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Volume 14, Number 7—July 2008

Volume 14, Number 7—July 2008   PDF Version [PDF - 4.51 MB - 179 pages]


  • Spread of Vector-borne Diseases and Neglect of Leishmaniasis, Europe PDF Version [PDF - 214 KB - 6 pages]
    J. Dujardin et al.
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    The risk for reintroduction of some exotic vector-borne diseases in Europe has become a hot topic, while the reality of others is neglected at the public health policy level. Leishmaniasis is endemic in all southern countries of Europe, with ≈700 autochthonous human cases reported each year (3,950 if Turkey is included). Asymptomatic cases have been estimated at 30–100/1 symptomatic case, and leishmaniasis has up to 25% seroprevalence in domestic dogs. Even though leishmaniasis is essentially associated with Leishmania infantum and visceral leishmaniasis, new species, such as L. donovani and L. tropica, might colonize European sand fly vectors. Drug-resistant L. infantum strains might be exported outside Europe through dogs. Despite this possibility, no coordinated surveillance of the disease exists at the European level. In this review of leishmaniasis importance in Europe, we would like to bridge the gap between research and surveillance and control.


  • Rickettsia felis as Emergent Global Threat for Humans PDF Version [PDF - 183 KB - 5 pages]
    C. E. Pérez-Osorio et al.
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    Rickettsia felis is an emergent pathogen belonging to transitional group rickettsiae. First described in 1990, R. felis infections have been reported to occur worldwide in fleas, mammals, and humans. Because clinical signs of the illness are similar to those of murine typhus and other febrile illnesses such as dengue, the infection in humans is likely underestimated. R. felis has been found throughout the world in several types of ectoparasites; cat fleas appear to be the most common vectors. R. felis infection should be considered an emergent threat to human health.


  • Household Responses to School Closure Resulting from Outbreak of Influenza B, North Carolina PDF Version [PDF - 133 KB - 7 pages]
    A. J. Johnson et al.
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    School closure is a proposed strategy for reducing influenza transmission during a pandemic. Few studies have assessed how families respond to closures, or whether other interactions during closure could reduce this strategy’s effect. Questionnaires were administered to 220 households (438 adults and 355 children) with school-age children in a North Carolina county during an influenza B virus outbreak that resulted in school closure. Closure was considered appropriate by 201 (91%) households. No adults missed work to solely provide childcare, and only 22 (10%) households required special childcare arrangements; 2 households incurred additional costs. Eighty-nine percent of children visited at least 1 public location during the closure despite county recommendations to avoid large gatherings. Although behavior and attitudes might differ during a pandemic, these results suggest short-term closure did not cause substantial hardship for parents. Pandemic planning guidance should address the potential for transmission in public areas during school closure.

  • Attributable Outcomes of Endemic Clostridium difficile–associated Disease in Nonsurgical Patients PDF Version [PDF - 162 KB - 8 pages]
    E. R. Dubberke et al.
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    Data are limited on the attributable outcomes of Clostridium difficile–associated disease (CDAD), particularly in CDAD-endemic settings. We conducted a retrospective cohort study of nonsurgical inpatients admitted for >48 hours in 2003 (N = 18,050). The adjusted hazard ratios for readmission (hazard ratio 2.19, 95% confidence interval [CI] 1.87–2.55) and deaths within 180 days (hazard ratio 1.23, 95% CI 1.03–1.46) were significantly different among CDAD case-patients and noncase patients. In a propensity score matched-pairs analysis that used a nested subset of the cohort (N = 706), attributable length of stay attributable to CDAD was 2.8 days, attributable readmission at 180 days was 19.3%, and attributable death at 180 days was 5.7%. CDAD patients were significantly more likely than controls to be discharged to a long-term-care facility or outside hospital. Even in a nonoutbreak setting, CDAD had a statistically significant negative impact on patient illness and death, and the impact of CDAD persisted beyond hospital discharge.

  • Toxinotype V Clostridium difficile in Humans and Food Animals PDF Version [PDF - 247 KB - 7 pages]
    M. A. Jhung et al.
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    Clostridium difficile is a recognized pathogen in neonatal pigs and may contribute to enteritis in calves. Toxinotype V strains have been rare causes of human C. difficile–associated disease (CDAD). We examined toxinotype V in human disease, the genetic relationship of animal and human toxinotype V strains, and in vitro toxin production of these strains. From 2001 through 2006, 8 (1.3%) of 620 patient isolates were identified as toxinotype V; before 2001, 7 (<0.02%) of ≈6,000 isolates were identified as toxinotype V. Six (46.2%) of 13 case-patients for whom information was available had community-associated CDAD. Molecular characterization showed a high degree of similarity between human and animal toxinotype V isolates; all contained a 39-bp tcdC deletion and most produced binary toxin. Further study is needed to understand the epidemiology of CDAD caused by toxinotype V C. difficile, including the potential of foodborne transmission to humans.

  • Medscape CME Activity
    Alcaligenes xylosoxidans Bloodstream Infections in Outpatient Oncology Office PDF Version [PDF - 175 KB - 7 pages]
    M. J. Kim et al.
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    In 2002, we investigated a cluster of patients with Alcaligenes xylosoxidans bloodstream infections by conducting a matched case–control study and a prospective study. Pulsed-field gel electrophoresis (PFGE) was performed on blood culture isolates, and 1 explanted central venous catheter (CVC) was tested for biofilm. We identified 12 cases of A. xylosoxidans bloodstream infection. Case-patients were more likely than controls to have had a CVC (7/7 [100%] vs 4/47 [8.7%], respectively; p<0.0001). Ten case isolates were indistinguishable by PFGE analysis, and A. xylosoxidans biofilm from the CVC matched the outbreak strain. We observed multiple breaches in infection control, which may have caused contamination of multidose vials used to flush the CVCs. Our study links A. xylosoxidans with CVC biofilm and highlights areas for regulation and oversight in outpatient settings.

  • Testing for Coccidioidomycosis among Patients with Community-Acquired Pneumonia PDF Version [PDF - 265 KB - 7 pages]
    D. C. Chang et al.
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    Coccidioidomycosis is a common cause of community-acquired pneumonia (CAP) in disease-endemic areas. Because testing rates influence interpretation of reportable-disease data and quality of CAP patient care, we determined the proportion of CAP patients who were tested for Coccidioides spp., identified testing predictors, and determined the proportion of tested patients who had positive coccidioidomycosis results. Cohort studies to determine the proportion of ambulatory CAP patients who were tested in 2 healthcare systems in metropolitan Phoenix found testing rates of 2% and 13%. A case-control study identified significant predictors of testing to be age >18 years, rash, chest pain, and symptoms for >14 days. Serologic testing confirmed coccidioidomycosis in 9 (15%) of 60 tested patients, suggesting that the proportion of CAP caused by coccidioidomycosis was substantial. However, because Coccidioides spp. testing among CAP patients was infrequent, reportable-disease data, which rely on positive diagnostic test results, greatly underestimate the true disease prevalence.

  • Determinants of Cluster Size in Large, Population-Based Molecular Epidemiology Study of Tuberculosis, Northern Malawi PDF Version [PDF - 301 KB - 7 pages]
    J. R. Glynn et al.
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    Tuberculosis patients with identical strains of Mycobacterium tuberculosis are described as clustered. Cluster size may depend on patient or strain characteristics. In a 7-year population-based study of tuberculosis in Karonga District, Malawi, clusters were defined by using IS6110 restriction fragment length polymorphism, excluding patterns with <5 bands. Spoligotyping was used to compare strains with an international database. Among 682 clustered patients, cluster size ranged from 2 to 37. Male patients, young adults, and town residents were over-represented in large clusters. Cluster size was not associated with HIV status or death from tuberculosis. Spoligotypes from 9 (90%) of 10 large cluster strains were identical or very similar (1 spacer different) to common spoligotypes found elsewhere, compared with 37 (66%) of 56 of those from nonclustered patients (p = 0.3). Large clusters were associated with factors likely to be related to social mixing, but spoligotypes of common strains in this setting were also common types elsewhere, consistent with strain differences in transmissibility.

  • Spotted Fever Group Rickettsiae in Ticks, Morocco PDF Version [PDF - 252 KB - 7 pages]
    M. Sarih et al.
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    A total of 370 ticks, encompassing 7 species from 4 genera, were collected during 2002–2006 from domestic animals and vegetation in the Taza region of northeastern Morocco. Rickettsial DNA was identified in 101 ticks (27%) by sequencing PCR products of fragments of the citrate synthase and outer membrane protein genes of Rickettsia spp. Seven rickettsiae of the spotted fever group were identified, including 4 pathogens: R. aeschlimannii in Hyalomma marginatum marginatum, R. massiliae in Rhipicephalus sanguineus, R. slovaca in Dermacentor marginatus, and R. monacensis in Ixodes ricinus. Two suspected pathogens were also detected (R. raoultii in D. marginatus and R. helvetica in I. ricinus). An incompletely described Rickettsia sp. was detected in Haemaphysalis spp. ticks.

  • Transmission of Bartonella henselae by Ixodes ricinus PDF Version [PDF - 146 KB - 7 pages]
    V. Cotté et al.
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    Bartonella spp. are facultative intracellular bacteria associated with several emerging diseases in humans and animals. B. henselae causes cat-scratch disease and is increasingly associated with several other syndromes, particularly ocular infections and endocarditis. Cats are the main reservoir for B. henselae and the bacteria are transmitted to cats by cat fleas. However, new potential vectors are suspected of transmitting B. henselae, in particular, Ixodes ricinus, the most abundant ixodid tick that bites humans in western Europe. We used a membrane-feeding technique to infect I. ricinus with B. henselae and demonstrate transmission of B. henselae within I. ricinus across developmental stages, migration or multiplication of B. henselae in salivary glands after a second meal, and transmission of viable and infective B. henselae from ticks to blood. These results provide evidence that I. ricinus is a competent vector for B. henselae.

  • Seasonality, Annual Trends, and Characteristics of Dengue among Ill Returned Travelers, 1997–2006 PDF Version [PDF - 412 KB - 8 pages]
    E. Meltzer et al.
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    We examined seasonality and annual trends for dengue cases among 522 returned travelers reported to the international GeoSentinel Surveillance Network. Dengue cases showed region-specific peaks for Southeast Asia (June, September), South Central Asia (October), South America (March), and the Caribbean (August, October). Travel-related dengue exhibited annual oscillations with several epidemics occurring during the study period. In Southeast Asia, annual proportionate morbidity increased from 50 dengue cases per 1,000 ill returned travelers in nonepidemic years to an average of 159 cases per 1,000 travelers during epidemic years. Dengue can thus be added to the list of diseases for which pretravel advice should include information on relative risk according to season. Also, dengue cases detected at atypical times in sentinel travelers may inform the international community of the onset of epidemic activity in specific areas.

  • A Prospective Study of Etiology of Childhood Acute Bacterial Meningitis, Turkey PDF Version [PDF - 296 KB - 8 pages]
    M. Ceyhan et al.
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    Determination of the etiology of bacterial meningitis and estimating cost of disease are important in guiding vaccination policies. To determine the incidence and etiology of meningitis in Turkey, cerebrospinal fluid (CSF) samples were obtained prospectively from children (1 month–17 years of age) with a clinical diagnosis of acute bacterial meningitis. Multiplex PCR was used to detect DNA evidence of Streptococcus pneumoniae, Haemophilus influenzae type b (Hib), and Neisseria meningitidis. In total, 408 CSF samples were collected, and bacterial etiology was determined in 243 cases; N. meningitidis was detected in 56.5%, S. pneumoniae in 22.5%, and Hib in 20.5% of the PCR-positive samples. Among N. meningitidis–positive CSF samples, 42.7%, 31.1%, 2.2%, and 0.7% belonged to serogroups W-135, B, Y, and A, respectively. This study highlights the emergence of serogroup W-135 disease in Turkey and concludes that vaccines to prevent meningococcal disease in this region must provide reliable protection against this serogroup.

  • Wide Distribution of a High-Virulence Borrelia burgdorferi Clone in Europe and North America PDF Version [PDF - 278 KB - 8 pages]
    W. Qiu et al.
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    The A and B clones of Borrelia burgdorferi sensu stricto, distinguished by outer surface protein C (ospC) gene sequences, are commonly associated with disseminated Lyme disease. To resolve phylogenetic relationships among isolates, we sequenced 68 isolates from Europe and North America at 1 chromosomal locus (16S–23S ribosomal RNA spacer) and 3 plasmid loci (ospC, dbpA, and BBD14). The ospC-A clone appeared to be highly prevalent on both continents, and isolates of this clone were uniform in DNA sequences, which suggests a recent trans-oceanic migration. The genetic homogeneity of ospC-A isolates was confirmed by sequences at 6 additional chromosomal housekeeping loci (gap, alr, glpA, xylB, ackA, and tgt). In contrast, the ospC-B group consists of genotypes distinct to each continent, indicating geographic isolation. We conclude that the ospC-A clone has dispersed rapidly and widely in the recent past. The spread of the ospC-A clone may have contributed, and likely continues to contribute, to the rise of Lyme disease incidence.


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