Investigations were performed by the Laboratory of Enteric Pathogens on Vero cytotoxin-producing Escherichia coli (VTEC) in England and Wales from 1992–4. Bacterial isolates, faeces and sera obtained from patients with diarrhoea, bloody diarrhoea and haemolytic uraemic syndrome were examined. Using serotyping, Vero cytotoxin gene probing and serodiagnostic tests for E. coli O157, evidence of infection was detected in 543, 434 and 491 individuals in 1992, 1993 and 1994 respectively; VTEC of serogroup O157 were isolated from 470, 385 and 411 cases. The O157 VTEC strains belonged to at least 19 different phage types (PT) although 84% belonged to PT2, PT49, PT8, PT1 or PT4. Antibodies to E. coli O157 lipopolysaccharide were detected in 13% of the cases. The average annual rate of infection with O157 VTEC was 0·83/100000 and 12% of the 1458 individuals with evidence of infection with VTEC or E. coli O157 developed haemolytic uraemic syndrome. There were at least 18 general outbreaks and many family outbreaks.

Over a 9-day period in February 1995, 16 newborn babies (age range 2–11 days) and 3 infants (24, 47 and 180 days of age) in a neonatal nursery ward developed diarrhoea accompanied by pyrexia and weight loss. Known enteropathogens were not detected in their stools but Escherichia coli displaying aggregative adherence to HEp-2 cells (enteroaggregative E. coli) were found in 12 (63%) ill infants and in none of 5 well neonates (P = 0·02). The illness lasted 3–9 days (mean 5·2) in 16 babies, whereas in 3 neonates it showed a protracted course of 18–20 days. The source of infection and the mode of transmission remained unclear. The outbreak isolates manifested properties common in this new group of diarrhoeagenic E. coli: mannose-resistant haemagglutination, haemolysis on blood agar, and clump formation in liquid culture medium. They belonged to the O4 E. coli serogroup and expressed multiple antibiotic resistance.

The pefA gene which encoded the serotype associated plasmid (SAP) mediated fimbrial major subunit antigen of Salmonella enterica serotype Typhimurium shared genetic identity with 128 of 706 salmonella isolates as demonstrated by dot (colony) hybridization. Seventy-seven of 113 isolates of Typhimurium and individual isolates of serotypes Bovis-morbificans, Cholerae-suis and Enteritidis phage type 9b hybridized pefA strongly, whereas 48 isolates of Enteritidis hybridized pefA weakly and one Enteritidis isolate of phage type 14b failed to hybridize. Individual isolates of 294 serotypes and 247 individual isolates of serotype Dublin did not hybridize pefA. Southern hybridization of plasmids extracted from Enteritidis demonstrated that the pefA gene probe hybridized strongly an atypical SAP of 80 kb in size harboured by one Enteritidis isolate of phage-type 9b, whereas the typical SAP of 58 kb in size harboured by 48 Enteritidis isolates hybridized weakly. One Enteritidis isolate of phage type 14b which failed to hybridize pefA in dot (colony) hybridization experiments was demonstrated to be plasmid free. A cosmid library of Enteritidis phage type 4 expressed in Escherichia coli K12 was screened by hybridization for the presence of pef sequences. Recombinant clones which were deduced to harbour the entire pef operon elaborated a PEF-like fimbrial structure at the cell surface. The PEF-like fimbrial antigen was purified from one cosmid clone and used in western blot experiments with sera from chickens infected with Enteritidis phage-type 4. Seroconversion to the fimbrial antigen was observed which indicated that the Enteritidis PEF-like fimbrial structure was expressed at some stage during infection. Nucleotide sequence analysis demonstrated that the pefA alleles of Typhimurium and Enteritidis phage-type 4 shared 76% DNA nucleotide and 82% deduced amino acid sequence identity.

In recent years infection caused by Salmonella serotype Enteritidis (SE) phage type 4 has spread through Europe but has been uncommon in the USA. The first recognized outbreak of this strain in the USA occurred in a Chinese restaurant in El Paso, Texas, in April 1993; no source was identified. In September 1993, a second outbreak caused by SE phage type 4 was associated with the same restaurant. To determine the cause of the second outbreak, we compared food exposures of the 19 patients with that of two control groups. Egg rolls were the only item significantly associated with illness in both analyses (first control group: oddsratio [OR] 8·2, 95% confidence interval [CI] 2·3–31·6; second control group: OR 13·1, 95% CI 2·1–97·0). Retrospective analysis of the April outbreak also implicated egg rolls (OR 32·4, 95% CI 9·1–126·6). Egg roll batter was made from pooled shell eggs and was left at room temperature throughout the day. These two outbreaks of SE phage type 4 likely could have been prevented by using pasteurized eggs and safe food preparation practices.

An increase in the number of human isolates of Salmonella virchow phage type (PT) 26 in England and Wales during 1994 was investigated. A national case control study was conducted which included 88 cases and 182 controls. The cases were mostly young adults (median age 26) and 13 (15%) were admitted to hospital. Acquisition of S. virchow PT 26 was associated with the consumption of any chicken (OR 2·5, CI 1·1–5·8), of chicken curry from restaurants and take aways (OR 2·9, CI 1·4–6·1), and of some other diverse types of pre-prepared chicken (OR 3·8, CI 1·9–7·6). Halal chicken was associated (P = 0·006) with illness in a subset. There were negative associations with contact with animals (OR 0·47, CI 0·23–0·95) and with the consumption of chicken cooked whole (OR 0·37, CI 0·21–0·66). The increase in S. virchow PT 26 may be due to changing epizoology and may be an indicator of what will become the dominant salmonella strain in poultry in future years. The increasing incidence of S. virchow PT 26 is of particular concern because of its association with more invasive disease in humans.

Cholera is one of the three diseases subject to the International Health Regulations. After a period of over 30 years, the seventh pandemic of cholera, which started in South East Asia in 1961, still shows no sign of a decline. On the contrary, it has increased its severity and invaded many other countries in Africa and Latin America. In the last two years, there has been a recrudescence of the disease in South East Asia and Western Pacific Regions. The discovery of a new strain of Vibrio cholerae 0139 in these regions is causing concern in view of its potential to cause major epidemics and higher mortality. Hong Kong had two intensive outbreaks of cholera in the last two years. The cause of these outbreaks was not clear, but adverse environmental conditions and increasing pollution of coastal waters have been implicated. The spread of cholera knows no geographical boundaries. There is a need for intensified efforts among health authorities in the affected areas to prevent the international spread of the disease.

Pulsed-field gel electrophoresis (PFGE) of Cpo I-digested genomic DNA and ribotyping (Bgl I) were applied to 60 Vibrio cholerae strains including 48 V. cholerae O139 from Thailand to compare their value in differentiating strains of the present V. cholerae O139 epidemic. PFGE patters were divided into groups A and B representing five and four subtypes, respectively, while ribotyping showed four different patterns. PFGE group B subtypes were only presented among O139 isolates from Thailand, whereas four O139 strains from Bangladesh and India showed identical PFGE group A subtypes observed in O139 isolates from Thailand. Two nontoxigenic O139 isolates from Thailand showed different and unique PFGE types as did five V. cholerae non-Ol non-O139 isolates containing a gene virulence complex found in V. cholerae O139. These results indicate that PFGE (Cpo I) can resolve recent evolutionary divergence within V. cholerae O139 and offers a useful supplementary tool for following the progressing V. cholerae O139 epidemic.

A multiplex polymerase chain reaction (PCR) was developed to detect the presence of the ail, yst, and virF genes of Yersinia enterocolitica simultaneously, quickly and accurately. The amplified fragment sizes were 356 base-pairs (bp) for the ail gene, 134 bp for the yst gene, and 231 bp for the virF gene. The specificity of the amplified products was confirmed by hybridization with digoxigenin-labelled oligonucleotide probes. Amplification was successful whether the template was derived from a single colony of bacteria, aliquots of boiled bacterial suspensions, from DNA extracted from pure or mixed cultures or from stool specimens. Amplification of the virF gene was also achieved from strains of Y. pseudotuberculosis carrying the 70 kb plasmid but not with preparations from other related Yersinia species or from other members of the family Enterobacteriaceae. The detection limit we established was 5–10 colony forming units per millilitre (cfu/ml) and 1·0 pg of DNA.

A collaborative exercise, supervised by the World Health Organisation, was set up to compare ELISAs used for the serological detection of Salmonella enteritica serotype Enteritidis in chickens. The aim was to ascertain how far agreement could be reached on the interpretation of optical density readings for high titre, intermediate titre and low titre sera. Two sets of sera were sent to 14 participants. The first set compared high, medium and low titre sera raised in specified-pathogen-free and commercial broiler breeder chickens. The second set comprised 20 sera of different antibody titres raised in commercial birds reared under laboratory conditions and sent blind. Both indirect and double-antibody sandwich blocking ELISAs were used with a number of different detecting antigens. With a few exceptions good agreement was reached on the interpretation of results obtained from high and low titre sera from the optical density obtained with a single serum dilution. Differences were observed in the interpretation of medium titre sera. The results suggested that most ELISAs produce reasonably comparable results and that practical problems may arise from interpretation of the results mainly as a result of the choice of the criteria used for differentiating sera obtained from infected and uninfected chickens. These problems are discussed.

Two Enteritidis PT4 isolates which differed in inherent tolerance to heat, acid, H2O2 and the ability to survive on surfaces were used to infect mice, day-old chicks or laying hens. The acid-, heat-, H2O2- and surface-tolerant isolate was more virulent in mice and more invasive in laying hens, particularly in reproductive tissue. However, no significant differences were observed in behaviour in chicks. Both PT4 isolates were able to infect chicks housed in the same room as infected birds, although the heat-tolerant isolate survived significantly better than the heat-sensitive one in aerosols.

A survey of 725 prepacked sandwiches was conducted examining for the presence on enrichment, and by plate count, of Listeria species. Sandwiches were found to contain Listeria sp. more frequently than their component foods. Chicken, beef and bacon fillings were associated with more frequent isolation. Salad also was associated with more frequent isolation, but the increase was not significant. On enrichment, over 15% of sandwiches contained Listeria species. L. innocua and L. monocytogenes were the only species isolated by plate count at numbers ≤ 100 cfu/g (1·5% of total samples). Potentially hazardous levels of L. monocytogenes (defined as ≤ 103 cfu/g) were found in two sandwiches examined (0·3%), indicating that although Total Viable Counts (TVCs) may often be high, the risk of listeriosis to vulnerable individuals from sandwiches is relatively low. It is importent to distinguish the risk of consuming potentially hazardous levels of a pathogen in food from the risk of contracting illiness as a result of such an event.

One hundred and fourteen cases of pneumococcal meningitis were identified by prospective laboratory based surveillance during 1990–3 in the North East Thames Region. Higher rates of disease were seen in Asians (2·1/100 000) than Caucasians (0·8/100 000) (P = 0·002). The incidence of meningitis was higher in children than adults, while mortality rates were highest in adults over the age of 60 (48%). In 72 cases, both blood and CSF were culture positive. Serotyping of 65 isolates collected identified 22 serotypes (and one non-typable) causing disease, the most common being serotype 6 (13 cases) and serotype 14 (11 cases). Overall, 90% of serotype antigens identified were represented in the 23 valent vaccine. Ribotyping of 62 isolates identified 35 different patterns, of which 26 were single types. Different ribotypes were found among isolates of the same serotypes, with the exception of serotype 14, where 9 of 11 isolates had the same ribotype pattern. Four percent of isolates had reduced susceptibility to penicillin, but no high level penicillin resistance was found.

During a prolonged outbreak of meningococcal disease caused by serogroup B serotype 15 sulphonamide-resistant strains in one British health district, there was considerable variation in attack rates by town. General practitioner (GP) antibiotic prescribing rates were compared in high and low incidence towns. The only significant difference found was that erythromycin prescribing was more frequent in the high incidence towns (rate ratio 4·0, 95% CI 3·2–4·8, in March 1987 and 3·0, 95% CI 2·4–3·7, in November 1987). This was probably due to increased GP consultation rates for upper respiratory tract infection (URTI), but higher erythromycin usage may have increased meningococcal acquisition rates or susceptibility to meningococcal disease. Antibiotic prescribing rate should be further investigated in defined areas of high and low incidence of meningococcal disease.

Although viral respiratory tract infections may predispose to meningococcal disease, strong evidence that they do so exists only for influenza. Data on laboratory reported cases of respiratory syncytial virus (RSV) infections and meningococcal disease in England and Wales from mid-1989 to mid-1994 were analysed. Although the rise in RSV cases preceded the rise in meningococcal disease cases each winter, the interval between the rise and fall of the two diseases was inconsistent, no association was found between time series after removal of the seasonal component, and there was no evidence that more cases of meningococcal disease occurred in winters with more RSV disease. RSV may have less effect on the two most likely mechanisms whereby influenza predisposes to meningococcal disease, namely lowered immunity and impaired pharyngeal defences.

We describe an outbreak of skin lesions due to Mycobacterium chelonae subsp. abscessus associated with injections of lidocaine (lignocaine) given by a ‘bioenergetic’ (a practitioner of alternative medicine) in Colombia. The lidocaine carpules and the lesions of the patients yielded mycobacteria with identical biochemical characteristics.

Using the methodology of Sartwell and a case control design we examined the incubation period and assessed risk factors. Of 667 potentially exposed individuals, a total of 298 patients were interviewed, of whom 232 had skin lesions. The median incubation period was 30·5 days (range 15–59 days). Male sex (OR 2·85, 95% CI 1·26–6·51), increasing age (OR 1·25, 95% CI 1·03–1·53), subcutaneous injection route (OR 3·72, 95% CI 1·09–12·7) and number of injections (OR 1·01, 95% CI 1·00–1·03) were risk factors for disease.

To our knowledge, this is the largest reported outbreak of M. chelonae infection, the first in which the organism has been isolated from the putative vehicle of infection, and the first in which the incubation period could be determined.

The costs and projected benefits of universal screening for hepatitis B virus (HBV) infection in pregnant women in East Anglia are calculated and compared with current practice. By adjusting data from West Midlands region for ethnicity, the prevalence of maternal hepatitis B surface-antigen (HBsAg) positivity in East Anglia is predicted to be 0·083% (1 in 1200). Published data on health risks of perinatal HBV infection and on immunisation efficacy are used to derive benefits of screening. The marginal direct cost of screening is identified from regional sources. Current clinical practice in East Anglia identifies 7 surface-antigen positive mothers per year, whereas 22 are expected. Routine antenatal screening in East Anglia would prevent 2·6 additional childhood carriers per year (compared with current practice), resulting in the prevention of 0·7 deaths per year occuring 40–50 years in the future. The direct cost per (undiscounted) life-year saved would be £2437, not including savings on treatment for chronic hepatitis B infection. Routine prenatal screening for maternal HBsAg should be introduced without delay and continue even if HBV vaccination is introduced into the UK childhood immunisation schedule.

To describe the features of hepatitis B virus (HBV) infection in Madagascar, a randomized sero-epidemiological survey was undertaken in the general population ≥ 1 year old of two provinces which represents 45% of the total population. In the 921 sera tested, the prevalence of HBV markers was 20·5% for HBsAg, 38·2% for anti-HBc and 6·9% for HBeAg. HBsAg and anti-HBc prevalence rates were significantly higher in males. A large difference in HBsAg prevalence was observed between urban (5·3%) and rural areas (26·0%). The same contrast in prevalence was noticed for the other HBV markers. In rural areas, HBV infection was more frequently acquired early in infancy, which suggests predominantly perinatal or postnatal transmission. The presence of HBV markers was not significantly associated with a history of blood transfusion, surgery or parenteral injection. High infectivity carriers represented 5·3% and the overall frequency of chronic carriers was 10·4%. These results place Madagascar among areas of high endemicity.

We undertook a retrospective descriptive comparison of the spectrum of pathogens responsible for bacteraemia and diarrhoea in HIV antibody positive and negative patients over 4 years (1988–92), in Nairobi, Kenya. The study population was recruited from primary to tertiary centers of clinical care and consisted of 2858 adults (15 years or older). There were 415 significant blood culture isolates, 192 from 1785 HIV negative patients and 223 from 953 HIV positive patients. There were 233 significant faecal isolates, 22 from 115 HIV negative patients and 211 from 531 HIV positive patients. The most common pathogens detected in blood were Streptococcus pneumoniae and Salmonella typhimurium and in faeces Shigella flexneri, S. typhimurium and Cryptosporidium parvum. The agents causing illness in HIV positive patients in Nairobi are similar to those prevalent in the HIV negative community and the investigation of a febrile illness with or wothout diarrhoea in an HIV positive patient should reflect this.

The purpose of this study was to examine the prevalence of antibody against hepatitis A (anti-HAV) in a population of homosexual men compared with that of heterosexual men in an area of intermediate HAV endemicity (Madrid, Spain). A total of 148 patients were recruited in a Sexually Transmitted Diseases Clinic: 74 homosexuals (mean age of 28±5 years) and 74 heterosexuals (29±5 years). The prevalence of anti-HAV antibody was 47% and 43% for homo-and heterosexuals, respectively. Among the factors evaluated (age, sexual orientation and practices, travel to high HAV endemicity areas) oral-anal contact was significantly associated with a higher prevalence of anti-HAV antibody (odds ratio, 2·8; 95% confidence interval, 1·1–7·4; P = 0·03). These results indicated that in an area of intermediate endemicity young homosexual men are not at increased risk of having acquired hepatitis A infection than heterosexuals. Oral–anal contact is an independent risk factor that influences the presence of anti-HAV antibody, regardless of sexual orientation.

An epidemiologic investigation was conducted to characterize and evaluate the possibility of a viral aetiology of an outbreak of acute vertigo in Hot Springs Country, Wyoming, during autumn 1992. Case-finding identified Hot Springs County residents who sought medical attention for new onset vertigo during 1 August, 1992–31 January 1993. Thirty-five case-patients and 61 matched controls were interviewed and serum specimens were obtained during January 1993. Case-patients were more likely than controls to report symptoms (e.g. fatigue, sore throat, fever, diarrhoea) of antecedent acute illness. Case-patients did not have a significantly greater prevalence or mean titre of IgG antibodies to respiratory syncytial virus, parainfluenza viruses, Epstein–Barr virus, and cytomegalovirus than controls. Serologic evidence of recent enterovirus infection (IgM antibodies) was found for 74% of case-patients compared with 54% of controls (P < 0·05), suggesting a possible association between vertigo and enterovirus infection. Future studies are needed to define the role of enteroviruses in inner-ear diseases.