20 sick with campy linked to raw milk in Colorado

Jakob Rodgers of The Gazette reports that up to 20 people have been sickened from raw milk supplied by a ranch in Pueblo County, leading health officials to warn against drinking unpasteurized milk from the farm.

santa-barf_sprout_raw_milk7The outbreak of campylobacteriosis – an infection causing nausea and diarrhea – stems from raw milk distributed by Larga Vista Ranch, which is about 20 miles east of Pueblo, according to El Paso and Pueblo county health officials.

The infections highlight the dangers of drinking raw, unpasteurized milk, said Dr. Christine Nevin-Woods, El Paso County Public Health’s medical director.

“Sometimes people think that raw foods of all kinds are healthier,” she said. “But in this case, raw milk is very dangerous to be drinking.”

Since Aug. 1, health officials have confirmed 12 such cases and eight probable cases, according to the El Paso and Pueblo county health departments. Of those 20 people, half live in El Paso County, and half live in Pueblo County.

The infections stem from milk supplied by a herdshare program, which allows people to purchase stakes in livestock, such as cows or goats, and to receive a portion of each animal’s milk or meat.

Some of the people sickened were not part of the herdshare program. They received the milk from people who were part of it, which is now allowed, health officials said.

An after-hours call to the ranch by The Gazette was not returned.

Chlorine is your friend, but chlorinating water in Christchurch’s northwest is off the table

As the third case of Guillain-Barre Syndrome has been linked to the Campylobacter contamination of Havelock North’s water supply, New Zealand, chlorinating water in Christchurch’s northwest is off the table, for now.

eight_col_1m1a9865The Christchurch City Council went against its own staff advice and unanimously decided on Thursday not to consider temporarily chlorinating the water from eight shallow wells that feed into three pump stations, serving about 20,000 residents.

The council instead decided to accelerate a $16 million programme to replace 22 shallow bores, supplying 80,000 northwest households.

The work was originally due to be finished by June 30, 2018, but most of the wells would now be decommissioned by March 2017. Fourteen of the most vulnerable shallow wells have already either been decommissioned or shut down.

Accelerating the work would cost an additional $480,000.

The council would also embark on a programme to raise community awareness of the risks of drinking untreated water from the shallow bores.

Canterbury’s medical officer of health, Alistair Humphrey, last month asked the council to explain why its continued use of the shallow wells did not present “an untenable risk”. Humphrey’s request was prompted by a gastro outbreak caused by campylobacter in the water supplying the town of Havelock North in Hawke’s Bay.

Staff will now talk to Humphrey to see if he was satisfied with the council’s response, without chlorinating the water. They will report back to the council in November.

Water from the bores was tested for E.coli daily, but it took at least 24 hours to get the results, so there was always a 24-hour period where contamination could go undetected, council three waters and waste boss John Mackie said.

He said the council complied with the water standards, but his professional advice to the council was to chlorinate the water, which would eliminate the risk.

Mayor Lianne Dalziel asked Mackie if the risk from the shallow bores had changed in the last few years. He said no.

She said it was only the perception of risk that had been heightened since the Havelock North contamination.

 

Crypto is all around us

This report outlines the evidence and main conclusions presented at an expert workshop on Cryptosporidium genotyping held on 16 and 17 June 2016, hosted by the Robert Koch Institute, Berlin, and funded by EU COST Action FA1408 “A European Network for Foodborne Parasites: Euro-FBP” (http://www.euro-fbp.org).

erddig-hall-wales-lamb-cryptosproidiumThe consultation brought together 23 scientists and experts in public and animal health from 12 European countries and the United States (US) to discuss how Cryptosporidium spp. surveillance and outbreak investigations could benefit from a harmonised approach to intra-species differentiation of the two main human pathogens, C. parvum and C. hominis. These are major zoonotic and anthroponotic causes of gastroenteritis, respectively. There is currently no standardised genotyping scheme for these protozoan parasites.

The workshop was organised in two parts: firstly, specialists described the current state of knowledge and need, and secondly, four working groups considered different aspects of the development, implementation and maintenance of Cryptosporidium genotyping schemes.

An overview of genotyping Cryptosporidium for public health purposes

Laetitia Kortbeek (National Institute for Public Health and the Environment, the Netherlands) described the diagnosis of Cryptosporidium and the usefulness of genotyping for epidemiology. Although cryptosporidiosis cases are notifiable in some European Union (EU) countries, testing and diagnostic practices are variable. Improved understanding of the epidemiology, sources and transmission of cryptosporidiosis is needed, but surveillance is also highly variable and the quality of the data provided to the European Centre for Disease Prevention and Control (ECDC) hinders comparisons between countries [1]. Improved diagnosis and basic surveillance across the EU would provide the means to estimate and compare the prevalence of cryptosporidiosis and detect changing trends in transmission.

The complexity of Cryptosporidium transmission was highlighted using data from the Netherlands, where a proportion of Cryptosporidium-positive stools are genotyped to identify species. In the second half of 2012, an excess of cases, mainly due to C. hominis, triggered an alert to other EU countries via ECDC’s Epidemic Intelligence Information System for Food and Waterborne Diseases (EPIS); the United Kingdom (UK) and Germany also reported an increase [2]. An ongoing case–control study in the Netherlands failed to reveal an endemic source. In the following year, C. parvum predominated and risk factors for infection included the use of inland bathing waters and animal contact (not unexpected for C. parvum). More discriminatory genotyping of isolates could contribute to the identification of parasite sources and routes of transmission. As a first step, partial sequencing of a gene encoding a highly variable surface antigen (gp60) has shown that C. hominis allele IbA10G2 is highly prevalent throughout Europe, whereas C. parvum has greater diversity at this locus [3]. There is no specific licensed treatment in the EU for cryptosporidiosis, so understanding the epidemiology and improving the ability to identify sources through genotyping are important for the interruption of transmission routes and subsequent disease reduction.

The confusing world of Cryptosporidium typing

Giovanni Widmer (Tufts University, US) described how consideration of the reproductive biology and genetics of the parasite and analysis of metadata from studies that used the same genotyping markers have provided further clarification of Cryptosporidium diversity, especially within C. parvum. The lifecycle involves asexual and sexual reproductive stages, requiring a multilocus scheme to account for sexual recombination within genetically diverse populations. Therefore, it is important to select markers that are sufficiently distant or located on different chromosomes, to ensure they are not in linkage. Excluding markers that provide redundant information reduces wastage and increases efficiency. As part of the marker selection process, ordination methods such as principal coordinates analysis and rank abundance plots can be used to estimate objectively how informative individual genetic markers and their combinations are. Because of the multivariate nature of multilocus data, ordination methods are ideal to visualise genetic similarity among isolates [4] and infer the likely source of an outbreak. In silico analysis of existing data can be used to improve and harmonise current genotyping approaches for surveillance and outbreak investigations.

Human epidemiology and food-borne outbreaks

Rachel Chalmers (National Cryptosporidium Reference Unit, UK) showed how supplementing epidemiological and environmental data with Cryptosporidium species and gp60 allele identification has strengthened the statistical evidence of association with food exposures in outbreaks. In May 2012, an excess of 300 cases of C. parvum was linked to the consumption of pre-cut mixed salad leaves, spinach and tomatoes [5]. The odds of association with eating pre-cut mixed salad leaves were increased when the case definition was restricted to those infected with gp60 allele IIaA15G2R1. In 2015, C. hominis infections exceeded expected numbers by more than 900 cases in late summer/early autumn, triggering an EPIS alert, with a similar increase reported by the Netherlands. Hypothesis-generating questionnaires revealed no sufficiently common exposures or risk factors to allow a case–control study. Isolates with the gp60 allele IbA10G2 predominated. Not only is this allele highly prevalent among C. hominis isolates from northern Europe, but there is also limited heterogeneity at other loci, highlighting the limitation of multilocus genotyping as an epidemiological tool for this species [3]. Suitable samples [6] with the IbA10G2 allele were further analysed by whole genome sequencing. Very few differences were seen in pairwise comparisons, with at most 50 single nucleotide polymorphisms (SNPs) observed in the ca 9.2 Mbp genome; the significance of these extremely small differences is currently unknown. In contrast, a C. parvum outbreak of more than 300 cases at the end of 2015 was defined by an unusual gp60 allele, IIdA24G1, recognised initially by the Scottish Parasite Diagnostic and Reference Laboratory, highlighting the value of genotyping routinely and including the data in national surveillance. A case–control study revealed food-linked exposures and the outbreak remains under investigation at the time of writing, demonstrating the difficulties in food chain investigations.

Zoonotic transmission

Karin Troell (National Veterinary Institute, Sweden) illustrated the importance of applying One Health approaches to the investigation of Cryptosporidium as a zoonosis. In Sweden, samples are tested from any likely host animal that is linked to a human cryptosporidiosis case, for example from household cats when C. felis has been detected in a patient [7]. This has led to collaborative studies on other, less common, species causing human infections. These findings reinforce the need for clinical diagnostics to detect not only C. parvum and C. hominis.

The most common zoonotic species in humans, C. parvum, has an unusual epidemiology in cattle in Sweden, where some studies have shown low prevalence even in young calves. This is in contrast to other countries where C. parvum is the main cause of cryptosporidiosis in pre-weaned calves [8]. Despite this, one of the most common C. parvum gp60 alleles in cattle, IIaA16G1R1, is also frequent in humans in Sweden. To support epidemiological investigations, a multilocus sequencing tool based on nine SNP markers across five chromosomes has been evaluated in a multiplex PCR on numerous samples; high discriminatory power and evidence of transmission between calves and humans in Sweden was shown.However, further studies of the population structure of C. parvum are needed across Europe to assess the broader applicability of this scheme.

How diversity relates to transmission to humans

Simone Cacciò (National Institute of Health, Italy) described the apparent geographic diversity of C. parvum in Ireland, Italy, and Scotland, as revealed by multilocus analyses. Studies so far indicate that in those countries, C. parvum populations from humans and livestock may have become isolated from each other, to the extent that the opportunity for genetic interchange appears limited [9]. To investigate the degree of genetic isolation, further studies are needed across Europe that include the major hosts for C. parvum. One study showed that in the UK, a high proportion of C. hominis isolates were indistinguishable at multiple loci, contrasting with those from Uganda, where a more diverse population structure was found [10]. Therefore, conclusions from one location may not be widely applicable and information is specific to host populations, whether these are defined geographically or demographically. A European-wide project (COMPARE; http://www.compare-europe.eu/) aims to increase the number of whole genome sequences for Cryptosporidium and to develop bioinformatic pipelines that would further the understanding of the population biology and determinants of virulence of the parasite. Information from COMPARE will undoubtedly benefit typing scheme development.

Four working groups considered how the evidence presented could be used to develop, implement and maintain suitable genotyping resources for Cryptosporidium.

Are the genetic and population structures of Cryptosporidium amenable to developing a genotyping scheme?

One working group considered whether reliable predictions of transmission can be made by combining genotyping with epidemiological and clinical data, considering that genetic diversity and population structures differ for C. parvum and C. hominis. It concluded that data are currently unavailable for much of Europe and are often not comparable because of lack of standardisation, indicating the need for further studies. Sampling frames need to follow the One Health concept, including both human and animal samples. Comparative analysis of increasingly available genome sequence data can provide a solid basis for marker selection. An evaluation process should be defined and applied to those markers already used.

What needs to be done to develop a standardised, multilocus genotyping scheme?

Another working group considered the development of separate multilocus schemes for C. parvum and C. hominis to provide robust, cost-effective assays, suitable for specialist and reference laboratories. Fragment sizing of regions containing tandem nucleotide repeats was considered alongside in-house sequencing. The decision whether to choose fragment sizing or sequencing will depend on the best workflow for individual laboratories, but markers that provide the same results with either method would be desirable. Sequence data from gp60 remains important. The most suitable markers need to be identified through a structured and objective process, ideally starting from whole-genome comparisons. Well-defined panels of samples are needed for biological and statistical evaluation of individual markers and their combinations, before progressing to inter-laboratory trials. DNA standards should be available. A web-based database needs be developed to contextualise metadata and genetic identification of isolates.

A multilocus genotyping scheme as a component of epidemic preparedness and response

A third working group considered multilocus genotyping as a component of a resilient response for health protection, highlighting that any scheme should be informative for epidemiological investigations and the detection and management of outbreaks, and that genotyping results should be incorporated into the collection of high quality epidemiological data. Differentiating between what is ‘nice to know’ and ‘essential to know’ is important: at present, there is more to be gained from genotyping C. parvum, as a high proportion of C. hominis cases in Europe have the gp60 allele IbA10G2, which is associated with low diversity at other markers. If genotyping all cases cannot be justified, selection will depend on outbreak size and available information and is probably best delivered as a test done in specialist or reference laboratories. Simulated outbreak exercises should be undertaken.

Sustainability of a standardised, multilocus genotyping scheme

The final working group discussed the elements needed to sustain a standardised scheme, including validation, external quality control (EQA), and inclusion of future developments, for example identification of new informative markers. A good mechanism for EQA should be established using an independent provider, also providing training modules and DNA standards. Central, ongoing collection of a minimum set of metadata are needed to facilitate surveillance of genotypes and meaningful comparisons and interpretation; this may be possible through the Cryptosporidium database at http://CryptoDB.org. Nomenclature for multilocus genotypes needs to be adopted for effective interdisciplinary communication.

Conclusions

Increased standardisation of diagnostic practices for Cryptosporidium is fundamental to the meaningful interpretation of surveillance data and distribution of species and genotypes. A robust, standardised, multilocus genotyping scheme should be developed, using a defined process to replace or supplement the multitude of genotyping methods used. Although further genotyping of C. parvum would be highly informative, this procedure may not always be warranted for the genetically more conserved C. hominis in Europe. A web-based database, enabling interpretation of genotype occurrence and distribution trends in an epidemiological context, is required. Genotype data should be incorporated into national surveillance programmes, and a standardised nomenclature provided for effective communication with public health professionals.

Towards a consensus on genotyping schemes for surveillance and outbreak investigations of Cryptosporidium, Berlin, June 2016

Eurosurveillance, Volume 21, Issue 37, 15 September 2016, DOI: http://dx.doi.org/10.2807/1560-7917.ES.2016.21.37.30338

R Chalmers, S Cacciò

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=22578

143 sickened from Salmonella-in-duck in Taiwan

Lee I-chia of the Taipei Times reports that a 15-year-old shop selling roast duck in Miaoli County’s Toufen Township (頭份) has been fined and temporarily shut after more than 140 people fell ill last week after consuming duck bought from the shop.

roast-duck-taiwanThe Miaoli County Public Health Bureau said that more than 140 people visited local hospitals after developing symptoms of food poisoning, including vomiting, diarrhea or a fever, after consuming roast duck bought from the store on Sept. 10 and last week.

The hospital where some of the people were hospitalized found salmonella bacteria in their stool samples and reported the cases to the health bureau.

The bureau on Tuesday last week sent investigators to collect samples from the shop.

As of Monday evening, the bureau said it had received 13 case reports concerning 143 people — including several family groups — who had allegedly developed food poisoning after eating duck meat from the shop and had notified the Ministry of Health and Welfare.

Lab test results received on Monday confirmed the shop’s duck meat was contaminated by salmonella bacteria and a sample collected from the shop’s cutting board had Bacillus cereus bacterium.

Everyone experiments in college: Florida State University hit with at least 22 cases of hand, foot and mouth disease

Florida State University is trying to contain an on-campus outbreak of an illness typically seen at day care.

fsu-hand-foot-mouth-diseaseAt what point did universities evolve from the ridiculously overpriced day cares they currently are (for young adults and most faculty)?

A university official told NBC News that as of Friday afternoon, there have been 22 total cases of hand, foot and mouth disease — a highly contagious virus in which sores develop in the mouth, and a skin rash with blisters appears on the hands and soles of the feet.

“I’m thinking we’ve got probably one more little spike [in cases], then hopefully it will have worn itself out,” said Lesley Sacher, executive director of university health services at the Tallahassee school.

The illness starts with a fever and sore throat, followed by painful mouth sores a day or two later, according to the Centers for Disease Control and Prevention. Some people don’t get symptoms but are still contagious.

It’s most often seen among infants and toddlers at day care centers who have a lot of direct skin contact as they play, but it’s not unheard of in adults.

And it’s easy for any infection to spread quickly in college dorms, particularly this time of year as students adjust to life in a dorm surrounded by others in close proximity, said Dr. Frank Esper, pediatric disease specialist at Rainbow Babies and Children’s Hospital in Cleveland.

“We see spikes in certain types of infections during that transition period. It’s one of the reasons we have a meningitis shot that is specifically targeting individuals going into dormitories,” he said.

Hand, foot and mouth is caused by Coxsackie A16 virus, a member of the enteroviruses family. Enteroviruses tend to thrive in the fall, but Esper said they can happen any time of the year.

6 confirmed sick: Crypto linked to raw milk in New Mexico

Officials with the New Mexico Department of Health are investigating cases of cryptosporidiosis among state residents.

napoleon-raw-milkThey say there have been six confirmed cases of “crypto” — a diarrheal disease caused by microscopic parasites — since Aug. 31.

Each reported consuming raw milk products.

The affected individuals are from Bernalillo County.

Epidemiologists, laboratory staff and inspectors are working to confirm the source of the outbreak.

The state Department of Agriculture and New Mexico Environmental Department also are involved in the investigation.

Health Department officials recommend that anyone in New Mexico who has raw milk products discard the product to prevent infection.

Unpasteurized cheese making record number sick in Texas

Claire Z. Cardona of The Dallas Morning News reports a record number of people in Dallas County have been sickened from an infection caused by consuming unpasteurized cheese, health officials said. 

brucellosisThere have been 13 brucellosis infections in residents so far this year, affecting patients between 6 and 80 years old, according to a health advisory released Thursday

All of the patients reported eating the cheese brought into the U.S. from Mexico by friends or relatives, consuming the cheese while traveling in Mexico or eating unidentified cheese products from local street vendors, officials said. 

The county typically sees two to six cases a year, though 11 were recorded in 2004. 

Health officials confirmed all the Dallas County cases by blood culture. In two instances, hospital lab personnel were exposed while handling the samples. 

The Brucella bacteria can infect livestock and is most commonly transmitted to humans who consume the unpasteurized dairy products. Some areas, such as Mexico and Central and South America, are considered high-risk, according to the Centers for Disease Control and Prevention. 

Stop kissing cats (and stop touching yourself)

I went through an extremely brief Ted Nugent phase when I was 16.

I was driving my then-girlfriend and her mom somewhere, and thought it’d be cool to put Wango Tango on the 8-track (a prehistoric device used to play music).

cat-scratch-fever-04What an asshole (me and Ted).

Erin Ross of NPR reports that cat-scratch disease, as the name suggests, is spread by cats. It’s long been considered a mild illness, but a study finds that people are getting more serious complications, which can be fatal.

And kissing kittens increases the risk of being infected.

“The scope and impact of the disease is a little bit larger than we thought,” says Dr. Christina Nelson, a medical epidemiologist with the Centers for Disease Control and Prevention and lead author on the study. It’s the first large-scale evaluation of the illness in the United States in over 15 years.

While the total number of people infected with the disease has gone down, the number of people becoming seriously ill has increased. Symptoms typically involve fatigue, fever and swollen lymph nodes. But in a small number of cases, cat-scratch disease can cause the brain to swell or infect the heart. Infections like those can be fatal if they aren’t properly treated.

“Most of the people who get seriously sick from cat-scratch are immunocompromised. The classic example is patients with HIV,” says Dr. Aaron Glatt, chairman of medicine and hospital epidemiology of South Nassau Community Hospital in New York. Glatt was not involved in the study

The fact that there are more people with suppressed immune systems today may be why a larger number of patients are getting dangerously ill, Glatt says. But Nelson thinks that severe cases of cat-scratch disease may have been misdiagnosed in the past. Either way, she says, this study, which was published Wednesday in Emerging Infectious Diseases, is a good first step.

“Cat-scratch is preventable,” Nelson says. “If we can identify the populations at risk and the patterns of disease, we can focus the prevention efforts.”

It’s preventable because you need direct contact with a cat to get it. The disease is caused by bacteria, usually Bartonella henselae, and passed between cats by fleas. The bacteria are also present in flea dirt — the official name for flea feces — which build up in the cats’ fur. It gets on their paws and in their mouths when they groom themselves. If a person is scratched by contaminated claws, they’re at risk of getting the disease.

The study combed health insurance claims from 2005 to 2013, and charted when and where cat-scratch disease is most likely to strike. It found that about 12,000 people will be diagnosed with cat-scratch disease each year, and 500 of them will be sick enough to be hospitalized.

Many of those infected will be children, probably because of the ways kids play with cats. And most of the infections will occur in the South, where heat-and-moisture-loving fleas are more common.

If you want to avoid cat-scratch disease altogether, says Nelson, go somewhere arid —like Colorado or Utah.

But moving to the Rockies isn’t an option for everyone. If you’re stuck in the South, how can you skip cat-scratch?

“Stay away from cats,” says Glass, although he acknowledges that in a country full of cat-lovers, this isn’t really realistic.

“Use adequate flea control and keep your cats indoors,” suggests Nelson. The bacteria can also enter your body through your nose, eyes or mouth, so the CDC recommends washing your hands after touching a cat. Kissing their flea dirt-filled fur probably isn’t a good idea, either. Neither is letting them lick you if you have any scrapes, scabs or open wounds.

Oh. And avoid kittens.

“Younger cats are more likely to have bacteria in their blood,” explains Nelson. Kittens aren’t immune to cat-scratch, so they’re an easy target for the bacteria.

So try to keep from kissing Felix … at least until he’s flea-free.

E.coli, Giardia and crypto: Beware the duck pond at NZ Botanical Gardens

Gisborne’s chief medical officer has warned parents that children do not have to be in contact with water to pick up bugs from dirty water at the Botanical Gardens.

botanical-garden-japaneseGisborne District Council this week confirmed the duck pond at the gardens contained E.coli, Giardia and Cryptosporidium.

Although a statement from GDC said someone would have to drink “a good amount” of water to get sick, medical officer of health Dr Margot McLean pointed out that was not the case.

“You don’t have to enter the pond or drink the pond water to pick up the bugs that can make you sick. You could also pick up the bugs by putting hands in the water or touching areas where there is duck poo.

“This shouldn’t put people off visiting the ducks, as long as extra care is taken with hand hygiene.

“Antibacterial wipes could be used immediately after leaving the area, however parents should supervise children washing their hands and use the 20/20 rule; 20 seconds to wash/20 seconds to dry on the return home.

“Any duck poo should be removed from shoes so that the poo doesn’t contaminate surfaces like floors, or hands.”

Better ways to monitor beaver fever

The current approach in the U.S. water industry for monitoring Cryptosporidium and Giardia has weaknesses that have contributed to the difficulty of interpreting resulting data. This often leads to potentially significant and dangerous misinterpretation. The purpose of this paper is to summarize information on which the conflicting conclusions on the occurrence and distribution of Cryptosporidium and Giardia have been based.

giardia_lambliaEffort is made to determine the most plausible and supportable interpretation. The objective is to provide a basis for rethinking the current approach to monitoring and management of Cryptosporidium and Giardia in water.

The importance of measuring recovery efficiency and reporting measurements of these organisms in terms of concentration to any quantitative application is emphasized. Data presentation to illustrate critical features of organism concentration levels and variation is reviewed. Analysis of major data sets resulting from the U.S. Environmental Protection Agency Information Collection Rule Supplemental Survey (USEPA ICR SS) and the Long-Term 2 Enhanced Surface Water Treatment Rule (LT2) monitoring and other previously published relevant data sets is presented to illustrate key features of Cryptosporidium and Giardia occurrence in surface water and their universal geographic distribution. Current thinking emphatically requires revision.

Cryptosporidium and Giardia in water: reassessment of occurrence and significance

ASCE

Jerry E.Ongerth

http://ascelibrary.org/doi/abs/10.1061/(ASCE)EE.1943-7870.0001161