Outbreaks of enteric illness in long-term care facilities (LTCFs) were reviewed to identify preventative recommendations. Systematic review methodology identified outbreak reports of gastrointestinal illness in LTCFs either published or that occurred from January 1997 to June 2007. The inclusion criteria captured 75 outbreaks; 23 (31%) associated with bacterial agents and 52 (69%) with viral agents. Transmission was mainly foodborne (52%) for those of bacterial origin and person-to-person (71%) for viral outbreaks. Norovirus infection was associated with 58% of hospitalizations. Sixty deaths were reported, about half from Salmonella infections. Recommendations for foodborne outbreaks emphasized appropriate sourcing and preparation of eggs, staff training, and temperature control during food preparation. Recommendations from outbreaks transmitted person-to-person centred on controlling residents' movements, effective environmental cleaning and disinfection, cancelling social events and restricting visitors, excluding ill staff, encouraging effective hand hygiene, and preventing cross-contamination through gloving and gowning. In none of the 75 published outbreak reports were the suggested recommendations evaluated for effectiveness in controlling the outbreak. Applied research of this type could greatly help in the acceptance of prevention and control strategies.

The disease burden and the age group of children most affected by Haemophilus influenzae remain controversial particularly in many countries of South Asia. Nasopharyngeal carriage of H. influenzae can indicate the transmission dynamics in these settings. In a prospective population-based study, nasopharyngeal swabs from 1000 children aged <2 years, belonging to various socioeconomic groups from rural and urban areas of northern India were taken. The prevalence of H. influenzae carriage was found to be 11·2%. Among these isolates, 69% belonged to type b and the rest were non-typable. The age group most affected was 18–21 months. The carriage rate was influenced by age and socioeconomic factors namely type of housing, overcrowding, and season. Hib carriage is quite common in northern India and it is associated with age, type of housing, overcrowding, and season. Since carriage gets established early, Hib vaccination should target children in early infancy.

Neisseria meningitidis capsular switching has been reported in several countries. In order to establish the genetic relationship within group B and C strains expressing subtypes 2a or 2b, and to evaluate whether C to B capsular switching occurred in Portugal, 64 meningococci (56 serogroup C and 8 serogroup B) isolated from invasive meningococcal disease were typed using molecular methods. The studied phenotypes, 2b:P1.5,2 and 2a:P1.5-1,10-8, were the most frequent among serogroup C, but were uncommon among serogroup B strains. The multi-locus sequence typing (MLST) allelic profile and the pulsed-field gel electrophoresis (PFGE) fingerprints showed that seven serogroup B strains were genotypically identical to C strains, suggesting that capsular switching occurred. Active laboratory surveillance to find evidence of capsule switching is a now priority as MenC was introduced in the Portuguese vaccination schedule in January 2006.

We aimed to develop a prediction rule for urinary tract infections (UTIs) in patients with type 2 diabetes mellitus (DM2). A 12-month prospective cohort study was conducted in patients with DM2 aged ⩾45 years to predict the occurrence of recurrent UTIs in women and lower UTIs in men. Predictors for recurrent UTI in women (n=81, 2%) and lower UTIs in men (n=93, 3%) were age, number of general practitioner (GP) visits, urinary incontinence, cerebrovascular disease or dementia. In women, renal disease was an additional predictor. The optimum corrected area under the receiver-operating curve (AUC) was 0·79 (95% CI 0·74–0·83) for women and 0·75 (95% CI 0·70–0·80) for men. Using a cut-off score of 4, women with a lower risk assignment had a probability of 0·3% for the outcome. For a cut-off score of 6, women with a higher risk assignment had a probability of 5·8%. For men these figures were 0·8 and 7·1 for a cut-off score of 2 and 4, respectively. Simple variables can be used for the risk stratification of patients.

Multidrug-resistant isolates of Acinetobacter baumannii from New York City generally belong to one of three ribotypes. To assess the accuracy of ribotyping, the relatedness of representative isolates was further assessed by rep-PCR, pulsed-field gel electrophoresis (PFGE), and DNA sequencing of five genes potentially associated with antimicrobial resistance (ampC, ompA, adeB, adeR, and abeM). The isolates fell into several major groups. The first group shared the same ribotype and had common mutations affecting OmpA, AdeR, and AbeM, but consisted of two subtypes with distinctive rep-PCR and PFGE patterns and ampC mutations. The second and third groups shared common alterations in OmpA, AdeR, and AbeM, but had distinct ribotype, rep-PCR, and PFGE patterns. The resistant isolates were unrelated to the β-lactam susceptible isolates. Many of the resistant strains shared OmpA and AdeB patterns observed in several European clonal groups. Further development of a multilocus sequencing typing scheme will help determine if multidrug-resistant isolates from diverse geographic areas are indeed ancestrally related.

It has been suggested that warm and humid weather is related to a high incidence of Legionnaires' disease (LD), but no data on this association existed in The Netherlands. The objective of this study was to investigate the short-term effects of the weather on LD in The Netherlands. National LD surveillance and meteorological data were obtained. We analysed the data using Poisson regression, adjusting for long-term trends, and using principal components analysis. The highest weekly incidence of LD occurred when the mean weekly temperature was +17·5°C. Mean weekly relative humidity, temperature and precipitation intensity were associated with LD incidence in the multivariable model. Warm, humid and showery summer weather was found to be associated with higher incidence of LD in The Netherlands. These results may be used to predict an increase in the number of cases of LD in The Netherlands during the summer.

The cytopathogenicity of 22 Legionella pneumophila isolates from 17 hospitals was determined by assessing the dose of bacteria necessary to produce 50% cytopathic effect (CPED50) in U937 human-derived macrophages. All isolates were able to infect and grow in macrophage-like cells (range log10 CPED50: 2·67–6·73 c.f.u./ml). Five groups were established and related to the serogroup, the number of PFGE patterns coexisting in the same hospital water distribution system, and the possible reporting of hospital-acquired Legionnaires' disease cases. L. pneumophila serogroup 1 isolates had the highest cytopathogenicity (P=0·003). Moreover, a trend to more cytopathogenic groups (groups 1–3) in hospitals with more than one PFGE pattern of L. pneumophila in the water distribution system (60% vs. 17%) and in hospitals reporting cases of hospital-acquired Legionnaires' disease (36·3% vs. 16·6%) was observed. We conclude that the cytopathogenicty of environmental L. pneumophila should be taken into account in evaluating the risk of a contaminated water reservoir in a hospital and hospital acquisition of Legionnaires' disease.

This study describes the epidemiology of community-acquired pneumonia (CAP) in elderly Australians for the first time. Using a case-cohort design, cases with CAP were in-patients aged ⩾65 years with ICD-10-AM codes J10-J18 admitted over 2 years to two tertiary hospitals. The cohort sample was randomly selected from all hospital discharges, frequency-matched to cases by month. Logistic regression was used to estimate risk ratios for factors predicting CAP or associated mortality. A total of 4772 in-patients were studied. There were 1952 cases with CAP that represented 4% of all elderly admissions: mean length of stay was 9·0 days and 30-day mortality was 18%. Excluding chest radiograph, 520/1864 (28%) cases had no investigations performed. The strongest predictors of CAP were previous pneumonia, history of other respiratory disease, and aspiration. Intensive-care-unit admission, renal disease and increasing age were the strongest predictors of mortality, while influenza vaccination conferred protection. Hospitalization with CAP in the elderly is common, frequently fatal and a considerable burden to the Australian community. Investigation is ad hoc and management empirical. Influenza vaccination is associated with reduced mortality. Patient characteristics can predict risk of CAP and subsequent mortality.

Diabetes mellitus (DM) is a known risk factor for pulmonary tuberculosis (PTB). This study aimed to determine if type 2 DM alters manifestations and treatment outcome of PTB. Records of 217 consecutive culture-proven PTB patients were analysed retrospectively. The manifestations and treatment outcomes of 74 patients with type 2 DM (PTB-DM group) were compared to 143 patients without DM (PTB group). PTB-DM patients showed higher frequencies of fever, haemoptysis, positive acid-fast bacilli sputum smears, and consolidation, cavity, and lower lung field lesions on chest radiographs, and higher mortality rate. Furthermore, type 2 DM, age ⩾65 years, and extensive radiographic disease were factors independently associated with an unfavorable outcome. This study confirmed that clinical manifestations and chest radiographs of PTB patients associated with type 2 DM significantly depart from the typical presentation. Type 2 DM seems to have a negative effect on treatment outcome of PTB.

Oral fluid is a non-invasive biological sample, which can be returned by post, making it suitable for large-scale epidemiological studies in children. We report our experience of oral fluid collection from 14 373 preschool-aged children in the UK Millennium Cohort Study. Samples were collected by mothers in the home setting following the guidance of trained interviewers, and posted to the laboratory. Samples were received from 11 698 children (81·4%). Children whose mothers were of Black Caribbean ethnicity and who lived in non-English-speaking households were less likely to provide a sample, and those with a maternal history of asthma more likely to provide a sample [adjusted risk ratio (95% CI) 0·85 (0·73–0·98), 0·87 (0·77–0·98) and 1·03 (1·00–1·05) respectively]. Collection of oral fluid samples is feasible and acceptable in large-scale child cohort studies. Formal interpreter support may be required to increase participation rates in surveys that collect biological samples from ethnic minorities.

Three different methods were used for estimating the basic reproductive number (R0) from data on 110 outbreaks of highly pathogenic avian influenza (HPAI) subtype H5N1 that occurred in village poultry in Romania, 12 May to 6 June 2006. We assumed a village-level infectious period of 7 days. The methods applied were GIS-based identification of nearest infectious neighbour (based on either Euclidean or road distance), the method of epidemic doubling time, and a susceptible–infectious (SI) modelling approach. In general, the estimated basic reproductive numbers were consistent: 2·14, 1·95, 2·68 and 2·21, respectively. Although the true basic reproductive number in this epidemic is unknown, results suggest that the use of a range of methods might be useful for characterizing epidemics of infectious diseases. Once the basic reproductive number has been estimated, better control strategies and targeted surveillance programmes can be designed.

We evaluated the effectiveness of a measles vaccine campaign in rural Kenya, based on oral-fluid surveys and mixture-modelling analysis. Specimens were collected from 886 children aged 9 months to 14 years pre-campaign and from a comparison sample of 598 children aged 6 months post-campaign. Quantitative measles-specific antibody data were obtained by commercial kit. The estimated proportions of measles-specific antibody negative in children aged 0–4, 5–9 and 10–14 years were 51%, 42% and 27%, respectively, pre- campaign and 18%, 14% and 6%, respectively, post-campaign. We estimate a reduction in the proportion susceptible of 65–78%, with ~85% of the population recorded to have received vaccine. The proportion of ‘weak’ positive individuals rose from 35% pre-campaign to 54% post-campaign. Our results confirm the effectiveness of the campaign in reducing susceptibility to measles and demonstrate the potential of oral-fluid studies to monitor the impact of measles vaccination campaigns.

A large outbreak of hepatitis E occurred in 2005 in Hyderabad, Andhra Pradesh, India. A total of 1611 cases were reported between 1 March and 31 December 2005 (attack rate 40/100 000). The epidemic curve suggested a continuing common source outbreak. Cases were centred around open sewage drains that crossed the old city. The attack rate was significantly higher in neighbourhood blocks supplied by water supply lines that crossed open drains (203/100 000) than in blocks supplied by non-crossing water pipes with a linear trend (38/100 000, P<0·00001). Crossing water pipelines were repaired and the attack rates declined.

We propose a mathematical model to simulate the dynamics of hepatitis C virus (HCV) infection in the state of São Paulo, Brazil. We assumed that a hypothetical vaccine, which cost was taken to be the initial cost of the vaccine against hepatitis B exists and it is introduced in the model. We computed its cost-effectiveness compared with the anti-HCV therapy. The calculated basic reproduction number was 1·20. The model predicts that without intervention a steady state exists with an HCV prevalence of 3%, in agreement with the current epidemiological data. Starting from this steady state three interventions were simulated: indiscriminate vaccination, selective vaccination and anti-HCV therapy. Selective vaccination proved to be the strategy with the best cost-effectiveness ratio, followed by indiscriminate vaccination and anti-HCV therapy.

Recently, human cases of nephropathia epidemica (NE) due to Puumala virus infection in Europe have increased. Following the hypothesis that high reservoir host abundance induces higher transmission rates to humans, explanations for this altered epidemiology must be sought in factors that cause bank vole (Myodes glareolus) abundance peaks. In Western Europe, these abundance peaks are often related to high tree seed production, which is supposedly triggered by specific weather conditions. We evaluated the relationship between tree seed production, climate and NE incidence in Belgium and show that NE epidemics are indeed preceded by abundant tree seed production. Moreover, a direct link between climate and NE incidence is found. High summer and autumn temperatures, 2 years and 1 year respectively before NE occurrence, relate to high NE incidence. This enables early forecasting of NE outbreaks. Since future climate change scenarios predict higher temperatures in Europe, we should regard Puumala virus as an increasing health threat.

Squirrelpox virus (SQPV) causes a fatal disease in free-living red squirrels (Sciurus vulgaris) which has contributed to their decline in the United Kingdom. Given the difficulty of carrying out and funding experimental investigations on free-living wild mammals, data collected from closely monitored natural outbreaks of disease is crucial to our understanding of disease epidemiology. A conservation programme was initiated in the 1990s to bolster the population of red squirrels in the coniferous woodland of Thetford Chase, East Anglia. In 1996, 24 red squirrels were reintroduced to Thetford from Northumberland and Cumbria, while in 1999 a captive breeding and release programme commenced, but in both years the success of the projects was hampered by an outbreak of SQPV disease in which seven and four red squirrels died respectively. Valuable information on the host–pathogen dynamics of SQPV disease was gathered by telemetric and mark–recapture monitoring of the red squirrels. SQPV disease characteristics were comparable to other virulent poxviral infections: the incubation period was <15 days; the course of the disease an average of 10 days and younger animals were significantly more susceptible to disease. SQPV disease places the conservation of the red squirrel in jeopardy in the United Kingdom unless practical disease control methods can be identified.

Two hundred and four Salmonella enterica serotype Typhi (S. Typhi) isolates were collected from seven Asian countries during 2002–2004. Multidrug-resistant S. Typhi (resistant to ⩾3 antibiotics) was detected in 84 (41·2%) isolates and 142 (69·6%) showed reduced susceptibility to ciprofloxacin (minimum inhibitory concentration=0·125–1·0 mg/l). This study highlights the worsening situation of antimicrobial resistance of S. Typhi in Asia.

Cryptosporidium is an important cause of diarrhoeal disease worldwide and, as several recent waterborne outbreaks have shown, poses a significant threat to public health in Ireland. We identified the Cryptosporidium spp. in 199 positive human stool samples by PCR–RFLP of the 18S rRNA and COWP gene loci. Subspecies were identified in 104 samples by sequence analysis of the 60 kDa glycoprotein (gp60) gene fragment. Overall C. parvum was identified in 80%, and C. hominis in 20% of cases. No other Cryptosporidium spp. were detected. C. parvum was by far the most common species in the rural, more sparsely populated west of Ireland and exhibited a pronounced spring peak coincident with a peak in the national cryptosporidiosis incidence rate. Our data indicated a trend towards higher proportions of C. hominis in older age groups. Ninety-nine per cent of all subtyped C. parvum isolates belonged to allele family IIa, of which allele IIaA18G3R1 was by far the most common (63%). According to a recent study by Thompson and colleagues [Parasitology Research (2007), 100, 619–624] this allele is also the most common in Irish cattle. Subtyping of the C. hominis isolates indicated that they belonged to a geographically widely distributed allele (IbA10G2) known to have caused several water- and foodborne outbreaks around the world. The predominance of C. parvum, its geographic and seasonal distribution and the IIaA18G3R1 subtype underlines the importance of zoonotic Cryptosporidium transmission in Ireland.

The incidence of Clostridium difficile-associated infections is increasing, but it remains to be defined whether any change in the seroprevalence of C. difficile has also occurred. In a population-based study of the general adult population, 734 subjects, aged 15–69 years, were examined on two occasions 8 years apart (1990 and 1998) for the presence of antibodies against C. difficile in serum. The overall seroprevalence of C. difficile increased significantly from 19% in 1990 to 27% in 1998 (P<0·0001). The seroprevalence increased with increasing age in both 1990 and 1998, but the increase was about four times higher in 1998 than in 1990. In conclusion, the observed increase in seroprevalence suggests a higher exposure to C. difficile in the general Danish adult population.