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Volume 18, Number 4—April 2012

Volume 18, Number 4—April 2012   PDF Version [PDF - 5.17 MB - 175 pages]


  • Medscape CME Activity
    Determinants for Autopsy after Unexplained Deaths Possibly Resulting from Infectious Causes, United States PDF Version [PDF - 234 KB - 7 pages]
    L. Liu et al.
    View Summary

    Autopsy findings, clinical history, and diagnostic tools can aid surveillance and investigation of infectious diseases.

       View Abstract

    We analyzed US multiple cause-of-death data for 2003–2006 for demographic and clinical determinants for autopsy in unexplained deaths possibly resulting from infectious causes. For 96,242 deaths, the definition for unexplained death was met and autopsy status was recorded. Most decedents were male, 40–49 years of age, and white. To identify factors associated with unexplained death, we used data from Arizona records. Multivariate analysis of Arizona records suggested that decedents of races other than white and black and decedents who had clinicopathologic syndromes in the cardiovascular, sepsis/shock, and multisyndrome categories recorded on the death certificate were least likely to have undergone autopsy; children with unexplained death were the most likely to have undergone autopsy. Improved understanding of unexplained deaths can provide opportunities for further studies, strengthen collaboration between investigators of unexplained deaths, and improve knowledge and awareness of infectious diseases of public health concern.

  • Medscape CME Activity
    Influenza-associated Hospitalizations by Industry, 2009–10 Influenza Season, United States PDF Version [PDF - 183 KB - 7 pages]
    S. E. Luckhaupt et al.
    View Summary

    Since the 2009 flu pandemic, questions have been raised about the risk for flu to health care workers. But what about other workers? Does having a job put a person at risk for flu? And does the type of job influence this risk? According to a CDC study, having a job is actually associated with a lower risk for hospitalization for flu, possibly because workers are generally young and healthy. But among workers who are hospitalized for flu, certain industries of employment were more common than others. Not surprisingly, the industry posing the highest risk was health care. Others included transportation and warehousing, administrative and support services, waste management and remediation services, and accommodation and food services. In the event of another pandemic, this information can be used to prioritize who should receive vaccine and to decide who needs personal protective equipment like face masks or respirators.

       View Abstract

    In response to pandemic (H1N1) 2009, data were collected on work status and industry of employment of 3,365 adults hospitalized with laboratory-confirmed influenza during the 2009–10 influenza season in the United States. The proportion of workers hospitalized for influenza was lower than their proportion in the general population, reflecting underlying protective characteristics of workers compared with nonworkers. The most commonly represented sectors were transportation and warehousing; administrative and support and waste management and remediation services; health care; and accommodation and food service.

  • Identification of Risk Factors for Chronic Q Fever, the Netherlands PDF Version [PDF - 182 KB - 8 pages]
    L. M. Kampschreur et al.
    View Summary

    Previous cardiac valvular surgery, vascular prosthesis, aortic aneurysm, renal insufficiency, and older age increased risk.

       View Abstract

    Since 2007, the Netherlands has experienced a large Q fever outbreak. To identify and quantify risk factors for development of chronic Q fever after Coxiella burnetii infection, we performed a case–control study. Comorbidity, cardiovascular risk factors, medications, and demographic characteristics from 105 patients with proven (n = 44), probable (n = 28), or possible (n = 33) chronic Q fever were compared with 201 patients who had acute Q fever in 2009 but in whom chronic Q fever did not develop (controls). Independent risk factors for development of proven chronic Q fever were valvular surgery, vascular prosthesis, aneurysm, renal insufficiency, and older age.

  • Geographic Distribution of Hantaviruses Associated with Neotomine and Sigmodontine Rodents, Mexico PDF Version [PDF - 192 KB - 6 pages]
    M. L. Milazzo et al.
    View Summary

    El Moro Canyon virus and Limestone Canyon virus are widely distributed and may cause hantavirus pulmonary syndrome.

       View Abstract

    To increase our knowledge of the geographic distribution of hantaviruses associated with neotomine or sigmodontine rodents in Mexico, we tested 876 cricetid rodents captured in 18 Mexican states (representing at least 44 species in the subfamily Neotominae and 10 species in the subfamily Sigmodontinae) for anti-hantavirus IgG. We found antibodies against hantavirus in 35 (4.0%) rodents. Nucleotide sequence data from 5 antibody-positive rodents indicated that Sin Nombre virus (the major cause of hantavirus pulmonary syndrome [HPS] in the United States) is enzootic in the Mexican states of Nuevo León, San Luis Potosí, Tamaulipas, and Veracruz. However, HPS has not been reported from these states, which suggests that in northeastern Mexico, HPS has been confused with other rapidly progressive, life-threatening respiratory diseases. Analyses of nucleotide sequence data from 19 other antibody-positive rodents indicated that El Moro Canyon virus and Limestone Canyon virus are geographically widely distributed in Mexico.

  • Shiga Toxin–producing Escherichia coli Serotype O78:H in Family, Finland, 2009 PDF Version [PDF - 167 KB - 5 pages]
    T. Lienemann et al.
    View Summary

    STEC carrying stx1c and hlyA genes can invade the human bloodstream.

       View Abstract

    Shiga toxin–producing Escherichia coli (STEC) is a pathogen that causes gastroenteritis and bloody diarrhea but can lead to severe disease, such as hemolytic uremic syndrome (HUS). STEC serotype O78:H is rare among humans, and infections are often asymptomatic. We detected a sorbitol-fermenting STEC O78:H:stx1c:hlyA in blood and fecal samples of a 2-week-old boy who had bacteremia and HUS and in fecal samples of his asymptomatic family members. The phenotypic and genotypic characteristics and the virulence properties of this invasive STEC were investigated. Our findings demonstrate that contrary to earlier suggestions, STEC under certain conditions can invade the human bloodstream. Moreover, this study highlights the need to implement appropriate diagnostic methods for identifying the whole spectrum of STEC strains associated with HUS.

  • Identification of Intermediate in Evolutionary Model of Enterohemorrhagic Escherichia coli O157 PDF Version [PDF - 206 KB - 7 pages]
    C. Jenke et al.
    View Summary

    Single-nucleotide polymorphism typing found missing link between human strains in strain from deer.

       View Abstract

    Highly pathogenic enterohemorrhagic Escherichia coli (EHEC) O157 cause a spectrum of clinical signs that include diarrhea, bloody diarrhea, and hemolytic uremic syndrome. The current evolutionary model of EHEC O157:H7/H consists of a stepwise evolution scenario proceeding from O55:H7 to a node (hypothetical intermediate) that then branches into sorbitol-fermenting (SF) O157:H and non-SF (NSF) O157:H7. To identify this hypothetical intermediate, we performed single nucleotide polymorphism analysis by sequencing of 92 randomly distributed backbone genomic regions of 40 O157:H7/H isolates. Overall, 111 single nucleotide polymorphisms were identified in 75/92 partial open reading frames after sequencing 51,041 nt/strain. The EHEC O157:H7 strain LSU-61 from deer occupied an intermediate position between O55:H7 and both O157 branches (SF and NSF O157), complementing the stepwise evolutionary model of EHEC O157:H7/H. The animal origin of this intermediate emphasizes the value of nonhuman reservoirs in the clarification of the evolution of human pathogens.

  • Emergence of Unusual G6P[6] Rotaviruses in Children, Burkina Faso, 2009–2010 PDF Version [PDF - 318 KB - 9 pages]
    J. Nordgren et al.
    View Summary

    High incidence highlights the need for long-term surveillance of rotavirus strains.

       View Abstract

    To obtain more information about rotavirus (ROTAV) genotypes in Burkina Faso, we characterized 100 ROTAVs isolated from fecal samples of children with acute gastroenteritis in the capital city of Ouagadougou, during December 2009–March 2010. Of note, 13% of the ROTAV-positive samples, including those with mixed infections, were positive for the unusual G6 genotype ROTAV strain. The genotypes identified were G9P[8], G6P[6], G1P[6], G3P[6], G1P[8], and G2P[4]. G9P[8] subgroup (SG)II strains dominated during the beginning of the ROTAV season, but later in the season, other G types associated with P[6] and SGI specificity emerged. This emergence was related to a shift in the overall age of infected children; ROTAV SGII infected younger children and induced more severe symptoms. The finding of a high incidence of G6P[6] strains highlights the need for long-term surveillance of ROTAV strains in Burkina Faso, especially when ROTAV vaccination is being considered in several African countries.

  • Comparison of Escherichia coli ST131 Pulsotypes, by Epidemiologic Traits, 1967–2009 PDF Version [PDF - 175 KB - 10 pages]
    J. R. Johnson et al.
    View Summary

    Certain high-prevalence pulsed-field gel electrophoresis types exhibited distinctive temporal patterns and epidemiologic associations.

       View Abstract

    Escherichia coli sequence type 131 (ST131), an emerging disseminated public health threat, causes multidrug-resistant extraintestinal infections. Among 579 diverse E. coli ST131 isolates from 1967–2009, we compared pulsotypes (>94% similar XbaI pulsed-field gel electrophoresis profiles) by collection year, geographic origin, source, and antimicrobial drug–resistance traits. Of 170 pulsotypes, 65 had >2 isolates and accounted for 85% of isolates. Although extensively dispersed geographically, pulsotypes were significantly source specific (e.g., had little commonality between humans vs. foods and food animals). The most prevalent pulsotypes were associated with recent isolation, humans, and antimicrobial drug resistance. Predominant pulsotype 968 was associated specifically with fluoroquinolone resistance but not with extended-spectrum β-lactamase production or blaCTX-M-15. Thus, several highly successful antimicrobial drug–resistant lineages within E. coli ST131 have recently emerged and diffused extensively among locales while maintaining a comparatively restricted host/source range. Identification of factors contributing to this behavior of ST131 could help protect public health.

Historical Review

  • Malaria in Highlands of Ecuador since 1900 PDF Version [PDF - 565 KB - 8 pages]
    L. L. Pinault and F. F. Hunter
    View Summary

    Eliminated after 1950, malaria may be reemerging in a new region.

       View Abstract

    A recent epidemic of malaria in the highlands of Bolivia and establishment of multiple Anopheles species mosquitoes in the highlands of Ecuador highlights the reemergence of malaria in the Andes Mountains in South America. Because malaria was endemic to many highland valleys at the beginning of the 20th century, this review outlines the 20th century history of malaria in the highlands of Ecuador, and focuses on its incidence (e.g., geographic distribution) and elimination from the northern highland valleys of Pichincha and Imbabura and the role of the Guayaquil to Quito railway in creating highland larval habitat and inadvertently promoting transportation of the vector and parasite. Involvement of control organizations in combating malaria in Ecuador is also outlined in a historical context.

  • Dengue and US Military Operations from Spanish–American War through Today PDF Version [PDF - 284 KB - 8 pages]
    R. V. Gibbons et al.
    View Summary

    Dengue may remain problematic for military personnel until an effective vaccine is licensed.

       View Abstract

    Dengue is a major cause of illness among travelers and a threat to military troops operating in areas to which it is endemic. Before and during World War II, dengue frequently occurred in US military personnel in Asia and the South Pacific. From the 1960s into the 1990s, dengue often occurred in US troops in Vietnam, the Philippines, Somalia, and Haiti. We found attack rates as high as 80% and periods of convalescence up to 3-1/2 weeks beyond the acute illness. The increase in dengue throughout the world suggests that it will remain a problem for military personnel until an effective vaccine is licensed.

Policy Review

  • Lessons Learned during Dengue Outbreaks in the United States, 2001–2011 PDF Version [PDF - 306 KB - 7 pages]
    A. A. Adalja et al.
    View Summary

    Public health authorities should involve the clinical and laboratory community and engage the local community in vector control and case reporting.

       View Abstract

    Since 2001, three autochthonous dengue fever outbreaks have occurred in the United States: in Hawaii (2001); Brownsville, Texas (2005); and southern Florida (2009–2011). We sought to characterize and describe the response to these outbreaks from the perspectives of public health and vector control officials. By conducting a medical literature review through PubMed and news media searches through Google, we identified persons involved in managing each outbreak; 26 persons then participated in qualitative, semistructured interviews. After analyzing the 3 outbreaks, we found the following prominent themes in the response efforts: timely detection of illness; communication of up-to-date, correct information; and development of a rapid response that engages the community. We therefore recommend that public health authorities involve the clinical and laboratory community promptly, provide accurate information, and engage the local community in vector control and case identification and reporting.


  • Bartonella spp. in Rats and Zoonoses, Los Angeles, California, USA PDF Version [PDF - 253 KB - 3 pages]
    V. Gundi et al.
    View Summary

    Because infections caused by organisms resistant to antimicrobial drugs are hard to treat, efforts have been made to use these drugs only when they are absolutely needed. But what if resistance occurs even when antimicrobial drugs are not used? This is exactly what happened to 9 patients infected with a type of bacteria (enterococci) not susceptible to standard treatment with the drug daptomycin. None of the patients had taken this drug for at least 3 months before the not susceptible bacteria were found, and 4 died. Although the source of resistance in these cases remains unknown, 1 possibility is the agricultural food chain. Of the 9 patients, 6 had been exposed to livestock or had often eaten beef. Regardless of the source of infection, clinicians should be aware of the possibility that this serious infection can develop in patients who might never have taken daptomycin.

       View Abstract

    Bartonella spp. were detected in rats (Rattus norvegicus) trapped in downtown Los Angeles, California, USA. Of 200 rats tested, putative human pathogens, B. rochalimae and B. tribocorum were found in 37 (18.5%) and 115 (57.5%) rats, respectively. These bacteria among rodents in a densely populated urban area are a public health concern.

  • Detection of Plasmodium spp. in Human Feces PDF Version [PDF - 218 KB - 3 pages]
    M. Jirků et al.
       View Abstract

    Comparison of diagnostic methods for Plasmodium spp. in humans from Uganda and the Central African Republic showed that parasites can be efficiently detected by PCR in fecal samples. These results, which rely solely on PCR-based examination of feces, validate numerous estimates of the prevalence of malaria in great apes.

  • Increase in Extraintestinal Infections Caused by Salmonella enterica Subspecies II–IV PDF Version [PDF - 180 KB - 3 pages]
    S. L. Abbott et al.
       View Abstract

    To garner information regarding site of infection and age and sex of persons infected with Salmonella enterica subspecies II–IV, we retrospectively analyzed data on Salmonella spp. infections in California, USA, 1985–2009. These subspecies were found to cause significantly more frequent invasive disease (e.g., bacteremia) than did Salmonella subspecies I strains.

  • Subclinical Infections with Crimean-Congo Hemorrhagic Fever Virus, Turkey PDF Version [PDF - 188 KB - 3 pages]
    H. Bodur et al.
       View Abstract

    To investigate Crimean-Congo hemorrhagic fever virus in Turkey, we conducted a seroepidemiologic survey during January–April 2009. Seroprevalence of infection was 10% in a sample from an outbreak region and increased with patient age, indicating that the virus had been previously present in Turkey. We also estimated that 88% of infections were subclinical.

  • Crimean-Congo Hemorrhagic Fever, Kazakhstan, 2009–2010 PDF Version [PDF - 326 KB - 3 pages]
    B. Knust et al.
       View Abstract

    We evaluated Crimean-Congo hemorrhagic fever (CCHF) surveillance data from southern Kazakhstan during 2009–2010 and found both spatial and temporal association between reported tick bites and CCHF cases. Public health measures should center on preventing tick bites, increasing awareness of CCHF signs and symptoms, and adopting hospital infection control practices.

  • Vector Blood Meals and Chagas Disease Transmission Potential, United States PDF Version [PDF - 310 KB - 4 pages]
    L. Stevens et al.
    View Summary

    Chagas disease most commonly occurs in Central and South America, where the parasite that causes the disease is spread by specific kinds of blood-sucking bugs (sometimes called kissing bugs). In the United States, only 7 cases of Chagas disease are known to have been transmitted by these bugs, but the numbers could increase. The bugs are already here. But do they carry the parasite, do they feed on people, and could they transmit the disease? A study in Arizona and California answered these questions with yes, yes, and yes. Some of these bugs do carry the parasite and others have fed on people; thus, the potential for Chagas disease in the United States might be higher than previously thought.

       View Abstract

    A high proportion of triatomine insects, vectors for Trypanosoma cruzi trypanosomes, collected in Arizona and California and examined using a novel assay had fed on humans. Other triatomine insects were positive for T. cruzi parasite infection, which indicates that the potential exists for vector transmission of Chagas disease in the United States.

  • Genomic Analysis of emm59 Group A Streptococcus Invasive Strains, United States PDF Version [PDF - 221 KB - 3 pages]
    N. Fittipaldi et al.
       View Abstract

    Genomic analysis of type emm59 group A Streptococcus invasive strains isolated in the United States discovered higher than anticipated genetic heterogeneity among strains and identified a heretofore unrecognized monoclonal cluster of invasive infections in the San Francisco Bay area. Heightened monitoring for a potential shift in the epidemic behavior of emm59 group A Streptococcus is warranted.

  • Characterization of Mycobacterium orygis as M. tuberculosis Complex Subspecies PDF Version [PDF - 328 KB - 3 pages]
    J. van Ingen et al.
       View Abstract

    The oryx bacilli are Mycobacterium tuberculosis complex organisms for which phylogenetic position and host range are unsettled. We characterized 22 isolates by molecular methods and propose elevation to subspecies status as M. orygis. M. orygis is a causative agent of tuberculosis in animals and humans from Africa and South Asia.

  • Cosavirus Infection in Persons with and without Gastroenteritis, Brazil PDF Version [PDF - 327 KB - 4 pages]
    A. Stöcker et al.
       View Abstract

    To determine possible cosavirus association with clinical disease, we used real-time reverse transcription PCR to test children and HIV-positive adults in Brazil with and without gastroenteritis. Thirteen (3.6%) of 359 children with gastroenteritis tested positive, as did 69 (33.8%) of 204 controls. Low prevalence, frequent viral co-infections, and low fecal cosavirus RNA concentrations argue against human pathogenicity.

  • Drug Susceptibility of Mycobacterium tuberculosis Beijing Genotype and Association with MDR TB PDF Version [PDF - 378 KB - 4 pages]
    J. de Steenwinkel et al.
       View Abstract

    To determine differences in the ability of Mycobacterium tuberculosis strains to withstand antituberculosis drug treatment, we compared the activity of antituberculosis drugs against susceptible Beijing and East-African/Indian genotype M. tuberculosis strains. Beijing genotype strains showed high rates of mutation within a wide range of drug concentrations, possibly explaining this genotype’s association with multidrug-resistant tuberculosis.

  • Ikoma Lyssavirus, Highly Divergent Novel Lyssavirus in an African Civet PDF Version [PDF - 478 KB - 4 pages]
    D. A. Marston et al.
       View Abstract

    Evidence in support of a novel lyssavirus was obtained from brain samples of an African civet in Tanzania. Results of phylogenetic analysis of nucleoprotein gene sequences from representative Lyssavirus species and this novel lyssavirus provided strong empirical evidence that this is a new lyssavirus species, designated Ikoma lyssavirus.

  • Coccidioides posadasii Infection in Bats, Brazil PDF Version [PDF - 290 KB - 3 pages]
    R. Cordeiro et al.
       View Abstract

    To analyze the eco-epidemiologic aspects of Histoplasma capsulatum in Brazil, we tested 83 bats for this fungus. Although H. capsulatum was not isolated, Coccidioides posadasii was recovered from Carollia perspicillata bat lungs. Immunologic studies detected coccidioidal antibodies and antigens in Glossophaga soricina and Desmodus rotundus bats.

  • Surveillance for West Nile, Dengue, and Chikungunya Virus Infections, Veneto Region, Italy, 2010 PDF Version [PDF - 217 KB - 3 pages]
    F. Gobbi et al.
       View Abstract

    In 2010, in Veneto Region, Italy, surveillance of summer fevers was conducted to promptly identify autochthonous cases of West Nile fever and increase detection of imported dengue and chikungunya in travelers. Surveillance highlighted the need to modify case definitions, train physicians, and when a case is identified, implement vector control measures

  • De Novo Daptomycin-Nonsusceptible Enterococcal Infections PDF Version [PDF - 165 KB - 3 pages]
    T. Kelesidis et al.
    View Summary

    Because infections caused by organisms resistant to antimicrobial drugs are hard to treat, efforts have been made to use these drugs only when they are absolutely needed. But what if resistance occurs even when antimicrobial drugs are not used? This is exactly what happened to 9 patients infected with a type of bacteria (enterococci) not susceptible to standard treatment with the drug daptomycin. None of the patients had taken this drug for at least 3 months before the not susceptible bacteria were found, and 4 died. Although the source of resistance in these cases remains unknown, 1 possibility is the agricultural food chain. Of the 9 patients, 6 had been exposed to livestock or had often eaten beef. Regardless of the source of infection, clinicians should be aware of the possibility that this serious infection can develop in patients who might never have taken daptomycin.

       View Abstract

    Potential emergence of enterococcal daptomycin nonsusceptibility among patients with no prior exposure to daptomycin poses clinical and public health challenges. We found that development of infections with daptomycin-nonsusceptible enterococci in these patients could be associated with sporadic emergence and clonal spread.

  • Dengue in Patients with Central Nervous System Manifestations, Brazil PDF Version [PDF - 167 KB - 3 pages]
    F. Araújo et al.
       View Abstract

    We investigated the prevalence of dengue in patients with suspected viral meningitis/meningoencephalitis in a dengue-endemic area. Cerebrospinal fluid analysis showed positive results and a 6.74× greater likelihood of identifying positive fluid in patients who died. Our findings support testing patients with neurologic manifestations for the virus in dengue-endemic areas.

  • Human Parvovirus 4 Infection, Cameroon PDF Version [PDF - 271 KB - 4 pages]
    M. Lavoie et al.
       View Abstract

    In a post hoc analysis of samples collected in 2009, we determined seroprevalence of parvovirus 4 (PARV4) among elderly Cameroonians. PARV4 seropositivity was associated with receipt of intravenous antimalarial drugs, intramuscular streptomycin, or an intramuscular contraceptive, but not hepatitis C virus seropositivity. Findings suggest parenteral acquisition of some PARV4 infections.

  • Neuroinvasive Disease and West Nile Virus Infection, North Dakota, USA, 1999–2008 PDF Version [PDF - 167 KB - 3 pages]
    P. J. Carson et al.
    View Summary

    Symptoms of West Nile virus infection can vary from none at all, to fever and aches, to brain infection or paralysis caused by invasion of the nervous system. Most infections go unrecognized and unreported. Because the virus can spread during blood transfusion or by organ transplants, knowing the odds of virus spread during these procedures is crucial. A study in North Dakota found that approximately 1 in 12 residents had been infected by West Nile virus, especially those who were male or young. Those at highest risk for nervous system invasion were male or older than 65 years. This information can be used to help prevent transfusion- and transplant-associated infections and to inform groups at high risk about prevention measures, especially during the summer, when West Nile virus is transmitted.

       View Abstract

    To determine risk for West Nile virus (WNV) neuroinvasive disease in North Dakota, we tested plasma samples from blood donors for WNV IgG and compared infection rates with reported WNV neuroinvasive disease incidence. We estimate that 1 in 244 WNV infections leads to neuroinvasive disease; risk is substantially increased among men and older persons.

Another Dimension


About the Cover

Online Reports

  • Peer Reviewed Report Available Online Only
    Multidisciplinary and Evidence-based Method for Prioritizing Diseases of Food-producing Animals and Zoonoses
    M. Humblet et al.
       View Abstract

    To prioritize 100 animal diseases and zoonoses in Europe, we used a multicriteria decision-making procedure based on opinions of experts and evidence-based data. Forty international experts performed intracategory and intercategory weighting of 57 prioritization criteria. Two methods (deterministic with mean of each weight and probabilistic with distribution functions of weights by using Monte Carlo simulation) were used to calculate a score for each disease. Consecutive ranking was established. Few differences were observed between each method. Compared with previous prioritization methods, our procedure is evidence based, includes a range of fields and criteria while considering uncertainty, and will be useful for analyzing diseases that affect public health.