Over 400 office workers from the same unit of a manufacturing company in Stockholm County, Sweden, fell ill with gastroenteritis. A retrospective cohort study of office workers in the affected unit demonstrated that canteen visitors on one day had an increased risk of illness [risk ratio (RR) 27·1, 95% confidence interval (CI) 15·7–46·8] compared to non-visitors. A second study, investigating canteen visitors' consumption of particular food items, showed that both tomatoes from the salad buffet (RR 5·6, 95% CI 3·2–9·6) and hamburgers (RR 4·9, 95% CI 2·4–9·8) were the most likely vehicles of infection. Norovirus GI.3 (Desert Shield) was identified in stool samples from three office workers and from a food handler who prepared the tomatoes for the salad buffet and hamburger ingredients before vomiting at the workplace on 12 November. The outbreak could have been prevented if the food items prepared by the food handler some hours before vomiting had not been served.

Although rabies incidence in humans in Western Europe is low, the repeated importation of rabid animals from enzootic areas threatens the rabies-free status of terrestrial animals and challenges the public health systems in this area. Most rabid animals imported into the European Union (EU) in recent years came from Morocco. The aim of this study was to develop a probabilistic risk assessment model to estimate the probability of rabies introduction, which was applied to the risk to the EU from dogs coming from Morocco. The mean annual probability of rabies introduction was 0·21 (90% CI 0·02–0·65). The pathways that contributed the most to this probability were: (a) EU citizens who adopted a dog in Morocco (59% of the total probability) and (b) EU citizens who travelled with their dog to Morocco by ferry (34% of the total probability). The model showed a marked seasonality in the risk of rabies with almost 40% of the annual probability occurring during the months of July and August. The application of stricter border controls (assuming 100% compliance) would result in a >270-fold reduction in the likelihood of rabies introduction into the EU from Morocco.

From 1996 to 2004, the incidence of Salmonella Javiana infections increased in FoodNet, the U.S. national active foodborne disease surveillance programme. Contact with amphibians and consumption of tomatoes have been associated with outbreaks of S. Javiana infection. To generate and test hypotheses about risk factors associated with sporadic S. Javiana infections, we interviewed patients with laboratory-confirmed S. Javiana infection identified in Georgia and Tennessee during August–October 2004. We collected data on food and water consumption, animal contact, and environmental exposure from cases. Responses were compared with population-based survey exposure data. Seventy-two of 117 identified S. Javiana case-patients were interviewed. Consumption of well water [adjusted odds ratio (aOR) 4·3, 95% confidence interval (CI) 1·6–11·2] and reptile or amphibian contact (aOR 2·6, 95% CI 0·9–7·1) were associated with infection. Consumption of tomatoes (aOR 0·5, 95% CI 0·3–0·9) and poultry (aOR 0·5, 95% CI 0·2–1·0) were protective. Our study suggests that environmental factors are associated with S. Javiana infections in Georgia and Tennessee.

Trichinella nativa infection (trichinellosis) is highly prevalent in Arctic wildlife, but the human burden of trichinellosis in present-day Greenland is unknown. The study aimed to determine Trichinella seroprevalence in an eastern Greenlandic hunting community and to evaluate risk factors for seropositivity. Overall, 998 inhabitants aged ⩾10 years in the Ammassalik municipality were tested for Trichinella-specific IgG antibodies. Background information was obtained from questionnaires. Seropositivity was 1·4% in persons aged <40 years and increased to >12% in those aged ⩾60 years. Older age, occupation as hunter or fisherman, and consumption of polar bear meat significantly increased the risk of Trichinella seropositivity. The seropositivity age pattern probably reflects changes in dietary preferences, but could also reflect mandatory meat inspection since 1966. However, preventive measures against Trichinella infection should be strengthened in Greenland.

Naegleria fowleri, a free-living, thermophilic amoeba ubiquitous in the environment, causes primary amoebic meningoencephalitis (PAM), a rare but nearly always fatal disease of the central nervous system. While case reports of PAM have been documented worldwide, very few individuals have been diagnosed with PAM despite the vast number of people who have contact with fresh water where N. fowleri may be present. In the USA, 111 PAM case-patients have been prospectively diagnosed, reported, and verified by state health officials since 1962. Consistent with the literature, case reports reveal that N. fowleri infections occur primarily in previously healthy young males exposed to warm recreational waters, especially lakes and ponds, in warm-weather locations during summer months. The annual number of PAM case reports varied, but does not appear to be increasing over time. Because PAM is a rare disease, it is challenging to understand the environmental and host-specific factors associated with infection in order to develop science-based, risk reduction messages for swimmers.

The aim of the study was to develop a procedure to remove spatial trends in irregularly spaced data, with trends partly due to regional differences. Median polish is often used on regularly spaced (lattice) data where column and row medians are removed. For irregularly spaced data a low-resolution map of the spatial locations is often used where data locations are assigned to the nearest lattice node followed by median polish. In this study regional polish was developed. The inverse distance weighted median was calculated based on observations from locations in the neighbourhood of the actual observation. The regional polish residual is obtained as the difference between the observed value and the weighted median. The regional polish procedure was applied to Salmonella Dublin data showing strong regional trends. Estimation of the range of influence between cattle herds with positive S. Dublin herd status was considerably improved with a stable parameter estimate and reduced standard error.

A case-control study was conducted in the urban area of Attica, Greece to investigate risk factors for sporadic Campylobacter jejuni infections in children aged <15 years. Over a 2-year period, 205 cases and 205 controls, matched by age group (<1, 1–4, 5–9, 10–14 years) and gender, were selected from the registries of the paediatric hospitals of this area. In conditional multivariate logistic regression analysis, ethnicity [odds ratio (OR) 5·06, 95% confidence interval (CI) 2·49–10·28], consumption of chicken the week prior to disease onset (OR 1·97, 95% CI 1·10–3·55) and playing in the garden (OR 1·83, 95% CI 1·05–3·19) were independently associated with disease occurrence; consumption of raw vegetables was a ‘protective’ factor (OR 0·48, 95% CI 0·27–0·85).

Circulation of methicillin-resistant Staphylococcus aureus (MRSA) outside hospitals could alter the impact of hospital-based control strategies. We investigated two groups of cases (each matched to controls with MRSA): 61 ‘community cases’ not in acute hospital in the year before MRSA isolation; and 21 cases with ciprofloxacin-sensitive (CipS) MRSA. Multi-locus sequence typing, spa-typing and Panton–Valentine leukocidin gene testing were performed and demographics obtained. Additional questionnaires were completed by community case GPs. Community cases comprised 6% of Oxfordshire MRSA. Three community cases had received no regular healthcare or antibiotics: one was infected with CipS. Ninety-one percent of community cases had healthcare-associated sequence type (ST)22/36; CipS MRSA cases had heterogeneous STs but many had recent healthcare exposure. A substantial minority of UK MRSA transmission may occur outside hospitals. Hospital strains are becoming ‘feral’ or persisting in long-term carriers in the community with regular healthcare contacts; those with recent healthcare exposure may nevertheless acquire non-hospital epidemic MRSA strains in the community.

The epidemiology, symptomology, and viral aetiology of endemic influenza remain largely uncharacterized in Cambodia. In December 2006, we established passive hospital-based surveillance to identify the causes of acute undifferentiated fever in patients seeking healthcare. Fever was defined as tympanic membrane temperature >38°C. From December 2006 to December 2008, 4233 patients were screened for influenza virus by real-time reverse-transcriptase polymerase chain reaction (rRT–PCR). Of these patients, 1151 (27·2%) were positive for influenza. Cough (68·8% vs. 50·5%, P<0·0001) and sore throat (55·0% vs. 41·9%, P<0·0001) were more often associated with laboratory-confirmed influenza-infected patients compared to influenza-negative enrollees. A clear influenza season was evident between July and December with a peak during the rainy season. Influenza A and B viruses were identified in 768 (66·3%) and 388 (33·7%) of the influenza-positive population (n=1153), respectively. In December 2008, passive surveillance identified infection of the avian influenza virus H5N1 in a 19-year-old farmer from Kandal province who subsequently recovered. From a subset of diagnostic samples submitted in 2007, 15 A(H1N1), seven A(H3N2) and seven B viruses were isolated. The predominant subtype tested was influenza A(H1N1), with the majority antigenically related to the A/Solomon Island/03/2006 vaccine strain. The influenza A(H3N2) isolates and influenza B viruses analysed were closely related to A/Brisbane/10/2007 or B/Ohio/01/2005 (B/Victoria/2/87-lineage) vaccine strains, respectively. Phylogenetic analysis of the HA1 region of the HA gene of influenza A(H1N1) viruses demonstrated that the Cambodian isolates belonged to clade 2C along with representative H1N1 viruses circulating in SE Asia at the time. These viruses remained sensitive to oseltamivir. In total, our data suggest that viral influenza infections contribute to nearly one-fifth of acute febrile illnesses and demonstrate the importance of influenza surveillance in Cambodia.

This study aimed to compare systematically approaches to estimating influenza-attributable mortality in older Australians. Using monthly age-specific death data together with viral surveillance counts for influenza and respiratory syncytial virus, we explored two of the most frequently used methods of estimating excess influenza-attributable disease: Poisson and Serfling regression models. These approaches produced consistent age and temporal patterns in estimates of influenza-attributable mortality in older Australians but some variation in the magnitude of the disease burden. Of Australians aged >50 years, average annual estimated influenza-attributable deaths (all cause) ranged from 2314 to 3457 for the Serfling and Poisson regression models, respectively. The excess influenza-attributable disease burden was substantial under all approaches.

Rabies was eradicated from the UK in 1922 through strict controls of dog movement and investigation of every incident of disease. Amendments were made to the UK quarantine laws and the Pet Travel Scheme (PETS) was subsequently introduced in 2000 for animals entering the UK from qualifying listed countries. European Regulation 998/2003 on the non-commercial movement of pet animals initiated the European Union Pet Movement Policy (EUPMP) in July 2004. The introduction of EUPMP harmonized the movement of pet animals within the EU (EUPMPlisted) but raised the possibility of domestic animals entering the UK from a non-EU state where rabies is endemic (EUPMPunlisted). A quantitative risk assessment was developed to estimate the risk of rabies entering the UK from Turkey via companion animals that are incubating the disease and enter through PETS or EUPMP compared to quarantine. Specifically, the risk was assessed by estimating the annual probability of rabies entering the UK and the number of years between rabies entries for each scheme. The model identified that the probability of rabies entering the UK via the three schemes is highly dependent on compliance. If 100% compliance is assumed, PETS and EUPMPunlisted (at the current level of importation) present a lower risk than quarantine, i.e. the number of years between rabies entry is more than 170 721 years for PETS and 60 163 years for EUPMPunlisted compared to 41 851 years for quarantine (with 95% certainty). If less than 100% compliance is assumed, PETS and EUPMPunlisted (at the current level of importation) present a higher risk. In addition, EUPMPlisted and EUPMPunlisted (at an increased level of importation) present a higher risk than quarantine or PETS at 100% compliance and at an uncertain level of compliance.

Melioidosis, an infectious disease caused by the Gram-negative bacterium Burkholderia pseudomallei, is now recognized as an important public health problem in Southeast Asia and tropical northern Australia. Although B. pseudomallei has been detected in various water and soil samples in southeast China, the enviromental distribution of B. pseudomallei in China is unclear. In the winter months of 2007, 154 and 130 soil and water samples, respectively, were collected from several locations in Guangxi, China. The samples were screened for B. pseudomallei by bacterial culture and identification and confirmed by PCR for species-specific 16S rDNA and flagellin genes. B. pseudomallei was detected in 8·4% of the soil samples but in none of the water samples. All positive samples were confined to a single low-lying region from rice paddy fields. Counts of B. pseudomallei ranged from 23 to 521 c.f.u./g soil. This is the first geographical distribution survey of B. pseudomallei in soil in Guangxi, China, and the data are of importance for further evaluating the impact of this pathogen on melioidosis in this region.

Hepatitis B virus (HBV) genotype D and hepatitis B e antigen (HBeAg) negative chronic hepatitis are the most prevalent in Mediterranean countries. No data have ever been published on their prevalence in Syria, a country of intermediate endemicity for HBV. The aims of the current study were to determine the HBV genotype distribution in Syria, the prevalence of HBeAg-positive and HBeAg-negative chronic hepatitis and to analyse the clinical characteristics of each group. A total of 220 patients were included. Ninety-seven percent of the patients were of genotype D, and 72% were HBeAg negative. The HBeAg-negative patients were older, had a lower viral load, had more cirrhosis and the mode of contamination was known less than for HBeAg-positive patients. These findings have major implications in understanding the natural history of the infection and are of great relevance in the choice of therapy.

Staphylococcus aureus is a relatively uncommon cause of community-onset pneumonia (COP) that may complicate influenza infection. We reviewed admissions to children's hospitals to describe more systematically this entity. Records of patients hospitalized at three children's hospitals between 1 October 2006 and 30 April 2007 who had a positive S. aureus culture from a sterile site or respiratory specimen were reviewed and data were abstracted for episodes of primary S. aureus COP. Overall, 30 episodes met criteria for primary S. aureus COP; 12 (41%) involved methicillin-resistant S. aureus. Patients in 11 (37%) episodes were seen by a healthcare provider for their symptoms prior to hospital admission; three received an antimicrobial, none of which had activity against the S. aureus isolated. Mechanical ventilation was required in 21 (70%) episodes; five (17%) patients died. When evaluating patients with severe COP, providers should be aware of the potential for S. aureus, including methicillin-resistant strains.

Respiratory outbreaks are common in aged-care facilities (ACFs), are both underreported and frequently identified late, and are often associated with considerable burden of illness and death. There is emerging evidence that active surveillance coupled with early and systematic intervention can reduce this burden. Active surveillance for influenza-like illness and rapid diagnosis of influenza were established in 16 ACFs in Sydney, Australia, prior to the winter of 2006. A point-of-care influenza test and laboratory direct immunofluorescence tests for common respiratory viruses were used for diagnosis. We achieved early identification of seven respiratory disease outbreaks, two of which were caused by influenza. For the influenza outbreaks, antiviral treatment and prophylaxis were initiated 4–6 days from symptom onset in the primary case. A simple active surveillance system for influenza was successfully implemented and resulted in early detection of influenza and other respiratory disease outbreaks. This enabled earlier implementation of prevention and control measures and increased the potential effectiveness of anti-influenza chemoprophylaxis.

Isolation rates in Canada of Salmonella enterica serovar Typhi increased from 0·29 to 0·55 isolations/100 000 population during 2000–2006. Although no ciprofloxacin resistance was detected, nalidixic acid resistance increased from 41% to 80%. Multidrug-resistant S. Typhi represented 18% of the strains tested. Pulsed-field gel electrophoresis (PFGE) analysis of 222 isolates resulted in 91 distinct patterns clustering into four major genetic similarity groups. The five most frequently occurring PFGE patterns accounted for 46% of the isolates. Drug-resistant isolates predominantly occurred in one PFGE similarity group. There were 39 phage types identified in 826 isolates analysed with 60% described by five phage types; 134 were untypable. The phage types associated with multidrug resistance were phage types 53, B1, D1, E1, E9, G3 and M1. Improved integration of epidemiological and laboratory case data will facilitate the protection of public health in Canada during an era of increasing travel and globalization.

Knowledge of the factors affecting the presence of Toxoplasma gondii in wildlife is limited. Here we analyse which local landscape characteristics are associated with the presence of toxoplasmosis in wild boar, Sus scrofa, on the island of Corsica, France. Meat juice samples from 1399 wild boars collected during two hunting seasons were tested for T. gondii antibodies using the modified agglutination test (titre 1:4). The overall seroprevalence was 0·55 (95% CI 0·50–0·59) for the first year and 0·33 (95% CI 0·29–0·35) for the second year. Seroprevalence varied according to age and county. At the county level, seropositivity in adults was related to farm density during year 1, and to habitat fragmentation, farm density and altitude during year 2. The exposure of wild boar to T. gondii is thus variable according to landscape characteristics and probably results in a variable risk of transmission of toxoplasmosis to humans.

W135 meningococcal disease was imported into Singapore in 2000 via Hajj pilgrims. Previous studies have showed sustained carriage of W135 with the potential for further transmission within communities. We therefore set out to determine whether W135 meningococcal disease would become endemic in Singapore after its introduction in 2000. Cases occurred until 2003, but no further cases have been reported since 2004.

A case-control and a case-crossover study were performed to investigate a Campylobacter jejuni outbreak in Crete in 2009. Most cases originated from rural areas, served by a different water-supply system from that of the adjacent town. Thirty-seven cases and 79 controls were interviewed; cases were interviewed for two different time periods for the case-crossover study. Stool cultures, PFGE and MLST subtyping were run in human samples. Univariately, consumption of tap water was associated with C. jejuni infection. Stratified analysis revealed that water-supply system was an effect modifier of this association. In the multivariable analysis, the rural areas' water supplier and drinking tap water were risk factors. No risk factors were revealed in the case-crossover study. No Campylobacter were isolated in the tested water samples. There is strong epidemiological evidence that tap water was the vehicle of the outbreak.

During epidemics of cholera in two rural sites (Bakerganj and Mathbaria), a much higher proportion of patients came for treatment with severe dehydration than was seen in previous years. V. cholerae O1 isolated from these patients was found to be El Tor in its phenotype, but its cholera toxin (CT) was determined to be that of classical biotype. Whether the observed higher proportion of severe dehydration produced by the El Tor biotype was due to a shift from El Tor to classical CT or due to other factors is not clear. However, if cholera due to strains with increased severity spread to other areas where treatment facilities are limited, there are likely to be many more cholera deaths.