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Volume 14, Number 10—October 2008

Volume 14, Number 10—October 2008   PDF Version [PDF - 6.34 MB - 179 pages]


  • Rise and Persistence of Global M1T1 Clone of Streptococcus pyogenes PDF Version [PDF - 166 KB - 7 pages]
    R. K. Aziz and M. Kotb
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    The resurgence of severe invasive group A streptococcal infections in the 1980s is a typical example of the reemergence of an infectious disease. We found that this resurgence is a consequence of the diversification of particular strains of the bacteria. Among these strains is a highly virulent subclone of serotype M1T1 that has exhibited unusual epidemiologic features and virulence, unlike all other streptococcal strains. This clonal strain, commonly isolated from both noninvasive and invasive infection cases, is most frequently associated with severe invasive diseases. Because of its unusual prevalence, global spread, and increased virulence, we investigated the unique features that likely confer its unusual properties. In doing so, we found that the increased virulence of this clonal strain can be attributed to its diversification through phage mobilization and its ability to sense and adapt to different host environments; accordingly, the fittest members of this diverse bacterial community are selected to survive and invade host tissue.


  • Pandemic Influenza and Excess Intensive-Care Workload PDF Version [PDF - 325 KB - 8 pages]
    R. E. Nap et al.
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    In the Netherlands a major part of preparedness planning for an epidemic or pandemic consists of maintaining essential public services, e.g., by the police, fire departments, army personnel, and healthcare workers. We provide estimates for peak demand for healthcare workers, factoring in healthcare worker absenteeism and using estimates from published epidemiologic models on the expected evolution of pandemic influenza in relation to the impact on peak surge capacity of healthcare facilities and intensive care units (ICUs). Using various published scenarios, we estimate their effect in increasing the availability of healthcare workers for duty during a pandemic. We show that even during the peak of the pandemic, all patients requiring hospital and ICU admission can be served, including those who have non–influenza-related conditions. For this rigorous task differentiation, clear hierarchical management, unambiguous communication, and discipline are essential and we recommend informing and training non-ICU healthcare workers for duties in the ICU.

  • Risk Factors for Nipah Virus Encephalitis in Bangladesh PDF Version [PDF - 173 KB - 7 pages]
    J. M. Montgomery et al.
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    Nipah virus (NiV) is a paramyxovirus that causes severe encephalitis in humans. During January 2004, twelve patients with NiV encephalitis (NiVE) were identified in west-central Bangladesh. A case–control study was conducted to identify factors associated with NiV infection. NiVE patients from the outbreak were enrolled in a matched case-control study. Exact odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using a matched analysis. Climbing trees (83% of cases vs. 51% of controls, OR 8.2, 95% CI 1.25–∞) and contact with another NiVE patient (67% of cases vs. 9% of controls, OR 21.4, 95% CI 2.78–966.1) were associated with infection. We did not identify an increased risk for NiV infection among persons who had contact with a potential intermediate host. Although we cannot rule out person-to-person transmission, case-patients were likely infected from contact with fruit bats or their secretions.

  • Deforestation and Vectorial Capacity of Anopheles gambiae Giles Mosquitoes in Malaria Transmission, Kenya PDF Version [PDF - 185 KB - 6 pages]
    Y. A. Afrane et al.
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    We investigated the effects of deforestation on microclimates and sporogonic development of Plasmodium falciparum parasites in Anopheles gambiae mosquitoes in an area of the western Kenyan highland prone to malaria epidemics. An. gambiae mosquitoes were fed with P. falciparum–infected blood through membrane feeders. Fed mosquitoes were placed in houses in forested and deforested areas in a highland area (1,500 m above sea level) and monitored for parasite development. Deforested sites had higher temperatures and relative humidities, and the overall infection rate of mosquitoes was increased compared with that in forested sites. Sporozoites appeared on average 1.1 days earlier in deforested areas. Vectorial capacity was estimated to be 77.7% higher in the deforested site than in the forested site. We showed that deforestation changes microclimates, leading to more rapid sporogonic development of P. falciparum and to a marked increase of malaria risk in the western Kenyan highland.

  • Ecologic Factors Associated with West Nile Virus Transmission, Northeastern United States PDF Version [PDF - 191 KB - 7 pages]
    H. E. Brown et al.
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    Since 1999, West Nile virus (WNV) disease has affected the northeastern United States. To describe the spatial epidemiology and identify risk factors for disease incidence, we analyzed 8 years (1999–2006) of county-based human WNV disease surveillance data. Among the 56.6 million residents in 8 northeastern states sharing primary enzootic vectors, we found 977 cases. We controlled for population density and potential bias from surveillance and spatial proximity. Analyses demonstrated significant spatial spreading from 1999 through 2004 (p<0.01, r2 = 0.16). A significant trend was apparent among increasingly urban counties; county quartiles with the least (<38%) forest cover had 4.4-fold greater odds (95% confidence interval [CI] 1.4–13.2, p = 0.01) of having above-median disease incidence (>0.75 cases/100,000 residents) than counties with the most (>70%) forest cover. These results quantify urbanization as a risk factor for WNV disease incidence and are consistent with knowledge of vector species in this area.

  • Deaths from Norovirus among the Elderly, England and Wales PDF Version [PDF - 280 KB - 9 pages]
    J. P. Harris et al.
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    The number of deaths in England and Wales associated with gastrointestinal pathogens, norovirus in particular, in persons >65 years was estimated for 2001–2006. Regression analysis was used to model monthly counts of gastrointestinal pathogens in fecal samples from infected patients against monthly counts of deaths from infectious and noninfectious intestinal diseases. Data came from the Office of National Statistics (death registrations from local registrars) and from the Health Protection Agency (laboratory results). Model results suggest that 20% (13.3%–26.8%) of deaths in persons >65 years of age caused by infectious intestinal disease other than Clostridium difficile were associated with norovirus infection in this period and that 13% (7.5%–18.5%) of deaths caused by noninfectious intestinal disease were associated with norovirus. An estimated 80 deaths each year in this age group may be associated with norovirus infection.

  • Norwalk Virus Shedding after Experimental Human Infection PDF Version [PDF - 160 KB - 5 pages]
    R. L. Atmar et al.
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    Noroviruses are the most common cause of viral gastroenteritis in the United States. To determine the magnitude and duration of virus shedding in feces, we evaluated persons who had been experimentally infected with Norwalk virus. Of 16 persons, clinical gastroenteritis (watery diarrhea and/or vomiting) developed in 11; symptomatic illness lasted 1–2 days. Virus shedding was first detected by reverse transcription–PCR (RT-PCR) 18 hours after participant inoculation and lasted a median of 28 days after inoculation (range 13–56 days). The median peak amount of virus shedding was 95 × 109 (range 0.5–1,640 ×109) genomic copies/g feces as measured by quantitative RT-PCR. Virus shedding was first detected by antigen ELISA ≈33 hours (median 42 hours) after inoculation and lasted 10 days (median 7 days) after inoculation. Understanding of the relevance of prolonged fecal norovirus excretion must await the development of sensitive methods to measure virus infectivity.

  • Prophylaxis after Exposure to Coxiella burnetii PDF Version [PDF - 177 KB - 9 pages]
    C. E. Moodie et al.
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    Coxiella burnetii is a category B bioterrorism agent. We numerically evaluated the risks and benefits from postexposure prophylaxis (PEP) after an intentional release of C. burnetii to the general population, pregnant women, and other high-risk populations. For each group, we constructed a decision tree to estimate illness and deaths averted by use of PEP/100,000 population. We calculated the threshold points at which the number of PEP-related adverse events was equal to the cases averted. PEP was defined as doxycycline (100 mg 2×/day for 5 days), except for pregnant women, where we assumed a PEP of trimethoprim-sulfamethoxazole (160 mg/800 mg 2×/day) for the duration of the pregnancy. PEP would begin 8–12 days postexposure. On the basis of upper-bound probability estimates of PEP-related adverse events for doxycycline, we concluded that the risk for Q fever illness outweighs the risk for antimicrobial drug–related adverse events when the probability of C. burnetii exposure is >7% (pregnant women using trimethoprim-sulfamethoxazole = 16%).

  • Cryptosporidium Species and Subtypes and Clinical Manifestations in Children, Peru PDF Version [PDF - 139 KB - 8 pages]
    V. A. Cama et al.
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    To determine whether clinical manifestations are associated with genotypes or subtypes of Cryptosporidium spp., we studied a 4-year longitudinal birth cohort of 533 children in Peru. A total of 156 infection episodes were found in 109 children. Data from first infections showed that C. hominis was associated with diarrhea, nausea, vomiting, general malaise, and increased oocyst shedding intensity and duration. In contrast, C. parvum, C. meleagridis, C. canis, and C. felis were associated with diarrhea only. C. hominis subtype families were identified (Ia, Ib, Id, and Ie); all were associated with diarrhea. Ib was also associated with nausea, vomiting, and general malaise. All C. parvum specimens belonged to subtype family IIc. Analysis of risk factors did not show associations with specific Cryptosporidium spp. genotypes or subtypes. These findings strongly suggest that Cryptosporidium spp. and subtypes are linked to different clinical manifestations in children.

  • Endemic and Epidemic Lineages of Escherichia coli that Cause Urinary Tract Infections PDF Version [PDF - 244 KB - 9 pages]
    A. R. Manges et al.
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    Women with urinary tract infections (UTIs) in California, USA (1999–2001), were infected with closely related or indistinguishable strains of Escherichia coli (clonal groups), which suggests point source dissemination. We compared strains of UTI-causing E. coli in California with strains causing such infections in Montréal, Québec, Canada. Urine specimens from women with community-acquired UTIs in Montréal (2006) were cultured for E. coli. Isolates that caused 256 consecutive episodes of UTI were characterized by antimicrobial drug susceptibility profile, enterobacterial repetitive intergenic consensus 2 PCR, serotyping, XbaI and NotI pulsed-field gel electrophoresis, multilocus sequence typing, and phylogenetic typing. We confirmed the presence of drug-resistant, genetically related, and temporally clustered E. coli clonal groups that caused community-acquired UTIs in unrelated women in 2 locations and 2 different times. Two clonal groups were identified in both locations. Epidemic transmission followed by endemic transmission of UTI-causing clonal groups may explain these clusters of UTI cases.

  • Medscape CME Activity
    Microbial Interactions during Upper Respiratory Tract Infections PDF Version [PDF - 155 KB - 8 pages]
    M. M. Pettigrew et al.
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    Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus often colonize the nasopharynx. Children are susceptible to bacterial infections during or soon after upper respiratory tract infection (URI). We describe colonization with these 4 bacteria species alone or in combination during URI. Data were from a prospective cohort of healthy children 6 to 36 months of age followed up for 1 year. Analyses of 968 swabs from 212 children indicated that S. pneumoniae colonization is negatively associated with colonization by H. influenzae. Competitive interactions shifted when H. influenzae and M. catarrhalis colonized together. In this situation, the likelihood of colonization with all 3 species is higher. Negative associations were identified between S. pneumoniae and S. aureus and between H. influenzae and S. aureus. Polymicrobial interactions differed by number and species of bacteria present. Antimicrobial therapy and vaccination strategies targeting specific bacterial species may alter the flora in unforeseen ways.

  • Pyogenic Liver Abscess as Endemic Disease, Taiwan PDF Version [PDF - 212 KB - 9 pages]
    F. Tsai et al.
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    Pyogenic liver abscess has become a health problem in Taiwanese society. However, the extent of this problem has remained unclear because of the lack of a population-based study. We therefore performed a nationwide analysis of pyogenic liver abscess in Taiwan from 1996 through 2004. We analyzed 29,703 cases from the Taiwan National Health Insurance database and 506 cases from National Taiwan University Hospital. Our analysis showed that the annual incidence of pyogenic liver abscess increased steadily from 11.15/100,000 population in 1996 to 17.59/100,000 in 2004. Diabetes, malignancy, renal disease, and pneumonia were associated with a higher risk for the disease. By contrast, death due to pyogenic liver abscess decreased over time, although population-based abscess-related death increased slightly. Renal disease, malignancy, pneumonia, and heart disease correlated with higher death rates; Klebsiella pneumoniae infection and therapeutic procedures were related to lower death rates. Diabetes did not significantly change death rates for the 506 patients from the hospital.

  • Estimating Community Incidence of Salmonella, Campylobacter, and Shiga Toxin–producing Escherichia coli Infections, Australia PDF Version [PDF - 186 KB - 9 pages]
    G. Hall et al.
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    To estimate multipliers linking surveillance of salmonellosis, campylobacteriosis, and Shiga toxin–producing Escherichia coli (STEC) infections to community incidence, we used data from a gastroenteritis survey and other sources. Multipliers for severe (bloody stool/long duration) and milder cases were estimated from the component probabilities of doctor visit, stool test, sensitivity of laboratory test, and reporting to surveillance system. Pathogens were classified by the same severity criteria and appropriate multipliers applied. Precision of estimates was quantified by using simulation techniques to construct 95% credible intervals (CrIs). The multiplier for salmonellosis was estimated at 7 (95% CrI 4–16), for campylobacteriosis at 10 (95% CrI 7–22), and for STEC at 8 (95% CrI 3–75). Australian annual community incidence rates per 100,000 population were estimated as 262 (95% CrI 150–624), 1,184 (95% CrI 756–2,670), and 23 (95% CrI 13–54), respectively. Estimation of multipliers allows assessment of the true effects of these diseases and better understanding of public health surveillance.



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