The highly remote pastoralist communities in Kaokoland, Namibia, have long been presumed to have high gonorrhoea prevalence. To estimate gonorrhoea prevalence and correlates of infection, we conducted a cross-sectional study of 446 adults across 28 rural villages. Gonorrhoea status was determined from urethral and vaginal swabs via qPCR assay. All participants answered a closed-ended interview about demographics, sexual behaviour and symptom history. Sixteen per cent of participants had high-level infections (⩾ID50 dose) and 48% had low-level infections (<ID50 dose). Women had higher prevalence than men of both high- and low-level infections. High-level infections were regionally and seasonally clustered, occurring in young adults in the Ehama region during the winter. Low-level infections were distributed homogenously across demographic characteristics, season, and region. All low-level infections and most high-level infections (men 78%, women 95%) were asymptomatic and left untreated. The epidemic-like nature of high-level gonorrhoea cases suggests that intervention efforts can be focused on seasons of high social activity.

Rapid and wide dispersal of passengers after flights makes investigation of flight-related outbreaks challenging. An outbreak of Salmonella Heidelberg was identified in a group of Irish travellers returning from Tanzania. Additional international cases sharing the same flight were identified. Our aim was to determine the source and potential vehicles of infection. Case-finding utilized information exchange using experts' communication networks and national surveillance systems. Demographic, clinical and food history information was collected. Twenty-five additional cases were identified from Ireland, The Netherlands, Norway, USA and Canada. We conducted a case-control study which indicated a significant association between illness and consumption of milk tart (OR 10·2) and an egg dish (OR 6) served on-board the flight. No food consumed before the flight was associated with illness. Cases from countries other than Ireland provided supplementary information that facilitated the identification of likely vehicles of infection. Timely, committed international collaboration is vital in such investigations.

Surveillance for new and re-emerging animal diseases in England and Wales is based on post-mortem and syndromic analysis of laboratory data collated in a central database by the Animal Health and Veterinary Laboratories Agency (AHVLA), with the aim of providing early warning of disease events prior to clinical diagnosis. Understanding the drivers for participation in such systems is critical to the success of attempts to improve surveillance sensitivity. The aim of this study was to investigate the decision-making process governing the submission of biological samples on which this surveillance system is based by use of questionnaires. Data extracted were used to structure and parameterize scenario trees modelling the probability of generating an entry in the surveillance database. The mean probability for database entry per case ranged from 0·085 for neurological disorders to 0·25 for enteric disease. These findings illustrate the importance of on-farm decision making to the generation of surveillance data.

The Dutch and modified Hald source attribution models were adapted to Italian Salmonella data to attribute human infections caused by the top 30 serotypes between 2002 and 2010 to four putative sources (Gallus gallus, turkeys, pigs, ruminants), at the points of animal reservoir (farm), exposure (food), and both combined. Attribution estimates were thus compared between different models, time periods and sampling points. All models identified pigs as the main source of human salmonellosis in Italy, accounting for 43–60% of infections, followed by G. gallus (18–34%). Attributions to turkeys and ruminants were minor. An increasing temporal trend in attributions to pigs and a decreasing one in those to G. gallus was also observed. Although the outcomes of the two models applied at farm and food levels essentially agree, they can be refined once more information becomes available, providing valuable insights about potential targets along the production chain.

The population structure of Staphylococcus aureus is changing globally but the situation regarding dominant clones in sub-Saharan Africa is not clear. We therefore assessed changes in the population structure of clinical S. aureus isolates obtained in 2007 (n = 75) and 2012 (n = 75) from Northeastern Nigeria. A reduction in resistance to penicillin, gentamicin, erythromycin and clindamycin was observed in 2012. A decrease of methicillin resistance rates (13·3% to 8·0%) was associated with the decline of the ST241 MRSA clone. The proportion of Panton–Valentine leukocidin (PVL)-positive isolates also decreased from 65·3% to 44%, and was linked with the emergence of PVL-negative ST601 clone in 2012. The significant decline in antibiotic resistance in the study area is in contrast to the worldwide trend of increasing resistance rates.

During a 5-year prospective study of nasopharyngeal (NP) colonization and acute otitis media (AOM) infections in children during the 7-valent pneumococcal conjugate vaccine (PCV) era (July 2006–June 2011) we studied risk factors for NP colonization and AOM. NP samples were collected at ages 6, 9, 12, 15, 18, 24, and 30 months during well-child visits. Additionally, NP and middle ear fluid (MEF) samples were collected at onset of every AOM episode. From 1825 visits (n = 464 children), 5301 NP and 570 MEF samples were collected and analysed for potential otopathogens. Daycare attendance, NP colonization by Moraxella catarrhalis, and siblings aged <5 years increased the risk of Streptococcus pneumoniae NP colonization. NP colonization with S. pneumoniae, M. catarrhalis, or Haemophilus influenzae and a family history of OM increased the risk of AOM. Risk factors that increase the risk of pneumococcal AOM will be important to reassess as we move into a new 13-valent PCV era, especially co-colonization with other potential otopathogens.

Acinetobacter is a well-recognized nosocomial pathogen. Previous reports of community-associated Acinetobacter infections have lacked clear case definitions and assessment of healthcare-associated (HCA) risk factors. We identified Acinetobacter bacteraemia cases from blood cultures obtained <3 days after hospitalization in rural Thailand and performed medical record reviews to assess HCA risk factors in the previous year and compare clinical and microbiological characteristics between cases with and without HCA risk factors. Of 72 Acinetobacter cases, 32 (44%) had no HCA risk factors. Compared to HCA infections, non-HCA infections were more often caused by Acinetobacter species other than calcoaceticus–baumannii complex species and by antibiotic-susceptible organisms. Despite similar symptoms, the case-fatality proportion was lower in non-HCA than HCA cases (9% vs. 45%, P < 0·01). Clinicians should be aware of Acinetobacter as a potential cause of community-associated infections in Thailand; prospective studies are needed to improve understanding of associated risk factors and disease burden.

Understanding the spatial distribution of disease is critical for effective disease control. Where formal address networks do not exist, tracking spatial patterns of clinical disease is difficult. Geolocation strategies were tested at rural health facilities in western Kenya. Methods included geocoding residence by head of compound, participatory mapping and recording the self-reported nearest landmark. Geocoding was able to locate 72·9% [95% confidence interval (CI) 67·7–77·6] of individuals to within 250 m of the true compound location. The participatory mapping exercise was able to correctly locate 82·0% of compounds (95% CI 78·9–84·8) to a 2 × 2·5 km area with a 500 m buffer. The self-reported nearest landmark was able to locate 78·1% (95% CI 73·8–82·1) of compounds to the correct catchment area. These strategies tested provide options for quickly obtaining spatial information on individuals presenting at health facilities.

We examined the spatial distribution pattern and meteorological drivers of dengue fever (DF) in Guangdong Province, China. Annual incidence of DF was calculated for each county between 2005 and 2011 and the geographical distribution pattern of DF was examined using Moran's I statistic and excess risk maps. A time-stratified case-crossover study was used to investigate the short-term relationship between DF and meteorological factors and the Southern Oscillation Index (SOI). High-epidemic DF areas were restricted to the Pearl River Delta region and the Han River Delta region, Moran's I of DF distribution was significant from 2005 to 2006 and from 2009 to 2011. Daily vapour pressure, mean and minimum temperatures were associated with increased DF risk. Maximum temperature and SOI were negatively associated with DF transmission. The risk of DF was non-randomly distributed in the counties in Guangdong Province. Meteorological factors could be important predictors of DF transmission.

Limited studies exist regarding whether incorporating micronutrient supplements during tuberculosis (TB) treatment may improve cell-mediated immune response. We examined the effect of micronutrient supplementation on lymphocyte proliferation response to mycobacteria or T-cell mitogens in a randomized trial conducted on 423 patients with pulmonary TB. Eligible participants were randomly assigned to receive a daily dose of micronutrients (vitamins A, B-complex, C, E, and selenium) or placebo at the time of initiation of TB treatment. We found no overall effect of micronutrient supplements on lymphocyte proliferative responses to phytohaemagglutinin or purified protein derivatives in HIV-negative and HIV-positive TB patients. Of HIV-negative TB patients, the micronutrient group tended to show higher proliferative responses to concanavalin A than the placebo group, although the clinical relevance of this finding is not readily notable. The role of nutritional intervention in this vulnerable population remains an important area of future research.

A hypothetical influenza infection-induced non-specific immunity may reduce the risk of subsequent non-influenza respiratory virus (NIRV) infection and bias the influenza vaccine effectiveness (VE) estimates in test-negative designs (TNDs). We conducted a simulation study using a simple TND model and explored the degree of bias in the VE estimates. The bias was marginal during the usual seasons and most of the time during pandemics; the bias only became large when the influenza infection attack rate increased to pandemic levels (>50%), the true VE was low to moderate, and the non-specific immunity almost completely protected from NIRV infections and lasted at least half the influenza season.

The objective of this study was to evaluate the effect of age-adjusted comorbidity and alcohol-based hand rub on monthly hospital antibiotic usage, retrospectively. A multivariate autoregressive integrated moving average (ARIMA) model was built to relate the monthly use of all antibiotics grouped together with age-adjusted comorbidity and alcohol-based hand rub over a 5-year period (April 2005–March 2010). The results showed that monthly antibiotic use was positively related to the age-adjusted comorbidity index (concomitant effect, coefficient 1·103, P = 0·0002), and negatively related to the use of alcohol-based hand rub (2-month delay, coefficient −0·069, P = 0·0533). Alcohol-based hand rub is considered a modifiable factor and as such can be identified as a target for quality improvement programmes. Time-series analysis may provide a suitable methodology for identifying possible predictive variables that explain antibiotic use in healthcare settings. Future research should examine the relationship between infection control practices and antibiotic use, identify other infection control predictive factors for hospital antibiotic use, and evaluate the impact of enhancing different infection control practices on antibiotic use in a healthcare setting.

Human infection with the emerging avian influenza A(H7N9) virus in China in 2013 has raised global concerns. We conducted a retrospective descriptive study of 27 confirmed human influenza A(H7N9) cases in Jiangsu Province, to elaborate poultry-related exposures and to provide a more precise estimate of the incubation periods of the illness. The median incubation period was 6 days (range 2–10 days) in cases with single known exposure and was 7·5 days (range 6·5–12·5 days) in cases with exposures on multiple days, difference between the two groups was not significant (Z = −1·895, P = 0·058). The overall median incubation period for all patients was estimated to be 7·5 days (range 2–12·5 days). Our findings further highlight the necessity for public health authorities to extend the period of medical surveillance from 7 days to 10 days.

Drug-resistant Mycobacterium tuberculosis bacterium (MTB) is spreading worldwide. Three drug-resistant isolates were detected in Burmese, Hmong, and Indian immigrants currently residing in Milwaukee, Wisconsin, USA. Ion Torrent full-gene sequencing and complete genetic analysis was performed within 5 days and compared to results from traditional drug sensitivity testing (DST). Genetic characterization of seven, full-length resistance-associated genes revealed two MDR and one highly resistant strain with important drug-resistant mutations that were confirmed by traditional DST. The rapid turnaround from sample-to-sequence underscores the public health value of Ion Torrent full-gene sequencing of MDR/XDR genes from epidemiologically significant clinical isolates.

Hand-foot-and-mouth disease (HFMD) is becoming one of the common airborne and contact transmission diseases in Guangzhou, southern China, leading public health authorities to be concerned about its increased incidence. In this study, we aimed to examine the effect of weather patterns on the incidence of HFMD in the subtropical city of Guangzhou for the period 2009–2012, and assist public health prevention and control measures. A negative binomial multivariable regression was used to identify the relationship between meteorological variables and HFMD. During the study period, a total of 166 770 HFMD-confirmed cases were reported, of which 11 died, yielding a fatality rate of 0·66/10 000. Annual incidence rates from 2009 to 2012 were 132·44, 311·40, 402·76, and 468·59/1 000 00 respectively. Each 1°C rise in temperature corresponded to an increase of 9·38% (95% CI 8·17–10·51) in the weekly number of HFMD cases, while a 1 hPa rise in atmospheric pressure corresponded to a decrease in the number of cases by 6·80% (95% CI −6·99 to −6·65), having an opposite effect. Similarly, a 1% rise in relative humidity corresponded to an increase of 0·67% or 0·51%, a 1 m/h rise in wind velocity corresponded to an increase of 4·01% or 2·65%, and a 1 day addition in the number of windy days corresponded to an increase of 24·73% or 25·87%, in the weekly number of HFMD cases, depending on the variables considered in the model. Our findings revealed that the epidemic status of HFMD in Guangzhou is characterized by high morbidity but low fatality. Weather factors had a significant influence on occurrence and transmission of HFMD.

This paper reports the first recreation-related leptospirosis outbreak in Sri Lanka in 20 office workers who were involved in white-water rafting during a staff outing. Two weeks after the rafting event on 7 September 2012, six participants developed fever, of which four had classical clinical features of leptospirosis. Four weeks after the exposure, an outbreak investigation was conducted for 19 of the 20 participants. Of the six fever patients, four were confirmed as having acute leptospirosis using either single sample MAT titre ⩾1/400 (n = 2) or positive IgM ELISA (n = 2). An afebrile patient with headache and myalgia also had a MAT titre ⩾1/400. Seventeen of the 19 participants investigated showed anti-leptospiral antibodies. None of the participants had a history of leptospirosis or recent outdoor exposures other than the rafting event. This outbreak provides evidence of the changing epidemiology of leptospirosis and suggests a wider range of risk exposures including those related to recreational activities of more affluent urban populations in addition to the well recognized occupational hazards of rural farming.

Infections with Vibrio spp. have frequently been associated with consumption of bivalve molluscs, especially oysters, but illness associated with clams has also been well documented. We describe the 2312 domestically acquired foodborne Vibrio infections reported to the Cholera and Other Vibrio Illness Surveillance system from 1988 to 2010. Clams were associated with at least 4% (93 persons, ‘only clams’) and possibly as many as 24% (556 persons, ‘any clams’) of foodborne cases. Of those who consumed ‘only clams’, 77% of infections were caused by V. parahaemolyticus. Clam-associated illnesses were generally similar to those associated with other seafood consumption. Clams associated with these illnesses were most frequently harvested from the Atlantic coastal states and eaten raw. Our study describes the contribution of clams to the overall burden of foodborne vibriosis and indicates that a comprehensive programme to prevent foodborne vibriosis need to address the risks associated with clams.

The prevalence of Chlamydia trachomatis varies between ethnic groups in The Netherlands. It is, however, unknown whether this is associated with specific serogroups. The objective of this study was to determine whether serogroup distribution is associated with ethnic origin in the region of The Hague, The Netherlands. Serogroups of 370 microbiologically confirmed C. trachomatis-positive samples were analysed. The samples were obtained from 247 women and 123 men between January and October 2008, of self-reported Dutch Caucasian, Dutch Antillean, Surinamese, N. African/Turkish or other descent. We observed a difference in serogroup distribution comparing Dutch Caucasian women to Dutch Antillean women (χ2 for distribution P = 0·035). Serogroup C was more common in Dutch Antillean women, whereas serogroup B was less common (P = 0·03). This difference was not observed for Dutch Antillean men. The observed difference in distribution of C. trachomatis serogroups between ethnic groups is relevant for further transmission studies.

We developed a syndromic surveillance (SyS) concept using emergency dispatch, ambulance and emergency-department data from different European countries. Based on an inventory of sub-national emergency data availability in 12 countries, we propose framework definitions for specific syndromes and a SyS system design. We tested the concept by retrospectively applying cumulative sum and spatio-temporal cluster analyses for the detection of local gastrointestinal outbreaks in four countries and comparing the results with notifiable disease reporting. Routine emergency data was available daily and electronically in 11 regions, following a common structure. We identified two gastrointestinal outbreaks in two countries; one was confirmed as a norovirus outbreak. We detected 1/147 notified outbreaks. Emergency-care data-based SyS can supplement local surveillance with near real-time information on gastrointestinal patients, especially in special circumstances, e.g. foreign tourists. It most likely cannot detect the majority of local gastrointestinal outbreaks with few, mild or dispersed cases.

This study aimed to investigate the distribution of congenital toxoplasmosis in the state of Minas Gerais, Southeastern Brazil and describe the demographic and socioeconomic profile of the municipalities associated with the disease. An ecological study was conducted using socioeconomic indicators of a database (MGSSRI) created by Fundação João Pinheiro (a government technical support agency of Minas Gerais), in order to show the development of the municipalities in the state. The prevalence of toxoplasmosis was the outcome and the items of the MGSSRI were the explanatory variables. Of 146 307 newborns screened (November 2006 to May 2007), 190 had congenital toxoplasmosis, yielding a prevalence of 1·3/1000, ranging from 0 to 76·9/1000 in the municipalities. The multivariate model indicated a higher occurrence of toxoplasmosis in municipalities with smaller populations and worse indexes of tax performance. Congenital toxoplasmosis appears to be a neglected disease in the state of Minas Gerais, given the high prevalence found and its concentration in municipalities with worse socioeconomic indexes.