenza planning and in particular for recommendations about the use of N95 respirators as part of personal protective equipment.

Research

  • Susceptibility of North American Ducks and Gulls to H5N1 Highly Pathogenic Avian Influenza Viruses PDF Version [PDF - 293 KB - 8 pages]
    J. D. Brown et al.
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    Species-related differences in clinical response and duration and extent of viral shedding exist between North American ducks and gulls infected with H5N1 HPAI viruses.

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    Since 2002, H5N1 highly pathogenic avian influenza (HPAI) viruses have been associated with deaths in numerous wild avian species throughout Eurasia. We assessed the clinical response and extent and duration of viral shedding in 5 species of North American ducks and laughing gulls (Larus atricilla) after intranasal challenge with 2 Asian H5N1 HPAI viruses. Birds were challenged at ≈10 to 16 weeks of age, consistent with temporal peaks in virus prevalence and fall migration. All species were infected, but only wood ducks (Aix sponsa) and laughing gulls exhibited illness or died. Viral titers were higher in oropharyngeal swabs than in cloacal swabs. Duration of viral shedding (1–10 days) increased with severity of clinical disease. Both the hemagglutination-inhibition (HI) and agar gel precipitin (AGP) tests were able to detect postinoculation antibodies in surviving wood ducks and laughing gulls; the HI test was more sensitive than the AGP in the remaining 4 species

  • Targeted Social Distancing Designs for Pandemic Influenza PDF Version [PDF - 661 KB - 11 pages]
    R. J. Glass et al.
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    Local community networks can mitigate pandemic influenza in the absence of vaccine and antiviral drugs.

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    Targeted social distancing to mitigate pandemic influenza can be designed through simulation of influenza's spread within local community social contact networks. We demonstrate this design for a stylized community representative of a small town in the United States. The critical importance of children and teenagers in transmission of influenza is first identified and targeted. For influenza as infectious as 1957–58 Asian flu (≈50% infected), closing schools and keeping children and teenagers at home reduced the attack rate by >90%. For more infectious strains, or transmission that is less focused on the young, adults and the work environment must also be targeted. Tailored to specific communities across the world, such design would yield local defenses against a highly virulent strain in the absence of vaccine and antiviral drugs.

  • Seroprevalence of Hepatitis E Virus Infection, Rural Southern People’s Republic of China PDF Version [PDF - 190 KB - 7 pages]
    R. Li et al.
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    HEV infection is thought to have been endemic in southern China for >60 years; swine are now the main source of human infection.

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    Genotype 4 hepatitis E virus (HEV) is the dominant cause of hepatitis E in the People's Republic of China; swine are the principal reservoir. Our study was conducted in 8 rural communities of southern China, where families keep pigs near their homes. Phylogenetic analysis showed that 23 of 24 concurrent virus isolates from this region are genotype 4 strains. Among the study populations, immunoglobulin G anti-HEV seroprevalence accumulated with age at ≈1% per year for persons >60 years of age. After age 30 years, seroprevalence increased at higher rates for male than for female study participants. The overall seroprevalence was 43% (range 25%–66%) among the communities. Infection rates were higher for participants between 25 and 29 years of age. The results suggest that HEV infection probably has been endemic in southern China for <60 years, with swine being the principal reservoir of human HEV infection in recent years.

  • Spatiotemporal Analysis of Invasive Meningococcal Disease, Germany PDF Version [PDF - 177 KB - 7 pages]
    J. Elias et al.
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    Meningococcal disease clustering was found by DNA sequence–based finetyping and cluster detection software.

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    Meningococci can cause clusters of disease. Specimens from 1,616 patients in Germany obtained over 42 months were typed by serogrouping and sequence typing of PorA and FetA and yielded a highly diverse dataset (Simpson's index 0.963). A retrospective spatiotemporal scan statistic (SaTScan) was applied in an automated fashion to identify clusters for each finetype defined by serogroup variable region (VR) VR1 and VR2 of the PorA and VR of the FetA. A total of 26 significant clusters (p<0.05) were detected. On average, a cluster consisted of 2.6 patients. The median population in the geographic area of a cluster was 475,011, the median cluster duration was 4.0 days, and the proportion of cases in spatiotemporal clusters was 4.2%. The study exemplifies how the combination of molecular finetyping and spatiotemporal analysis can be used to assess an infectious disease in a large European country.

  • Schistosomiasis among Travelers: New Aspects of an Old Disease PDF Version [PDF - 102 KB - 5 pages]
    E. Schwartz et al.
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    Schistosomiasis is increasingly encountered among travelers returning from the tropics; signs and symptoms of travelers may differ from those of local populations. During 1993–2005, schistosomiasis was diagnosed in 137 Israeli travelers, most of whom were infected while in sub-Saharan Africa. Clinical findings compatible with acute schistosomiasis were recorded for 75 (66.4%) patients and included fever (71.3%), respiratory symptoms (42.9%), and cutaneous symptoms (45.2%). At time of physical examination, 42 patients (37.1%) still had symptoms of acute schistosomiasis, chronic schistosomiasis had developed in 23 (20.4%), and 48 (42.5%) were asymptomatic. Of patients who were initially asymptomatic, chronic schistosomiasis developed in 26%. Diagnosis was confirmed by serologic testing for 87.6% of patients, but schistosome ova were found in only 25.6%. We conclude that acute schistosomiasis is a major clinical problem among travelers, diagnostic and therapeutic options for acute schistosomiasis are limited, and asymptomatic travelers returning from schistosomiasis-endemic areas should be screened and treated.

  • Gastroenteritis and Transmission of Helicobacter pylori Infection in Households PDF Version [PDF - 130 KB - 8 pages]
    S. Perry et al.
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    In northern California homes, exposure to gastroenteritis in an H. pylori–infected contact markedly increased H. pylori infection.

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    The mode of transmission of Helicobacter pylori infection is poorly characterized. In northern California, 2,752 household members were tested for H. pylori infection in serum or stool at a baseline visit and 3 months later. Among 1,752 person considered uninfected at baseline, 30 new infections (7 definite, 7 probable, and 16 possible) occurred, for an annual incidence of 7% overall and 21% in children <2 years of age. Exposure to an infected household member with gastroenteritis was associated with a 4.8-fold (95% confidence interval [CI] 1.4–17.1) increased risk for definite or probable new infection, with vomiting a greater risk factor (adjusted odds ratio [AOR] 6.3, CI 1.6–24.5) than diarrhea only (AOR 3.0, p = 0.65). Of probable or definite new infections, 75% were attributable to exposure to an infected person with gastroenteritis. Exposure to an H. pylori–infected person with gastroenteritis, particularly vomiting, markedly increased risk for new infection.

  • Serotype Competence and Penicillin Resistance in Streptococcus pneumoniae PDF Version [PDF - 138 KB - 6 pages]
    Y. Hsieh et al.
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    Enhanced molecular surveillance of virulent clones with higher competence can detect serotype switching.

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    From 2003 to 2005, we prospectively collected 118 isolates of pneumococci belonging to 7 serotypes to investigate their competence under the influence of the synthetic competence-stimulating peptides. The degree of competence of the various serotypes differed significantly. Serotype 6B had the highest competence, followed by serotypes 14, 19F, 9V, 23F, 3, and 18C. Isolates belonging to serotype 6B had greater genetic diversity than isolates belonging to serotype 3, which has high genetic clustering. Isolates belonging to serotypes 3 and 18C that were 100% sensitive to penicillin were significantly less competent than isolates belonging to serotypes 6B, 14, 19F, 9V, and 23F, which were frequently resistant to penicillin. Under the 7-valent pneumococcal conjugate vaccine program, enhanced molecular surveillance of virulent clones with higher competence to detect serotype switching will become more important.

  • Staphylococcus aureus–associated Skin and Soft Tissue Infections in Ambulatory Care PDF Version [PDF - 296 KB - 9 pages]
    L. F. McCaig et al.
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    The rise in visits to outpatient and emergency departments for skin and soft tissue infections may reflect the emergence of community-associated methicillin-resistant Staphylococcus aureus.

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    To describe the number and treatment of skin and soft tissue infections likely caused by Staphylococcus aureus in the United States, we analyzed data from the 1992–1994 and 2001–2003 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Each year, data were reported by an average of 1,400 physicians, 230 outpatient departments, and 390 emergency departments for 30,000, 33,000, and 34,000 visits, respectively. During 2001–2003, the number of annual ambulatory care visits for skin and soft tissue infections was 11.6 million; the visit rate was 410.7 per 10,000 persons. During the study period, rates of overall and physician office visits did not differ; however, rates of visits to outpatient and emergency departments increased by 59% and 31%, respectively. This increase may reflect the emergence of community-acquired methicillin-resistant S. aureus infections.

  • Humans as Reservoir for Enterotoxin Gene–carrying Clostridium perfringens Type A PDF Version [PDF - 243 KB - 6 pages]
    A. Heikinheimo et al.
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    Humans may play a role in the transmission of gastrointestinal diseases caused by C. perfringens.

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    We found a prevalence of 18% for enterotoxin gene–carrying (cpe+) Clostridium perfringens in the feces of healthy food handlers by PCR and isolated the organism from 11 of 23 PCR-positive persons by using hydrophobic grid membrane filter-colony hybridization. Several different cpe genotypes were recovered. The prevalence was 3.7% for plasmidial IS1151-cpe, 2.9% for plasmidial IS1470-like-cpe, 0.7% for chromosomal IS1470-cpe, and 1.5% for unknown cpe genotype. Lateral spread of cpe between C. perfringens strains was evident because strains from the same person carried IS1470-like cpe but shared no genetic relatedness according to pulsed-field gel electrophoresis analysis. Our findings suggest that healthy humans serve as a rich reservoir for cpe+ C. perfringens type A and may play a role in the etiology of gastrointestinal diseases caused by this organism. The results also indicate that humans should be considered a risk factor for spread of C. perfringens type A food poisoning and that they are a possible source of contamination for C. perfringens type A food poisoning.

  • Clostridium difficile PCR Ribotypes in Calves, Canada PDF Version [PDF - 129 KB - 7 pages]
    A. Rodriguez-Palacios et al.
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    C. difficile, including epidemic PCR ribotypes 017 and 027, were isolated from dairy calves in Canada.

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    We investigated Clostridium difficile in calves and the similarity between bovine and human C. difficile PCR ribotypes by conducting a case-control study of calves from 102 dairy farms in Canada. Fecal samples from 144 calves with diarrhea and 134 control calves were cultured for C. difficile and tested with an ELISA for C. difficile toxins A and B. C. difficile was isolated from 31 of 278 calves: 11 (7.6%) of 144 with diarrhea and 20 (14.9%) of 134 controls (p = 0.009). Toxins were detected in calf feces from 58 (56.8%) of 102 farms, 57 (39.6%) of 144 calves with diarrhea, and 28 (20.9%) of 134 controls (p = 0.0002). PCR ribotyping of 31 isolates showed 8 distinct patterns; 7 have been identified in humans, 2 of which have been associated with outbreaks of severe disease (PCR types 017 and 027). C. difficile may be associated with calf diarrhea, and cattle may be reservoirs of C. difficile for humans.

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