To determine the incidence, risk factors for, and the influence of bloodstream infections (BSIs) on mortality of patients in intensive-care units (ICUs), prospectively collected data from all patients with a stay in an ICU >48 h, during a 1-year period, were analysed. Of 572 patients, 148 developed a total of 232 BSI episodes (incidence 16·3 episodes/1000 patient-days). Gram-negative organisms with high level of resistance to antibiotics were the most frequently isolated pathogens (157 strains, 67·8%). The severity of illness on admission, as estimated by APACHE II score (OR 1·07, 95% CI 1·04–1·1, P<0·001), the presence of acute respiratory distress syndrome (OR 3·57, 95% CI 1·92–6·64, P<0·001), and a history of diabetes mellitus (OR 2·37, 95% CI 1·36–4·11, P=0·002) were risk factors for the occurrence of BSI whereas the development of an ICU-acquired BSI was an independent risk factor for death (OR 1·76, 95% CI 1·11–2·78, P=0·015). Finally, the severity of organ dysfunction on the day of the first BSI episode, as estimated by SOFA score, and the level of serum albumin, independently affected the outcome (OR 1·44, 95% CI 1·22–1·7, P<0·001 and OR 0·47, 95% CI 0·23–0·97, P=0·04 respectively).

Laboratory-based surveillance by OzFoodNet in Australia and FoodNet in the USA indicated that the incidence of Campylobacter infections in 2001 in Australia was about nine times higher than in the USA. We assessed whether this disparity could be explained by differences in the frequency of stool culturing. Using data from population surveys of diarrhoea and symptom profiles for Campylobacter from case-control studies, indices of healthcare behaviour taking into account the severity of Campylobacter infections were calculated. These suggest that culture-confirmed Campylobacter infections underestimate the incidence of community cases by similar ratios in the two countries. The incidence of Campylobacter infections in Australia was about 12 times higher than in the USA after consideration of healthcare system differences.

Data from a field study of 14 months duration in a naturally colonized dairy herd and data from an experiment with calves were used to quantify transmission of verocytotoxin-producing Escherichia coli (VTEC O157) in cattle. For the latter, two groups of 10 calves were randomly assigned and put out in one of two pastures. From each group, five animals were experimentally inoculated with 109 c.f.u. O157 VTEC and, considered infectious, put back in their group. Each of the susceptible contact calves became positive within 6 days of being reunited. The estimate of the basic reproduction ratio (R0) in the experiment was 7·3 (95% CI 3·92–11·5), indicating that each infectious calf will infect seven other calves on average during an assumed infectious period of 28 days in a fully susceptible population. The R0 among dairy cows appeared to be about 10 times lower (0·70, 95% CI 0·48–1·04). After the transmission experiment, six contact-infected animals that were shedding continuously during the experiment were housed in a tie stall during winter. After 40 days, all six tested negative for O157 VTEC. In June, after a period of 34 weeks in which the heifers remained negative, they were put out in a clean and isolated pasture to observe whether they started shedding again. On each pasture that was infected with O157 VTEC during the transmission experiment the previous summer, newly purchased susceptible calves were placed. None of the heifers or calves started shedding during 14 weeks, indicating that both the heifers and the previously contaminated pasture did not function as reservoir of O157 VTEC.

Between 1979 and 2000, foxes constituted the main reservoir of rabies in the Northern regions of Israel. Following the implementation of the fox-targeted oral vaccination programme (ORV) in 1998, rabies was eradicated from this area. Subsequently during 2004–2007, the biological and molecular characterization of the rabies isolates showed that stray dogs emerged as the main animal reservoir in Northern Israel while lower numbers of cases were reported in domestic animals. The virus isolates from foxes and dogs differed, in their molecular characterization, suggesting two distinct separate lineages. The transition from fox-mediated rabies to dog-mediated rabies is of great concern to public health because of the close contact between dogs and the human population.

Dengue is a vector-borne disease transmitted by the mosquito Aedes aegypti. The incidence of dengue disease shows a clear dependence on seasonal variation. How does the temperature affect the incidence? We addressed this question indirectly by estimating the size of the A. aegypti population for different temperatures applying population dynamics theory. In order to achieve this objective we designed temperature-controlled experiments to assess the entomological parameters regarding the mosquito's life-cycle at different temperatures. By obtaining the mortality, transition and oviposition rates for different stages of the life-cycle of the mosquito we were able to calculate the basic offspring number Q0, which is the capacity of vector reproduction and ultimately gives the size of the vector population.

A total of 522 Danish blood donors were followed during 2004–2005 to describe the seroepidemiology of Legionella infections in healthy individuals from a general population. Antibodies to Legionella spp. were measured by indirect immunofluorescence antibody test. The prevalence of Legionella antibodies (titre ⩾1:128) was 26·8% and remained fairly constant during the year of follow-up. However, 6·9% of the blood donors developed a fourfold or greater rise in antibody titres. A history of visits to Danish summer cottages was associated with both Legionella seropositivity (OR 1·53, 95% CI 1·02–2·30) and seroconversion (OR 2·66, 95% CI 1·21–5·83). There were no consistent associations between either levels of antibody titres or seroconversion and self-reported health symptoms, absence from work due to illness, or to any risk factors. We conclude that community-acquired Legionella infections are frequent; however, they rarely result in severe illness.

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.

This study evaluates the utility and cost effectiveness of empirical and prophylactic antibiotic treatment of leptospirosis compared with conventional management. We developed decision trees comparing empirical antibiotic treatment (within 4–7 days of symptom onset) or prophylaxis to conventional antibiotic treatment (initiated ⩾7 days post-onset). Costs were calculated using both US and Barbados pricing. Empirical treatment provided slightly lower probability of survival, while prophylactic treatment resulted in slightly higher survival rates. Antibiotic treatment initiated after 4–7 symptomatic days was ineffective in preventing serious health outcomes, but cost less with the exception of azithromycin (US pricing). Empirical treatment in Barbados cost less than conventional treatment. Prophylaxis reduced rare serious health outcomes and resulted in significant cost savings for the United States and Barbados. Prophylactic therapy for high-risk individuals or prompt diagnosis and early treatment (before 4 days of symptoms) appear to be cost-effective approaches to prevent severe complications of leptospirosis.

This study investigated the clinical characteristics of, and outcomes and risk factors for hospital mortality of 390 patients admitted with severe sepsis or septic shock in an intensive care unit (ICU). Prospectively collected data from patients collected between 1 July 2004 and 30 June 2006 were analysed. Overall hospital mortality was 49·7% and comorbidities were found in 40·3% of patients, the most common of which was haematological malignancy. The respiratory tract was the most common site of infection (50%). Hospital-acquired infections accounted for 55·6% of patients with Gram-negative bacteria predominant (68%). Multivariate analysis showed that acute respiratory distress syndrome, pulmonary artery catheter placement, comorbidities, hospital-acquired infection, APACHE II score and maximum LOD score, were independent risk factors for hospital mortality. In conclusion, severe sepsis and septic shock are common causes of ICU admission. Patients with risk factors for increased mortality should be carefully monitored and aggressive treatment administered.

In this study, two sheep, eight dromedary camels and two Bactrian camels were inoculated with foot-and-mouth disease virus (FMDV) type A SAU 22/92. Five naive dromedary camels and four sheep were kept in direct or indirect contact with the inoculated camels. The inoculated sheep, which served as positive controls, displayed typical moderate clinical signs of FMD and developed viraemia and high antibody titres. The presence of the virus was also detected in probang and mouth-swab samples for several days after inoculation. In contrast, the inoculated dromedary camels were not susceptible to FMDV type A infection. None of them showed clinical signs of FMD or developed viraemia or specific anti-FMDV antibodies despite the high dose of virus inoculated. All the contact sheep and contact dromedaries that were kept together with the inoculated camels remained virus-negative and did not seroconvert when tested up to 28 days post-inoculation (p.i.). In comparison with the non-susceptible dromedaries, the two inoculated Bactrian camels showed moderate to severe clinical signs of FMD; however, the clinical signs of FMD appeared rather late, between 8 and 14 days p.i., compared to the inoculated sheep. Characteristic FMD lesions in the Bactrian camels, accompanied with severe lameness, were only observed on the hind feet. The presence of the virus in the serum samples of both Bactrian camels was detected by real-time RT–PCR in one of the animals on days 3 and 7 p.i. and in the second animal from days 1 to 3 p.i. and subsequently again on day 21 p.i. The Bactrian camels developed high titres of antibodies to the inoculated FMDV which appeared at 7–10 days p.i. and lasted up to 130 days p.i. Only low and transient amounts of FMDV were detected in the mouth-swab and probang samples collected from both Bactrian camels.

Tularemia is a rare, notifiable zoonosis in Germany. Since November 2004, several lines of evidence including outbreaks in humans or animals and confirmed infections in indigenous hare and rodent populations have indicated a re-emergence of tularemia in different German federal states. Unfortunately, reliable basic information on the seroprevalence in different geographical regions, permitting the identification of risk factors, does not exist. Combining a sensitive screening assay with a highly specific confirmative immunoblot test, we performed a serological investigation on 2416 sera from a population-based, cross-sectional health survey of the city population of Leutkirch, Baden-Wuerttemberg. A total of 56 sera gave positive results indicating a seroprevalence of 2·32%. Thus, the seroprevalence is tenfold higher than that previously reported in a nationwide study in 2004. Francisella tularensis can cause a wide variety of clinical syndromes including severe, sometimes fatal disease. Missing epidemiological data on its spatial and temporal distribution in an endemic country complicate an appropriate risk assessment necessary for public health authorities to be prepared for an adequate outbreak management. This is of special concern regarding the extraordinary potential of F. tularensis as an agent of bioterrorism. Our investigation performed in a presumed low-risk area demonstrated that tularemia might be seriously underestimated in Germany and probably in other central European countries as well.

To identify determinants for mortality and sequelae and to analyse the spatial distribution of meningococcal disease, we linked four national Danish registries. In the period 1974–2007, 5924 cases of meningococcal disease were registered. Our analysis confirms known risk factors for a fatal meningococcal disease outcome, i.e. septicaemia and high age (>50 years). The overall case-fatality rate was 7·6%; two phenotypes were found to be associated with increased risk of death; C:2a:P1.2,5 and B:15:P1.7,16. B:15:P1.7,16 was also associated with excess risk of perceptive hearing loss. The incidence rates of meningococcal disease were comparable between densely and less densely populated areas, but patients living further from a hospital were at significantly higher risk of dying from the infection. To improve control of meningococcal disease, it is important to understand the epidemiology and pathogenicity of virulent ‘successful clones’, such as C:2a:P1.2,5 and B:15:P1.7,16, and, eventually, to develop vaccines against serogroup B.

Between 3 April and 18 May 2007, 21 confirmed cases of measles were reported in members of the Irish traveller ethnic group who attended a funeral in London, England. The Health Protection Agency conducted an investigation to determine the extent of this outbreak in order to inform prevention of future outbreaks. From 23 March to 30 June, 173 outbreak-associated cases from seven regions throughout England were identified; 156 cases were in Irish travellers and 17 were epidemiologically linked to cases in that community. In total, 124 cases were laboratory confirmed (IgM or RNA); none were vaccinated against measles. MMR vaccination was offered on traveller sites. Low vaccination coverage and the movement of traveller communities present particular challenges for measles elimination in Europe. We recommend parallel approaches to improve integration of Irish travellers within routine health services whilst offering targeted interventions to increase vaccine uptake in this marginalized community.

The number of pertussis cases in Japan has decreased dramatically following the nationwide use of an acellular pertussis vaccine combined with diphtheria-tetanus toxoids (DTaP vaccines) which began in 1981. However, the effectiveness of the DTaP vaccine has not been systematically evaluated using appropriate epidemiological methods during a non-epidemic period in Japan. We evaluated the vaccine effectiveness (VE) of the Kaketsuken DTaP vaccine which contains two-component pertussis antigens in Japanese children from 1999 to 2001 using a matched case-control design and data from the Basic Resident Registration and Maternal and Child Health Handbooks. The DTaP vaccination history of 15 children with pertussis and 59 controls was obtained. The VE of 3 or 4 pertussis vaccinations compared with non-vaccination (baseline) was 96·9% for coughing attacks that lasted ⩾7 days, 96·4% for those lasting ⩾14 days, and 95·9% for those lasting ⩾21 days. These findings suggest that DTaP vaccination effectively prevented pertussis during a non-epidemic period in Japan.

Insecticide-based vector control is the primary strategy for curtailing dengue transmission. We used a mathematical model of the seasonal population dynamics of the dengue mosquito vector, Aedes aegypti, both to assess the effectiveness of insecticide interventions on reducing adult mosquito abundance and to predict evolutionary trajectories of insecticide resistance. We evaluated interventions that target larvae, adults, or both. We found that larval control and adult control using ultra-low-volume insecticide applications can reduce adult mosquito abundance with effectiveness that depends on the frequency of applications. We also found that year-long continuous larval control and adult control, using either insecticide treatment of surfaces and materials or lethal ovitraps, imposed the greatest selection for resistance. We demonstrated that combined targeting of larvae and adults at the start of the dengue season is optimal. This intervention contrasts with year-long continuous larval control policies adopted in settings in which dengue transmission occurs.

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.

The worldwide spread of severe acute respiratory syndrome (SARS) raised questions about the risk of importation of such infection, in particular by air travel. Entry screening was implemented in some countries although poor evidence on its effectiveness is reported. We developed a model to estimate the number of imported SARS cases between regions, using the 2003 SARS epidemic data to apply this model for two scenarios: from Beijing to Frankfurt and from Hong Kong to London. We back-calculated the data to estimate individuals’ time of infection and built a model where every individual has a probability of being isolated, of traveling, and of being undetected at arrival. The findings, consistent with what was observed in 2003, suggest that entry screening does not affect the predicted number of imported cases. Inversely, importation depends on the transmission dynamic in the country of origin (including control measures in place) and on the intensity of air travel between regions.

In Baden-Wuerttemberg, a federal state in south-west Germany, a large outbreak of 1089 laboratory-confirmed human Puumala virus (PUUV) infections occurred in 2007. We conducted a survey to describe the disease burden and a case-control study to identify risk factors for acquiring PUUV. Case-patients were interviewed about clinical outcome and both case-patients and randomly recruited controls were interviewed about exposure. We calculated matched odds ratios (mOR) using a conditional logistic regression model. Multivariable analysis of 191 matched case-control pairs showed that case-patients were more likely than controls to have seen small rodents/their droppings (mOR 1·9, 95% CI 1·2–3·0), cleaned utility rooms (mOR 1·8, 95% CI 1·0–3·4) and visited forest shelters (mOR 3·9, 95% CI 1·1–14·3). Two thirds of case-patients required hospitalization. During PUUV epidemics rodent control measures and use of protective equipment should be considered in utility rooms and shelters.

Use of well persons as the comparison group for laboratory-confirmed cases of sporadic salmonellosis may introduce ascertainment bias into case-control studies. Data from the 1996–1997 FoodNet case-control study of laboratory-confirmed Salmonella serogroups B and D infection were used to estimate the effect of specific behaviours and foods on infection with Salmonella serotype Enteritidis (SE). Persons with laboratory-confirmed Salmonella of other serotypes acted as the comparison group. The analysis included 173 SE cases and 268 non-SE controls. SE was associated with international travel, consumption of chicken prepared outside the home, and consumption of undercooked eggs prepared outside the home in the 5 days prior to diarrhoea onset. SE phage type 4 was associated with international travel and consumption of undercooked eggs prepared outside the home. The use of ill controls can be a useful tool in identifying risk factors for sporadic cases of Salmonella.

We surveyed antimicrobial susceptibility in faecal Escherichia coli in primary schoolchildren in rural Tamil Nadu, India. Resistance profiles of E. coli samples from local water sources were also obtained. We investigated sociodemographic characteristics as risk factors for resistance and local paediatric prescription patterns. In 119 stool samples, carriage of resistance to ⩾1 antibiotic was 63% and multiple drug resistance was 32%. Resistance outcomes were associated with school of attendance, having a sibling attend the same school, younger age, and less crowded households. Eight of nine water samples were resistant to ⩾1 antibiotic. Recent history of medication use was not associated with resistance carriage. Resistance patterns may have been influenced by local paediatric prescription patterns and veterinary antibiotic use. Frequent, low-cost surveillance of commensal resistance can guide development of locally appropriate treatment guidelines. School-based hygiene programmes should be considered as means of limiting the spread of antibiotic resistance.