Healthcare-associated hepatitis B virus (HBV) outbreaks have been reported in the USA and from several countries in Europe. Patient-to-patient transmission of HBV in these settings has been linked to several different types of exposure but one of the most common exposures implicated is the use of ‘finger-stick’ lancet devices for blood glucose testing. This article is an account of the investigations into a series of HBV outbreaks linked to the use of lancing devices in community healthcare settings in the UK. Between February 2004 and December 2006, nine individuals with acute HBV infection were reported to five local units of the Health Protection Agency. Investigations identified a further 12 individuals with HBV infection in residents in these settings. The epidemiological and environmental evidence suggests that HBV transmission occurred mostly from a significant breakdown in infection control measures in blood glucose testing. The occurrence of these outbreaks has highlighted the confusion that exists and the need for clear recommendations regarding the use of such devices in the UK.

Between March and June 2008, 12 cases of hepatitis A were notified in Winchester. Cases were from a primary school and a nursery school with no direct linkage. Hepatitis A virus (HAV) RNA sequenced from nine cases confirmed the strain in both schools to be identical. The outbreak could have affected three other schools and a maternity unit and was controlled by immunization and screening of neonates in the maternity unit by dried blood spots. No neonates were infected and no further cases were reported until 5 months later when the index case's mother became infected with same strain of virus associated with the outbreak despite vaccination. Neither the source of the outbreak or the subsequent infection of the index case's mother was identified; however, with the timing of the cases continued transmission in the community by children with asymptomatic infection or a recurrent source cannot be ruled out.

We estimated the excess risk of in-patient hospitalization in a large cohort of persons diagnosed with hepatitis C virus (HCV) infection, controlling for social deprivation. A total of 20 749 individuals diagnosed with HCV in Scotland by 31 December 2006 were linked to the Scottish hospital discharge database, and indirectly standardized hospitalization rates, adjusting for sex, age, year and deprivation were calculated. We observed significant excess morbidity considering episodes for: any diagnosis [standardized morbidity ratio (SMR) 3·4, 95% CI 3·3–3·5]; liver-related diagnoses (SMR 41·3, 95% CI 39·6–43·0); and only non-liver-related diagnoses (SMR 2·14, 95% CI 2·08–2·19). Cox regression analyses of the 2000–2006 data indicated increased relative risks of hospitalization for males [hazard ratio (HR) 1·1, 95% CI 1·0–1·2], older age (per 10 years) (HR 1·55, 95% CI 1·5–1·6), and those testing HIV-positive (HR 1·6, 95% CI 1·3–1·8). This study has revealed substantial excess all-cause and liver-related morbidity in the Scottish HCV-diagnosed population, even after allowing for deprivation.

To evaluate the prevalence of hepatitis C virus (HCV) and/or hepatitis B virus (HBV) infections in HIV-infected patients in China, an epidemiological serosurvey was conducted from May 2007 to September 2008 using a random cluster sampling design of infectious disease hospitals in seven high HIV-prevalent provinces (municipalities). Univariate analysis and logistic regression were used to study the determinants of HIV and HBV and/or HCV co-infection. The overall prevalence was 41·83% (95% CI 40·36–43·30) for anti-HCV and 12·49% (95% CI 11·50–13·48) for HBsAg, respectively. The prevalence of anti-HCV and HBsAg varied according to the route of HIV transmission. Compared to those with sexually acquired HIV infection, intravenous drug users and blood donors/recipients had the greatest risk of carrying anti-HCV. Needle sharing and unprotected sexual exposures are important modes of transmission for HBV. Further interventions including health education and harm reduction strategies should be implemented in high-risk populations.

Hepatitis E infections in humans are usually acquired in endemic countries in Asia or Africa. In Sweden 17 cases infected in Europe, between 1993 and 2009, were identified. All had clinical hepatitis E with unknown source of infection. Hepatitis E virus (HEV) was identified in faecal samples from 63 piglets in 12 pig farms in Sweden. HEV was also identified in blood from 13 out of 159 investigated Swedish wild boars from nine counties. Partial HEV genomes from humans, pigs and wild boars were sequenced and compared by phylogeny. The results showed close relatedness between HEV strains from piglets from the same farm and from wild boars from the same county. HEV strains from humans showed relatedness with strains from pigs and wild boars from the same county. This study showed that HEV strains form geographical clusters in the phylogenetic tree. The methods used in this study may thus be used for tracing the origin of an infecting strain. Furthermore, this study indicated that there are endemic sources of human HEV infections in Sweden.

Since Kenya first reported Rift Valley fever (RVF)-like disease in livestock in 1912, the country has reported the most frequent epizootics of RVF disease. To determine the pattern of disease spread across the country after its introduction in 1912, and to identify regions vulnerable to the periodic epizootics, annual livestock disease records at the Department of Veterinary Services from 1910 to 2007 were analysed in order to document the number and location of RVF-infected livestock herds. A total of 38/69 (55%) administrative districts in the country had reported RVF epizootics by the end of 2007. During the 1912–1950 period, the disease was confined to a district in Rift Valley province that is prone to flooding and where livestock were raised in proximity with wildlife. Between 1951 and 2007, 11 national RVF epizootics were recorded with an average inter-epizootic period of 3·6 years (range 1–7 years); in addition, all epizootics occurred in years when the average annual rainfall increased by more than 50% in the affected districts. Whereas the first two national epizootics in 1951 and 1955 were confined to eight districts in the Rift Valley province, there was a sustained epizootic between 1961 and 1964 that spread the virus to over 30% of the districts across six out of eight provinces. The Western and Nyanza provinces, located on the southwestern region of the country, had never reported RVF infections by 2007. The probability of a district being involved in a national epizootic was fivefold higher (62%) in districts that had previously reported disease compared to districts that had no prior disease activity (11%). These findings suggests that once introduced into certain permissive ecologies, the RVF virus becomes enzootic, making the region vulnerable to periodic epizootics that were probably precipitated by amplification of resident virus associated with heavy rainfall and flooding.

Within Europe, Puumala virus (PUUV) is the causal agent of nephropathia epidemica (NE) in humans, a zoonotic disease with increasing significance in recent years. In a region of Belgium with a historically high incidence of NE, bank voles (the PUUV reservoir hosts), were monitored for PUUV IgG antibody prevalence in nine study sites before, during, and after the highest NE outbreak recorded in Belgium in 2005. We found that the highest numbers of PUUV IgG-positive voles coincided with the peak of NE cases at the regional level, indicating that a PUUV epizootic in bank voles directly led to the NE outbreak in humans. On a local scale, PUUV infection in voles was patchy and not correlated to NE incidence before the epizootic. However, during the epizootic period PUUV infection spread in the vole populations and was significantly correlated to local NE incidence. Initially, local bank-vole numbers were positively associated with local PUUV infection risk in voles, but this was no longer the case after the homogeneous spreading of PUUV during the PUUV outbreak.

This study aimed to investigate the spatial clustering and dynamic dispersion of dengue incidence in Queensland, Australia. We used Moran's I statistic to assess the spatial autocorrelation of reported dengue cases. Spatial empirical Bayes smoothing estimates were used to display the spatial distribution of dengue in postal areas throughout Queensland. Local indicators of spatial association (LISA) maps and logistic regression models were used to identify spatial clusters and examine the spatio-temporal patterns of the spread of dengue. The results indicate that the spatial distribution of dengue was clustered during each of the three periods of 1993–1996, 1997–2000 and 2001–2004. The high-incidence clusters of dengue were primarily concentrated in the north of Queensland and low-incidence clusters occurred in the south-east of Queensland. The study concludes that the geographical range of notified dengue cases has significantly expanded in Queensland over recent years.

We investigated the effect of social inequalities on the uptake of human papillomavirus (HPV) vaccination, combining data from a feasibility study conducted in 2007–2008 in 2817 secondary schoolgirls in two UK primary-care trusts, with census and child health records. Uptake was significantly lower in more deprived areas (P<0·001) and in ethnic minority girls (P=0·013). The relatively small proportion of parents who actively refused vaccination by returning a negative consent form were more likely to come from more advantaged areas (P<0·001). Non-responding parents were from more deprived (P<0·001) and ethnic minority (P=0·001) backgrounds. Girls who did not receive HPV vaccination were less likely to have received all their childhood immunizations particularly measles, mumps and rubella (MMR). Different approaches may be needed to maximize HPV vaccine uptake in engaged and non-responding parents, including ethnic-specific approaches for non-responders.

Streptococcus equi subsp. zooepidemicus rarely causes meningitis in humans by contact with domestic animals or their unpasteurized products. In this paper we reviewed the literature pertaining to the epidemiological and clinical aspects relating to this infection on previously reported cases of human disease. Additionally, the case of a 51-year-old female who acquired meningitis with this organism after contact with a horse is described. This patient was successfully treated with ceftriaxone, yet penicillin remains the treatment of choice. This aetiological agent should be considered in the proper epidemiological context.

This study assessed risk factors for 30-day mortality in 66 patients with carbapenem-resistant Acinetobacter baumannii (CRAB) infection or colonization during an outbreak in an intensive-care unit. Clinical and demographic characteristics were evaluated. The overall 30-day mortality was 47·0%. In the multivariate Cox regression model, septic shock [adjusted hazard ratio (aHR) 5·01, 95% confidence interval (CI) 2·32–10·01] and APACHE II score at onset of infection (aHR 1·11, 95% CI 1·04–1·18) were significantly associated with 30-day mortality. Administration of appropriate therapy was a protective factor, but it was not statistically significant (aHR 0·48, 95% CI 0·21–1·12). A sample of isolates tested (n=27) carried the blaOXA-23 gene. Severity of baseline condition and severity of infection presentation were major risk factors for mortality during the outbreak. Patients who received appropriate therapy tended to have lower mortality rates, although therapy was started late and dosage was suboptimal in most cases.

Despite the increasing burden of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, the risk factors are not well understood. We conducted a hypothesis-generating study using three parallel case-control studies to identify risk factors for CA-MRSA and community-associated methicillin-susceptible S. aureus (CA-MSSA) infections. In the multivariate model, antimicrobial use in the 1–6 months prior to culture was associated with CA-MRSA infection compared to CA-MSSA [adjusted odds ratio (aOR) 1·7, P=0·07] cases. Antimicrobial use 1–6 months prior to culture (aOR 1·8, P=0·04), history of boils (aOR 1·6, P=0·03), and having a household member who was a smoker (aOR 1·3, P=0·05) were associated with CA-MRSA compared to uninfected community controls. The finding of an increased risk of CA-MRSA infection associated with prior antimicrobial use highlights the importance of careful antimicrobial stewardship.

Following an outbreak of vanA-positive Enterococcus faecium in 2005 in Kyoto prefecture, regional surveillance of vancomycin-resistant enterococci (VRE) was initiated. This revealed vanA- or vanB-positive Enterococcus gallinarum in multiple facilities. Eighty-eight vanA-positive E. gallinarum faecal carriers from 12 facilities and ten vanB-positive E. gallinarum faecal carriers from eight facilities were found. Pulsed-field gel electrophoresis profiles of the first isolate from each facility showed that 11 of the 12 vanA isolates and three of the eight vanB-positive E. gallinarum isolates belonged to a single clone. This study confirms the clonal spread of vanA- or vanB-positive E. gallinarum in a region and underlines the importance of surveillance of VRE for the presence of vancomycin resistance determinants.

Listeriosis is a foodborne disease associated with significant mortality. This study attempts to identify risk factors for sporadic listeriosis in Australia. Information on underlying illnesses was obtained from cases' treating doctors and other risk factors were elicited from the patient or a surrogate. We attempted to recruit two controls per case matched on age and primary underlying immune condition. Between November 2001 and December 2004 we recruited 136 cases and 97 controls. Of perinatal cases, living in a household where a language other than English was spoken was the main risk factor associated with listeriosis (OR 11·3, 95% CI 1·5–undefined). Of non-perinatal cases we identified the following risk factors for listeriosis: prior hospitalization (OR 4·3, 95% CI 1·0–18·3), use of gastric acid inhibitors (OR 9·4, 95% CI 2·4–37·4), and consumption of camembert (OR 4·7, 95% CI 1·1–20·6). Forty percent of cases with prior hospitalization were exposed to high-risk foods during hospitalization.

We studied changes in species distribution and antimicrobial resistance patterns of Shigella during 1980–2008, using the Diarrhoeal Diseases Surveillance system of Dhaka Hospital of ICDDR,B. In hospitalized patients Shigella prevalence decreased steadily from 8–12% in the 1980s to 3% in 2008. Endemic S. flexneri was the most commonly isolated species (54%). Epidemic S. dysenteriae type 1 had two peaks in 1984 and 1993, but was not found after 2000, except for one case in 2004. The therapeutic options are now limited: in 2008 a total of 33% of S. flexneri were resistant to ciprofloxacin and 57% to mecillinam. In the <5 years age group, severely underweight, wasted and stunted children were more at risk of shigellosis compared to well-nourished children (P<0·001). Although hospitalization for Shigella diarrhoea is decreasing, the high levels of antimicrobial resistance and increased susceptibility of malnourished children continue to pose an ongoing risk.

Although norovirus infection is generally known to be a mild disease, there is some evidence for severe outcome. An outbreak in a Dutch psychiatric institution, originating from pilgrims returning from Lourdes (France), provided an opportunity for performing a retrospective cohort study in order to identify risk factors for norovirus disease and excess mortality. Relative risks (RR) including 95% confidence intervals (CI) showed that attending the pilgrimage (RR 2·0, 95% CI 1·4–3·0) and age >70 (RR 1·7, 95% CI 1·2–2·2) were risk factors for symptomatic infection. In a subset of patients, for whom more detailed information was available, the use of statins was associated with norovirus disease when adjusted for underlying condition (adjusted odds ratio 3·9, 95% CI 1·2–13·0). Mortality was higher in cases infected during the pilgrimage compared to other residents (RR 20·9, 95% CI 4·7–93·8). Norovirus disease can lead to severe outcome. The newly identified risk of statins for contracting norovirus disease may have considerable consequences for the Western world and needs prospective confirmation.

Recently, multiple-locus variable-number tandem-repeat analysis (MLVA) has been proposed as an alternative to pulsed-field gel electrophoresis (PFGE) for characterization of Escherichia coli O157:H7. In this study we characterized 118 E. coli O157:H7 isolates from cases of gastrointestinal disease in New Zealand using XbaI PFGE profiles and a MLVA scheme that assessed variability in eight polymorphic loci. The 118 isolates characterized included all 80 E. coli O157:H7 referred to New Zealand's Enteric Reference Laboratory in 2006 and 29 phage-type 2 isolates from 2005. When applied to these isolates the discriminatory power of PFGE and MLVA was not significantly different. However, MLVA data may be more epidemiologically relevant as isolates from family clusters of disease had identical MLVA profiles, even when the XbaI PFGE profiles differed slightly. Furthermore, most isolates with indistinguishable XbaI PFGE profiles that did not appear to be epidemiologically related had distinct MLVA profiles.

In 1996 an outbreak of severe soft tissue infections caused by Vibrio vulnificus unexpectedly erupted in fish consumers in Israel with relatively little morbidity in fish farmers. To test the hypothesis that recurrent exposure of fishermen to the virulent strain may have provided protection against severe or symptomatic disease, we investigated the association between the immune response to V. vulnificus biotype 3 lipopolysaccharide (BT3 LPS) and disease susceptibility in fish farmers and fish consumers. Serum samples were tested for IgA and IgG of anti-BT3 LPS in fishermen and fish consumers who suffered from V. vulnificus BT3 infections and their matched controls. Pre-existing levels of IgG (IgG0) of anti-BT3 LPS were significantly lower in diseased fishermen who developed disease associated with the homologous biotype, compared to controls. In multivariate analysis, levels of IgG0 anti-BT3 LPS remained the only variable significantly associated with disease occurrence in fishermen. Higher levels of pre-existing IgG anti-BT 3 LPS antibodies may be associated with protection against severe or symptomatic disease with the homologous biotype in fishermen but not in subjects from the general public.

A time-series analysis was performed to identify the impact of bed occupancy rates and length of hospital stay on the incidence of Clostridium difficile infections (CDI). Between January 2003 and July 2008, a mean incidence of 0·5 CDI cases/1000 patient days was recorded. Application of a multivariate model (R2=0·50) showed that bed occupancy rates on general wards (P<0·01) and length of stay in intensive care units (ICUs) (P<0·01) influenced the incidence of CDI. Overcrowding on general wards and long periods in ICUs were identified as being positively associated with the incidence of CDI.