Non-O157 Shiga toxin-producing Escherichia coli (STEC) infections are increasingly detected, but sources are not well established. We summarize outbreaks to 2010 in the USA. Single-aetiology outbreaks were defined as ⩾2 epidemiologically linked culture-confirmed non-O157 STEC infections; multiple-aetiology outbreaks also had laboratory evidence of ⩾2 infections caused by another enteric pathogen. Twenty-six states reported 46 outbreaks with 1727 illnesses and 144 hospitalizations. Of 38 single-aetiology outbreaks, 66% were caused by STEC O111 (n = 14) or O26 (n = 11), and 84% were transmitted through food (n = 17) or person-to-person spread (n = 15); food vehicles included dairy products, produce, and meats; childcare centres were the most common setting for person-to-person spread. Of single-aetiology outbreaks, a greater percentage of persons infected by Shiga toxin 2-positive strains had haemolytic uraemic syndrome compared with persons infected by Shiga toxin 1-only positive strains (7% vs. 0·8%). Compared with single-aetiology outbreaks, multiple-aetiology outbreaks were more frequently transmitted through water or animal contact.

The fact that Helicobacter pylori can revert to a coccoid form has stimulated speculation about its role in transmission and as a possible cause of reinfection in duodenal ulcer disease. Bismuth subcitrate (32 μg/ml), bismuth subsalicylate (64 μg/ml), amoxicillin (0·05 μg/ml) and erythromycin (4 μg/ml) inhibited the growth of H. pylori and stimulated the formation the formation of basically respiring but non-culturable coccoid structures. The presence of polyphosphates as energy and phosphorus source permits a certain level of endogenous metabolism to preserve RNA and DNA, as well as structural components like cell wall, cell membrane and cytoplasma for at least 3 months. However, the applied standard laboratory methods were insufficient for regrowth of H. pylori out of the coccoid form.

Despite US sanitation advancements, millions of waterborne disease cases occur annually, although the precise burden of disease is not well quantified. Estimating the direct healthcare cost of specific infections would be useful in prioritizing waterborne disease prevention activities. Hospitalization and outpatient visit costs per case and total US hospitalization costs for ten waterborne diseases were calculated using large healthcare claims and hospital discharge databases. The five primarily waterborne diseases in this analysis (giardiasis, cryptosporidiosis, Legionnaires' disease, otitis externa, and non-tuberculous mycobacterial infection) were responsible for over 40 000 hospitalizations at a cost of $970 million per year, including at least $430 million in hospitalization costs for Medicaid and Medicare patients. An additional 50 000 hospitalizations for campylobacteriosis, salmonellosis, shigellosis, haemolytic uraemic syndrome, and toxoplasmosis cost $860 million annually ($390 million in payments for Medicaid and Medicare patients), a portion of which can be assumed to be due to waterborne transmission.

The chemical disinfection of virus-contaminated non-porous inanimate surfaces was investigated using coxsackievirus B3, adenovirus type 5, parainfluenzavirus type 3 and coronavirus 229E as representatives of important nosocomial viral pathogens. A 10 µl amount of the test virus, suspended in either faeces or mucin, was placed onto each stainless steel disk (about 1 cm in diameter) and the inoculum allowed to dry for 1 h under ambient conditions. Sixteen disinfectant formulations were selected for this study based on the findings of an earlier investigation with a human rotavirus.After 1 min exposure to 20 µl of the disinfectant, the virus from the disks was immediately eluted into tryptose phosphate broth and plaque assayed. Using an efficacy criterion of a 3 log10 or greater reduction in virus infectivity titre and irrespective of the virus suspending medium, only the following five disinfectants proved to be effective against all the four viruses tested: (1) 2% glutaraldehyde normally used as an instrument soak.(2) a strongly alkaline mixture of 0·5% sodium o-benzyl-p-chlorophenate and 0·6% sodium lauryl sulphate, generally used as a domestic disinfectant cleaner for hard surfaces, (3) a 0·04% solution of a quaternary ammonium compound containing 7% hydrochloric acid, which is the basis of many toilet bowl cleaners. (4) chloraminc T at a minimum free chlorine level of 3000 p.p.m. and (5) sodium hypochlorite at a minimum free chlorine concentration of 5000 p.p.m. Of those chemicals suitable for use as topical antiseptics, 70% ethanol alone or products containing at least 70% ethanol were ineffective only against coxsackievirus B3. These results emphasize the care needed in selecting chemical disinfectants for routine use in infection control.

1. A slit sampler for air-borne bacteria is described, in which air is sucked through a narrow slit on to the surface of agar in an ordinary Petri dish.

2. This method has proved very rapid and simple in use, and has appeared more efficient than other methods against which it has been tested.

3. The collection efficiency for an aerosol consisting of Staph. albus, sprayed from distilled water as single cocci, is about 96%. The method thus collects the finest bacteria-carrying, particles almost as efficiently as coarser ones.

4. In contrast to this, the exposure of plain open Petri dishes appears to collect the larger particles in the air of crowded rooms at least 200 times as efficiently as it does single washed bacteria. This highly selective effect renders it advisable to use great caution in evaluating tests made in plain open dishes.

5. The methods of determining sampling efficiency, and their errors are discussed in detail.

The evidence presented supports the hypothesis that the experimental form of anthrax induced by depositing a cloud of single spores on lung epithelium is initiated in the lymphatic regions and not in lung tissue.

Proportionately few of the deposited spores reach the lymph glands. The majority remain inactive in so far as induction of disease is concerned. Slowly, however, they seem to go through the first stages of germination but do not multiply and therefore die. This is probably the major factor operative in their disappearance from the lung.

Effective prophylactic measures are suggested for dealing with an unimmunized host exposed to anthrax infection by the pulmonary route.

We used molecular subtyping to investigate an outbreak of listeriosis involving residents of 24 US states. We defined a case as infection with Listeria monocytogenes serotype 4b yielding one of several closely related patterns when subtyped by pulsed-field gel electrophoresis. Patients infected with strains yielding different patterns were used as controls. A total of 108 cases were identified with 14 associated deaths and four miscarriages or stillbirths. A case-control study implicated meat frankfurters as the likely source of infection (OR 17·3, 95% CI 2·4–160). The outbreak ended abruptly following a manufacturer-issued recall, and the outbreak strain was later detected in low levels in the recalled product. A second strain was recovered at higher levels but was not associated with human illness. Our findings suggest that L. monocytogenes strains vary widely in virulence and confirm that large outbreaks can occur even when only low levels of contamination are detected in sampled food. Standardized molecular subtyping and coordinated, multi-jurisdiction investigations can greatly facilitate detection and control of listeriosis outbreaks.

The aim of the following investigations was to ascertain the limits within which men can continue to exist normally, and to work, when the air temperature is abnormally high: also to study the abnormal phenomena which are produced when these limits are exceeded.

Vitamin D has been shown to be an important immune system regulator. Vitamin D insufficiency during winter may cause increased susceptibility to upper respiratory tract infections (URIs). To determine whether vitamin D supplementation during the winter season prevents or decreases URI symptoms, 162 adults were randomized to receive 50 μg vitamin D3 (2000 IU) daily or matching placebo for 12 weeks. A bi-weekly questionnaire was used to record the incidence and severity of URI symptoms. There was no difference in the incidence of URIs between the vitamin D and placebo groups (48 URIs vs. 50 URIs, respectively, P=0·57). There was no difference in the duration or severity of URI symptoms between the vitamin D and placebo groups [5·4±4·8 days vs. 5·3±3·1 days, respectively, P=0·86 (95% CI for the difference in duration −1·8 to 2·1)]. The mean 25-hydroxyvitamin D level at baseline was similar in both groups (64·3±25·4 nmol/l in the vitamin D group; 63·0±25·8 nmol/l in the placebo group; n.s.). After 12 weeks, 25-hydroxyvitamin D levels increased significantly to 88·5±23·2 nmol/l in the vitamin D group, whereas there was no change in vitamin D levels in the placebo group. There was no benefit of vitamin D3 supplementation in decreasing the incidence or severity of symptomatic URIs during winter. Further studies are needed to determine the role of vitamin D in infection.

Laboratory-based surveillance of salmonella isolates serotyped at four state health departments (Illinois, Michigan, Minnesota and Wisconsin) led to the identification of multistate outbreaks of salmonella infections during 1990 (176 cases of S. javiana) and 1993 (100 cases of S. montevideo). Community-based case-control studies and product traceback implicated consumption of tomatoes from a single South Carolina tomato packer (Packer A) MOR 16·0; 95% CI 2·1, 120·6; P<0·0001 in 1990 and again in 1993 (MOR 5·7; 95% CI 1·5, 21·9; P=0·01) as the likely vehicle. Contamination likely occurred at the packing shed, where field grown tomatoes were dumped into a common water bath. These outbreaks represent part of a growing trend of large geographically dispersed outbreaks caused by sporadic or low-level contamination of widely distributed food items. Controlling contamination of agricultural commodities that are also ready-to-eat foods, particularly fruits and vegetables, presents a major challenge to industry, regulators and public health officials.

There is a strong relationship between socioeconomic status (SES) and health outcomes in the United States, although the mechanisms are poorly understood. Increasing evidence points to links between lifelong exposure to infectious disease and subsequent chronic disease. Exposure and susceptibility to infections may be one way SES affects long-term health, although little population-based research to date has examined social patterning of infections in the United States. This paper tests the relationship between income, education, race/ethnicity and seroprevalence of cytomegalovirus (CMV) infection at different ages in a representative sample of the US population, and tests potential mediators for these relationships. The study finds significant racial and socioeconomic disparities in CMV seroprevalence beginning at early ages and persisting into middle age. Potential exposures do not explain the relationship between SES and CMV positivity. Because reactivation of latent CMV infections may contribute to chronic disease and immune decline later in life, future research should determine the exposure or susceptibility pathways responsible for these disparities in the prevalence of CMV infection.

Estimation of prevalence of disease, including construction of confidence intervals, is essential in surveys for screening as well as in monitoring disease status. In most analyses of survey data it is implicitly assumed that the diagnostic test has a sensitivity and specificity of 100%. However, this assumption is invalid in most cases. Furthermore, asymptotic methods using the normal distribution as an approximation of the true sampling distribution may not preserve the desired nominal confidence level. Here we proposed exact two-sided confidence intervals for the prevalence of disease, taking into account sensitivity and specificity of the diagnostic test. We illustrated the advantage of the methods with results of an extensive simulation study and real-life examples.

An investigation of the bacterial flora in over 200 homes is reported. The occurrence of potential pathogens and the levels of contamination at individual sites, particularly in the kitchen, toilet and bathroom is described and the implications for hygiene practices in the home discussed.

Increasing numbers of non-travel-associated hepatitis E virus (HEV) infections have been reported in Europe in recent years. Our objective was to review the evidence on risk factors and transmission routes of autochthonous HEV infection and hepatitis E in Europe in order to develop recommendations for future research, prevention and control. A systematic literature review was performed to identify all primary reports and studies published during 1998–2008 on hepatitis E in humans and animals in Europe by searching Pubmed, reference lists of major articles and international conference proceedings. Each of the 106 included studies was categorized into one of three evidence levels (EL) based on study design and diagnostic methodology. The evidence was generally weak (73 were assigned to EL1, two to both EL1 and EL2, and 30 to EL2), further compounded by the use of poorly validated serological assays in some studies. Only one case-control study was assigned to EL3. Persons with autochthonous hepatitis E infection were on average older than the general population and predominantly male. There was no evidence for one main transmission route of HEV infection or risk factor for hepatitis E. However, zoonotic transmission seemed likely and person-to-person transmission too inefficient to cause clinical disease. Multiple routes of transmission probably exist and should be further investigated through analytical studies and reliable diagnostic kits. Based on current evidence that points to zoonotic transmission from pigs, thorough cooking of all porcine products, prevention of cross-contamination in the kitchen and improved education for occupationally exposed people (e.g. pig farmers, veterinarians and sewage workers) may help prevent HEV infection. Although evidence for parenteral transmission is limited, it is recommended that a risk assessment is undertaken.

The following experiments were begun with the object of ascertaining the distribution in nature of certain lactose-fermenting organisms which are by some grouped under the name Bacillus coli, but by others are regarded as belonging to a different class of organisms; a difference of opinion which is most probably the principal factor in causing the value of B. coli as an index of pollution to be such a vexed question among bacteriologists. The investigation, however, resolved itself into a search for the B. lactis aerogenes principally, and secondarily for the other lactose fermenters. Incidentally certain other points are referred to which it was thought might prove of interest though not actually pertaining to the subject of the paper.

The present study was undertaken to investigate the frequency of the nasal carrier rate of Staphylococcus aureus. The investigation was performed on 104 healthy persons. The total number of swabs performed was 1498 and this resulted in isolation of 522 S. aureus strains. All strains have been identified, tested for antibiotic susceptibility, and phage-typed. The carrier-index (number of positive swabs/number of total swabs for each individual person) was compared with different sampling and culturing methods, phage type, age, and resistance to antibiotics. There was statistical difference in carrier rate according to sex (P ·05). Among the 104 persons 15 (14·4%) were persistent carriers, 17 (16·3%) intermittent carriers, 55 (52·9%) occasional carriers and 17 (16·3%) non-carriers. Among intermittent and occasional carriers the phage-type distribution was different from the S. aureus strains isolated from Danish hospitalized patients in 1992, while the persistent carriers had similar phage-type distribution.

Whole apples have not been previously implicated in outbreaks of foodborne bacterial illness. We investigated a nationwide listeriosis outbreak associated with caramel apples. We defined an outbreak-associated case as an infection with one or both of two outbreak strains of Listeria monocytogenes highly related by whole-genome multilocus sequence typing (wgMLST) from 1 October 2014 to 1 February 2015. Single-interviewer open-ended interviews identified the source. Outbreak-associated cases were compared with non-outbreak-associated cases and traceback and environmental investigations were performed. We identified 35 outbreak-associated cases in 12 states; 34 (97%) were hospitalized and seven (20%) died. Outbreak-associated ill persons were more likely to have eaten commercially produced, prepackaged caramel apples (odds ratio 326·7, 95% confidence interval 32·2–3314). Environmental samples from the grower's packing facility and distribution-chain whole apples yielded isolates highly related to outbreak isolates by wgMLST. This outbreak highlights the importance of minimizing produce contamination with L. monocytogenes. Investigators should perform single-interviewer open-ended interviews when a food is not readily identified.

Data were collected on the prevalence of salmonella at different stages during the life cycle of 18 broiler flocks on different farms as well as during slaughter in different poultry slaughterhouses. For the isolation of salmonella, the highest sensitivity (93.9%) was obtained by enrichment in the semi-solid agar Diasalm. The ‘overshoe method’ utilizing several pairs of overshoes provided the highest sensitivity for determining the salmonella status of the broilers during rearing. A clear decrease of the relative importance of the first production stages was demonstrated for the salmonella contamination of the end product, whereas horizontal transmission of salmonella to broilers during rearing and to broiler carcasses in the slaughterhouse was shown to be the main determinative factor. Ten of the 18 flocks received a salmonella positive status with the highest shedding occurring during the first 2 weeks of rearing. The shedding of the animals was significantly negatively influenced by the use of subtherapeutic or therapeutic doses of antibiotics. The intake of portable material in the broiler house was identified as the most important risk factor for horizontal transmission. Significant associations were found between the contamination level of a flock and hygiene of the broiler house, feed and water in the broiler house and both animal and non-animal material sampled in the environment. No correlation was found between contamination during the rearing period and contamination found after slaughtering. The presence of faecal material in the transport crates and predominantly the identity of the slaughterhouse seemed to be the determining factors for carcass quality. Improved hygiene management during transport of broilers and in some slaughterhouses could significantly reduce the risk of salmonella contamination of poultry meat.

A 10-month longitudinal household study of pre-school children and their families was undertaken with monthly visits collecting epidemiological data and nasopharyngeal swabs in Hertfordshire, England from 2001 to 2002. Pneumococcal culture was with standard methods. In total, 121 families (489 individuals) took part. Mean prevalence of carriage ranged from 52% for age groups 0–2 years, 45% for 3–4 years, 21% for 5–17 years and 8% for [ges ]18 years. Carriage occurred more than once in 86% of children aged 0–2 years compared to 36% of those aged [ges ]18 years. The most prevalent serotypes in the 0–2 years age group were 6B followed by 19F, 23F, 6A and 14. Young children were responsible for the majority of introductions of new serotypes into a household. Erythromycin resistance (alone or in combination) occurred in 10% of samples and penicillin non-susceptibility in 3·7%. Overall the recently licensed 7-valent conjugate vaccine (PCV) would protect against 64% of serotypes with no intra-serogroup cross protection and 82% with such protection. Nasopharyngeal carriage of S. pneumoniae is common in a UK setting in the pre-conjugate vaccine era. PCV would protect against a large proportion of carriage isolates. However, the impact of vaccination on non-vaccine serotypes will need to be monitored.