Between November 1992 and February 1993, a large outbreak of Escherichia coli O157[ratio ]H7 infections occurred in the western USA and was associated with eating ground beef patties at restaurants of one fast-food chain. Restaurants that were epidemiologically linked with cases served patties produced on two consecutive dates; cultures of recalled ground beef patties produced on those dates yielded E. coli O157[ratio ]H7 strains indistinguishable from those isolated from patients, confirming the vehicle of illness. Seventy-six ground beef patty samples were cultured quantitatively for E. coli O157[ratio ]H7. The median most probable number of organisms was 1·5 per gram (range, <0·3–15) or 67·5 organisms per patty (range, <13·5–675). Correlation of the presence of E. coli O157[ratio ]H7 with other bacterial indicators yielded a significant association between coliform count and the presence of E. coli O157[ratio ]H7 (P=0·04). A meat traceback to investigate possible sources of contamination revealed cattle were probably initially colonized with E. coli O157[ratio ]H7, and that their slaughter caused surface contamination of meat, which once combined with meat from other sources, resulted in a large number of contaminated ground beef patties. Microbiological testing of meat from lots consumed by persons who became ill was suggestive of an infectious dose for E. coli O157[ratio ]H7 of fewer than 700 organisms. These findings present a strong argument for enforcing zero tolerance for this organism in processed food and for markedly decreasing contamination of raw ground beef. Process controls that incorporate microbiological testing of meat may assist these efforts.

The distribution of 3001 cases of verocytotoxigenic Escherichia coli (VTEC) reported in the Province of Ontario, Canada, were examined to describe the magnitude of this condition geographically and to evaluate the spatial relationship between livestock density and human VTEC incidence using a Geographical Information System. Incidence of VTEC cases had a marked seasonal pattern with peaks in July. Areas with a relatively high incidence of VTEC cases were situated predominantly in areas of mixed agriculture. Spatial models indicated that cattle density had a positive and significant association with VTEC incidence of reported cases (P=0·000). An elevated risk of VTEC infection in a rural population could be associated with living in areas with high cattle density. Results of this study suggested that the importance of contact with cattle and the consumption of contaminated well water or locally produced food products may have been previously underestimated as risk factors for this condition.

We assessed the rate of salmonella infections and risk factors associated with infection in North East Thames in 1993. Cases of culture confirmed infection were identified through microbiology laboratories and environmental health officers in the North East Thames. A total of 1730 cases were reported and 209 of these individuals (those who could be contacted within a 3-week interval after onset of symptoms) and matched controls were interviewed by telephone. In addition randomly selected controls were interviewed over a 4-month period about recent gastric acid lowering medication and antimicrobial ingestion. Sixty-six serotypes were identified: S. enteritidis was isolated from 1179 (69%) cases, S. typhimurium from 221 (13%), S. virchow from 77 (4%) and S. newport 25 (1%). Infections were more frequent in summer months. Highest rates were documented in children under 2 years of age for S. enteritidis (108/100000) and under 1 year for S. typhimurium (36/100000). Using the Townsend score, highest isolation rates of S. enteritidis were in more prosperous areas (36/100000 vs. 27/100000; odds ratio (OR) 1·3, 95% confidence intervals (CIs) 1·2–1·6, P<0·0001), while for S. typhimurium, there was no relation between deprivation index and isolation rates areas (6·4/100000 vs. 6·1/100000; OR 1·1, 95% CIs 0·8–1·5, P=0·77). The case control study showed a significant association between ingestion of products containing raw eggs and S. enteritidis infection (8/111 cases vs. 0/110 controls; OR undefined, lower 95% CIs 3·4). Individuals with salmonella infection were significantly more likely to have travelled abroad in the week before the onset of illness [42/186 (23%) vs. 1/182 (0·5%) ; OR 40, 95% CIs=5·5–291, P<0·001] and to report gastroduodenal disease [11/143 (7 %) vs. 3/143 (2 %); OR 5·0, 95% CIs=1·1–23, P=0·04]. There was an association between illness and gastric acid-lowering medications [unmatched controls OR 22·3 (95% CIs 1·5–3·7, P=0·0002), matched controls OR 3·7 (95% CIs 1·0–3·8, P=0·07)], but no association with antimicrobial ingestion.

In May 1996, the Georgia Division of Public Health was notified about a cluster of persons with Salmonella Enteritidis (SE) infections in Waycross, Georgia. A matched pair case-control study to determine risk factors for illness found a statistically significant association of SE infection with a history of having eaten at Restaurant A during the 5 days before onset of illness (relative risk = 13 [95% confidence interval (CI)=3–62, P<0·01]). In a second case-control study, to determine specific food exposures, consumption of a deep-fried Mexican dish (chile relleno) (4 of 21 cases vs. 0 of 26 controls, odds ratio undefined, 95% CI>1·46, P=0·034) was found to be significantly associated with SE infection. An environmental investigation found evidence of suboptimal food storage and cooking temperatures at Restaurant A; cross contamination of foods may have contributed to the low attributable risk identified for chile rellenos. Five of 37 Restaurant A food and environment specimens yielded SE strains. All five positive specimens were from chiles rellenos. Of the seven outbreak-associated strains (six patient isolates and one food isolate from Restaurant A) for which phage typing was conducted, all were phage type 34. A FDA traceback investigation through Restaurant A's single-egg supplier identified the potential source as three interrelated farms in South Carolina. Environmental culture from one of these farms yielded SE phage type 34. As a result of this outbreak, FDA helped institute a statewide egg quality-assurance programme in South Carolina to minimize SE contamination of eggs.

Results of a surveillance on cholera conducted with patients seen at the Children Hospital in Bangkok, Thailand from August 1993 to July 1995 are presented. Annually, isolation rates for Vibrio cholerae varied between 1·7 and 4·4% of patients with diarrhoea. V. cholerae O1 serotype Ogawa accounted for between 31 and 47% of patients cultured positive for V. cholerae, whereas the O139 serotype dominated in early 1994 after which it disappeared. Non-O1, non-O139 strains were isolated at similar rates as serotype O1 in 1993 and 1994, but accounted for 69% of V. cholerae culture positive specimens in 1995. However, the annual proportion of the isolation of non-O1, non-O139 strains showed little variation and remained low between 1·0 and 1·3%. Serotyping of 69 epidemiological unrelated non-O1, non-O139 strains produced 37 different O-serotypes. BglI ribotyping of serotypes containing more than two strains demonstrated a high degree of heterogeneity within and between serotypes, except seven serotype O37 strains which showed an identical ribotype suggesting clonality. None of the 69 strains hybridized with a cholera toxin probe and only two strains hybridized with a heat-stable enterotoxin probe. Susceptibility testing to 12 antibiotics showed that 40 of 69 (58%) non-O1, non-O139 strains were resistant to colistin, streptomycin and sulphisoxazole and 28 of 69 (41%) were multiple antibiotic resistant (MAR; [ges ]4 antibiotics). Although 26 of 69 (38%) strains contained one or more plasmids, the plasmids were of low molecular weights and did not seem to encode antibiotic resistance. The results of the present study showed that a high proportion of heterogenous MAR V. cholerae non-O1, non-O139 strains were isolated from children at the hospital. With reference to the emergence of V. cholerae O139 in 1992, we suggest that non-O1, non-O139 strains should be monitored carefully to detect new serotypes with a possible epidemic potential, but also to determine the development and mechanism of antibiotic resistance.

An internationally agreed and validated set of phages is used worldwide for the typing of strains of Staphylococcus aureus of human origin. However, because of the sometimes reduced susceptibility of methicillin-resistant strains (MRSA) to these phages, some of the national typing centres use locally isolated and characterized sets of experimental phages. In this trial, 42 such phages were distributed to 6 centres and tested against 744 isolates of MRSA with the intention of defining a phage set to augment the international set. The use of these experimental phages increased the percentage typability from 75% with the international set to 93% and the number of identifiable lytic patterns from 192 to 424. A subset of 10 experimental phages was selected. When this subset was compared with the experimental panel, the typability rate was 91% and 370 distinct patterns were obtained. This subset of phages has been distributed for international trial.

A prospective cohort study with 1 year follow-up evaluated the relation between MRSA carriage and mortality, likelihood of hospitalization and functional status in residents of a nursing home for the elderly. Included were all 447 residents living in the home in early June 1994. From all patients, swabs were taken from nose, throat and perineum. Additional swabs (sputum, urine or wounds) were taken when indicated. The relative risk (RR) of dying within 6 months in MRSA carriers compared to non-carriers was 2·29 (95% CI=1·04–5·04). This RR remained stable (1·57–2·40) after adjustment for co-variables using Mantel–Haenszel stratified analysis. After 1 year, the RR was reduced to 1·30 (95% CI=0·65–2·58). Univariate survival analysis confirmed a difference in survival between carriers and non-carriers after 6 months (log-rank P=0·04) and no difference after 1 year. Cox regression analysis resulted in a hazard ratio for dying within 6 months of 1·73 (95% CI=0·72–4·17). No relation was found between carriage and either likelihood of hospitalization or indicators of functional status. These results are compatible with a possible relation between 6 months mortality and MRSA carriage in nursing home patients. It calls for a large scale, multicentre cohort study in order to either confirm or refute these findings.

Protein A of Staphylococcus aureus contains a polymorphic Xr-region characterized by a tandem repeat of eight amino acid units. In this study, the diversity of genes encoding the repeat regions and their relatedness among S. aureus strains was analyzed. Ten different protein-A types characterized by repeat numbers 4–13 were identified in a total of 293 clinical isolates. The protein-A type with 10 repeat units (10 repeats) in the Xr-region was most frequently detected in methicillin-resistant S. aureus, whereas the majority of methicillin- susceptible strains were distributed almost evenly into protein-A types with 7–11 repeats. Strains that belonged to a single coagulase type were classified into multiple protein-A types, e.g. strains with the common coagulase types II and VII were differentiated into 7 and 8 protein-A types, respectively.

Nucleotide sequence analysis of the Xr-region of 42 representative strains revealed the presence of 37 different genotypes (spa types), which were constituted by a combination of several of 24 different repeat unit genotypes. Based on the similarity in arrangement of repeat unit genotypes, 34 strains with different repeat numbers were classified into 5 genetic clusters (C1–C5). The clusters C1, C2 and C3 consisted exclusively of strains with identical coagulase types II, III, and IV, respectively. These findings suggested that the protein-A gene of S. aureus has evolved from a common ancestral clone in individual clusters independently.

We present data on pneumococcal isolates collected from deep and superficial sites over a 16-year period at the Edinburgh City Hospital. The 10 most frequent serotypes overall were 6, 19, 11, 9, 3, 14, 1, 15 and 18 in children and 19, 23, 6, 6, 9, 11, 3, 15, 14, 22 and 4 in adults. Over 88% (2588/2932, 88·3%) of these pneumococci were of serotypes represented in the 23-valent polysaccharide pneumococcal vaccine. Within the 20–45 years age group, 228/434 (52·5%) of specimens were from HIV-infected individuals. The isolations showed a seasonal distribution with peaks in February and troughs in September. The annual numbers of blood culture isolates showed an upward trend. Recurrent isolations were more frequent in HIV-infected individuals (49/132, 37%) than in non-HIV-infected individuals (218/2421, 9·9%) (relative risk = 5·05, 95% confidence interval, 3·46–7·03). The prevalence of resistance to penicillin and erythromycin was lower than that reported in other parts of the UK.

Sharps injuries are a major cause of transmission of hepatitis B and C viruses and human immunodeficiency virus in health-care workers. To determine the yearly incidence and causes of sharps injuries in health-care workers in Taiwan, we conducted a questionnaire survey in a total of 8645 health care workers, including physicians, nurses, laboratory technicians, and cleaners, from teaching hospitals of various sizes. The reported incidence of needlestick and other sharps injuries was 1·30 and 1·21 per person in the past 12 months, respectively. Of most recent episodes of needlestick/sharps injury, 52·0% were caused by ordinary syringe needles, usually in the patient units. The most frequently reported circumstances of needlestick were recapping of needles, and those of sharps injuries were opening of ampoules/vials. Of needles which stuck the health-care workers, 54·8% had been used in patients, 8·2% of whom were known to have hepatitis B or C, syphilis, or human immunodeficiency virus infection. Sharps injuries in health-care workers in Taiwan occur more frequently than generally thought and risks of contracting blood-borne infectious diseases as a result are very high.

The objective was to assess the potential bias in unlinked anonymous HIV-seroprevalence surveys from objections to specimens being included. Objection rates in seroprevalence surveys were examined. Statistically large clusters of objections were considered to be the result of health care worker behaviour, and were disregarded. Underlying objection rates were estimated from remaining data and compared to seroprevalence. Overall objection rates approached or exceeded seroprevalence in many participating centres. However, underlying objection rates declined with time while prevalences were generally unchanging. Also, underlying rates correlated poorly with observed seroprevalences. Findings were therefore consistent with processes producing the clusters of objections and underlying objection rates independently of serostatus of individuals. Although national seroprevalence estimates produced by the surveys are reasonably free from objection bias, regional seroprevalence estimates outside London remain vulnerable to bias as a result of some centres returning data whose quality cannot be guaranteed.

This study was conducted to evaluate factors affecting the levels of total IgG (tIgG) and measles specific IgG (mIgG) in mother and cord sera, and the efficiency of transplacental transport of tIgG and mIgG. The study was conducted in four hospitals in Oporto, Portugal, where 1539 women and their newborns were enrolled. Measles IgG levels were lower among vaccinated mothers and respective cord sera than among vaccinated counterparts. Cord mIgG was strongly correlated with maternal levels in both vaccinated and unvaccinated groups. Transplacental transport efficiency (TTE) of mIgG decreased with increasing maternal levels, although almost one third of the observed effect was due to measurement error. The TTE was not affected by vaccination status. Monitoring maternal measles antibody levels and maternal vaccination status could be useful to determine when the age for measles vaccination can be reduced.

In 1996, three adenovirus type 7 (Ad7) strains were isolated from children with fever and upper respiratory diseases in Japan. Restriction endonucleases (REs) analysis and PCR amplification of the E3 7·7 kDa ORF revealed that these strains were genotype Ad7h and closely related to an Argentine Ad7h strain, which has been reported to be highly virulent and so far predominant only in South America. These strains showed weak cross-neutralizing activity and specific haemagglutination-inhibition activity to Ad3 antiserum. The present findings suggest that Ad7h in South America has spread to other parts of the world. Since the seroprevalence to Ad7 in the current Japanese population is very low due to the absence of Ad7 circulation in Japan for decades, Ad7 outbreak as a typical case of re-emerging infectious diseases is a cause for serious concern.

A variant of variola virus is described which produces a late polypeptide of 25 kDa instead of one of 27 kDa and which has an additional endonuclease cleavage site for SalI in the viral DNA. These markers were shown to be genetically independent and to characterize 14 of the 48 variola strains which were examined. The variant strains were isolated from smallpox outbreaks originating in or from Pakistan between 1961 and 1974 and also from two cases at a Mission Hospital in Vellore, India in 1964. No variant strains were found among 9 other isolates from cases of variola major occurring in other parts of India or in Bangladesh, nor among 4 isolates from Indonesia, 15 from Africa or 6 isolates of variola minor.

A cross-sectional serosurvey for markers of prior Cryptosporidium infection was conducted among homosexual or bisexual males infected with human immunodeficiency virus (HIV); of 262 individuals approached, 236 (90%) agreed to participate. Serological response to two Cryptosporidium antigens was measured using a Western blot assay. The intensity or detection of serological responses to two Cryptosporidium antigens was not associated with CD4 cell counts or tap water consumption. A number of sexual practices were related to increased serological response for only the 27-kDa marker, including having had sex within the past 2 years, having anal sex and having had a larger number of sex partners during the past 2 years. Attending a spa or sauna was related to serological response to both the 27-kDa and 17-kDa markers. Based on these results, activities related to sexual activity appear to be a significant risk factors for prior Cryptosporidium infection.

The relationship between ocular toxoplasmosis and levels of toxoplasma specific antibodies was examined in 195 patients. Using clinical information collected by questionnaires, patients were divided into: 97 with ocular toxoplasmosis (group 1) and 98 with ocular lesions not due to toxoplasma (group 2). The geometric mean of dye test titres (±S.D. natural log titre) in group 1 was 53·2 (±0·95) compared with 24·6 (±1·11) in group 2 (P<0·001). Young females tended to have more active lesions compared with young males (P<0·05). There was an age-dependent difference in dye test titres between the groups (P<0·001). Group 1 showed a decline in titre with age compared with an increase in group 2. Ocular toxoplasmosis was diagnosed most frequently among 21–30 year olds. More group 1 patients had dye test titres [ges ]65 iu/ml than group 2 (P<0·05). Dye test titres [ges ]65 iu/ml support a diagnosis of ocular toxoplasmosis whereas lower titres suggest other causes for eye lesions.

The world's first documented toxoplasmosis outbreak associated with a municipal water supply was recognized in 1995 in Victoria, British Columbia, Canada. It was hypothesized that domestic cat (Felis catus) or cougar (Felis concolor) faeces contaminated a surface water reservoir with Toxoplasma gondii oocysts. An extensive investigation of the Victoria watershed 1 year following the outbreak documented the presence of an endemic T. gondii cycle involving the animals inhabiting the area. Cats and cougars were observed throughout the watershed. Serological evidence of T. gondii infection was demonstrated among domestic cats living in the Victoria area. Cougars were found to shed T. gondii oocysts. Serological evidence of T. gondii infection in deer mice living in the riparian environments of the watershed suggested that T. gondii oocysts were being shed near the water edge. Contamination of Victoria's water supply with T. gondii oocysts potentially occurred during the study period and future waterborne toxoplasmosis outbreaks in this and other communities are possible.

Although information on amoebiasis among institutionalized psychiatric patients is available, reports on the relationship between behaviour and this infection are not abundant. From July 1995 to June 1996, stool and blood samples were collected from 565 patients in three psychiatric hospitals of North Taiwan. Stool samples were examined using the direct smear and formalin-ethyl acetate sedimentation techniques as well as ProSpecT® Entamoeba histolytica Microplate Assay kit. Blood samples were examined by the Amebiasis Serology Microwell ELISA kit. Among these patients, 14 (2·5%) harboured one or two species of intestinal parasites. There were 6 (1·1%) E. histolytica/E. dispar cyst passers: 5 positive in stool ELISA test and 2 with antibodies against E. histolytica. Among demographic factors, type of psychiatric disorder and disability, only a significant sexual difference in seropositivity of E. histolytica was observed. These findings indicate that the infected patients acquired the infections before they entered the hospitals.

A panel of 16S ribosomal RNA gene probes has been developed for the study of the epidemiology of heartwater; five of these detect different cowdria genotypes, one detects five distinct genotypes; one detects any Group III Ehrlichia species other than Cowdria and one detects any Group II Ehrlichia species. These probes have been used on PCR-amplified rickettsial 16S rRNA genes from over 200 Amblyomma hebraeum ticks. Control ticks were laboratory-reared and either uninfected or fed on sheep experimentally infected with different cowdria isolates, field ticks were collected from animals in heartwater-endemic areas. All tick-derived DNA samples were also examined by PCR amplification and probing for two other cowdria genes (map1 and pCS20) which have previously been used for heartwater epidemiology. This paper describes the first direct comparison of all currently available DNA probes for heartwater-associated organisms.

The objectives of this study were to investigate the coagulase gene polymorphism of Staphylococcus aureus isolates obtained from bovine mastitic milk and to determine the resistance of predominant and rare coagulase genotypes to bovine blood neutrophil bactericidal activities. A total of 453 isolates were collected from four countries: the Czech Republic, France, Korea and the United States. The isolates were subtyped into 40 types by restriction fragment length polymorphism (RFLP) of the coagulase gene. Twenty-three strains from predominant and rare genotypes were evaluated for their ability to resist neutrophil bactericidal activities. There were significant (P<0·01) differences in the average percent neutrophil killing of the predominant (16·7%) and rare (39·7%) genotypes when bacteria were opsonized with antiserum. The results indicate that the profiles of coagulase genotype differ among geographic locations, and only a few genotypes prevail in each location. In addition, the predominant genotypes were more resistant to neutrophil bactericidal activities than rare genotypes.