Population-based estimates of incidence and risk factors for acute gastrointestinal illness (AGI) are important for infectious disease surveillance and healthcare planning. We conducted a nationwide representative cross-sectional telephone survey of 21 262 adults over a 12-month period during 2008–2009 in Germany. Participants were asked if they had either AGI-related diarrhoea or vomiting in a 4-week recall period. We estimated 0·95 episodes/person per year (95% confidence interval 0·90–0·99), corresponding to 64·9 million episodes of AGI annually in adults, which results in 24·5 million outpatient visits, 19·9 million hospital days and 63·2 million days of work lost. We observed an overall declining trend of AGI with increasing age. Diarrhoea was more often reported than vomiting. The mean duration of illness was 3·8 days and did not differ between age groups. Social factors seemed to be weak predictors compared to state of health and health behaviour characteristics. This study allows international comparisons and contributes to the estimation of the global burden of AGI.

In May 2011, an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157 was reported from Yamagata Prefecture, Japan. Investigations, including a case-control study, revealed that the outbreak was linked to two varieties of rice cakes produced by a local manufacturer between 2 and 7 May. Active and passive surveillance identified 136 suspected cases, 142 confirmed cases, 26 asymptomatic cases, and 25 secondary cases. While no environmental samples taken from the manufacturing premises tested positive for STEC, other than a stool sample taken from one employee, on-site and epidemiological investigations indicated that STEC was introduced during the manufacturing process of rice cakes rather than through contamination of raw materials. This was the first reported outbreak of STEC associated with cakes and confectionery in Japan, which indicates that contamination and outbreaks of STEC can occur in any food unless proper precautions are taken.

We investigated the cost-effectiveness of different influenza control strategies in a school setting in Taiwan. A susceptible-exposure-infected-recovery (SEIR) model was used to simulate influenza transmission and we used a basic reproduction number (R0)–asymptomatic proportion (θ) control scheme to develop a cost-effectiveness model. Based on our dynamic transmission model and economic evaluation, this study indicated that the optimal cost-effective strategy for all modelling scenarios was a combination of natural ventilation and respiratory masking. The estimated costs were US$10/year per person in winter for one kindergarten student. The cost for hand washing was estimated to be US$32/year per person, which was much lower than that of isolation (US$55/year per person) and vaccination (US$86/year per person) in containing seasonal influenza. Transmission model-based, cost-effectiveness analysis can be a useful tool for providing insight into the impacts of economic factors and health benefits on certain strategies for controlling seasonal influenza.

This cohort study examines trends in pneumonia mortality in Finland and the effects of a WHO recommendation restricting the registering of pneumonia as the underlying cause of death (COD) for several chronic diseases. All cases having pneumonia in any COD fields in 2000–2008 were extracted from the COD statistics. We examined trends in underlying-cause pneumonia mortality where pneumonia was also the immediate COD. Results are presented as age-specific and age-standardized rates. In the study period 2000–2008, there were 90 626 deaths with pneumonia in COD fields, while the underlying-cause pneumonia mortality rate decreased from 32 to 6/100 000 person-years. Immediate-cause pneumonia was less often chosen as underlying-cause towards 2008 suggesting an effect from changing coding practices. Changes in coding practices need to be considered when comparing different countries or time periods in pneumonia mortality.

Serological surveys for diphtheria were conducted in six European countries including Czech Republic, Hungary, Ireland, Latvia, Luxembourg, Slovakia and one country outside Europe, Israel. For each country, a nationally representative population sample was collected across the entire age range and was tested for antibodies to diphtheria toxin. Although each national laboratory used its preferred assay, the results were all standardized to those of the in vitro neutralization test and expressed in international units (IU) which allowed comparative analyses to be performed. The results showed that increasing age is related to a gradual increase in seronegative subjects (<0·01 IU/ml of diphtheria antitoxin antibodies). This may reflect waning immunity following childhood vaccination without repeated booster vaccinations in adults. Differences in seronegativity were also found according to gender. In subjects aged 1–19 years, geometric mean titres of antitoxin are clearly related to the different vaccination schedules used in the participating countries. Although clinical disease remains rare, the susceptibility to diphtheria observed in these serosurveys highlights the importance of strengthened surveillance.

We estimated prevalence and incidence of liver condition outcomes, and costs to the health service of diagnosed hepatitis B virus (HBV) in Tayside, UK. HBV patients were identified from electronic virology data between 1989 and 2003. The health resource costs of HBV for surface antigen-positive (HBsAg+) patients and HBV (HBsAg+ or immune, i.e. recovered) patients were calculated. A total of 633 patients had HBV (275 HBsAg+), and were more likely to be male (62% vs. 48%), older (mean age 42·6 vs. 39·2 years) and deprived than the general population. The prevalence of immune individuals increased steadily. Post-HBV diagnosis, 24% of immune and 13% of HBsAg+ patients were diagnosed with a liver condition. The median cost per immune patient (£3023) was greater than per HBsAg+ patient (£1498) (P = 0·02). While increasing prevalence of immune HBV patients highlights an increase in screening and treatment, the costs associated with this group are high.

Despite a number of risk-factor studies in different countries, the epidemiology of Campylobacter colonization in broilers, particularly spatial dependencies, is still not well understood. A series of analyses (visualization and exploratory) were therefore conducted in order to obtain a better understanding of the spatial and temporal distribution of Campylobacter in the Danish broiler population. In this study, we observed a non-random temporal occurrence of Campylobacter, with high prevalence during summer and low during winter. Significant spatio-temporal clusters were identified in the same areas in the summer months from 2007 to 2009. Range of influence between broiler farms were estimated at distances of 9·6 km and 13·5 km in different years. Identification of areas and time with greater risk indicates variable presence of risk factors with space and time. Implementation of safety measures on farms within high-risk clusters during summer could have an impact in reducing prevalence.

In September 2006, the 7-valent pneumococcal conjugate vaccine (PCV7) was added to the UK immunization programme. We aimed to evaluate the impact of PCV7 on the incidence of all-cause community-acquired pneumonia (CAP) in children. A prospective survey was undertaken in 2008–2009 at 11 hospitals in North East England of children aged 0–16 years with radiologically confirmed pneumonia. Data were compared to those from a similar survey undertaken in the same hospitals in 2001–2002. A total of 542 children were enrolled, of which 74% were aged <5 years. PCV7 uptake was 90·7%. The incidence of pneumonia was 11·8/10 000 [95% confidence interval (CI) 10·9–12·9], and the hospitalization rate was 9·9/10 000 (95% CI 9·0–10·9). Compared to 2001, there was a 19% (95% CI 8–29) reduction in the rate of CAP in those aged <5 years, and in those <2 years a 33·1% (95% CI 20–45) reduction in the incidence of CAP and 38·1% (95% CI 24–50) reduction in hospitalization rates. However, for those unvaccinated aged ⩾5 years, there was no difference in the incidence of CAP and hospitalization rate between both surveys. Since 2001, the overall reduction in incidence was 17·7% (95% CI 8–26) and for hospitalization 18·5% (95% CI 8–28). For the <5 years age group there was a lower incidence of CAP in PCV7-vaccinated children (25·2/10 000, 95% CI 22·6–28·2) than in those that were not vaccinated (37·4/10 000, 95% CI 29·2–47·1). In conclusion, PCV7 has reduced both incidence and rate of hospitalization of pneumonia in children, particularly in the <2 years age group.

Healthcare workers (HCWs) may be a reservoir for Staphylococcus aureus transmission to patients. We examined whether HCW status is associated with S. aureus nasal carriage and population structure (spa types) in 1302 women (334 HCWs) and 977 men (71 HCWs) aged 30–69 years participating in the population-based Tromsø Study in 2007–2008. Multivariable logistic regression models were used. While no methicillin-resistant S. aureus (MRSA) was isolated, overall, 26·2% of HCWs and 26·0% of non-HCWs were S. aureus nasal carriers. For women overall and women residing with children, the odds ratios for nasal carriage were 1·54 [95% confidence interval (CI) 1·09–2·19] and 1·86 (95% CI 1·14–3·04), respectively, in HCWs compared to non-HCWs. Moreover, HCWs vs. non-HCWs had a 2·17 and 3·16 times higher risk of spa types t012 and t015, respectively. This supports the view that HCWs have an increased risk of S. aureus nasal carriage depending on gender, family status and spa type.

Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia cause significant morbidity and mortality in hospitalized patients. Using a nested case-control design, 204 MRSA bacteraemia cases were compared to 301 unmatched methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia controls and were matched 1:2 with non-infected controls. The independent risk factors for MRSA bacteraemia compared to MSSA bacteraemia were older age (P = 0·048), major organ transplant during current hospital stay (P = 0·016) and quinolone use (P = 0·016). Cases were more likely than non-infected controls to have renal failure (P = 0·003), cirrhosis (P = 0·013), and a central venous catheter (P = 0·003) after controlling for other risk factors. This large case-control study made it possible to assess risk factors for MRSA bacteraemia using two sets of controls and showed that risk factors differed greatly depending on the control group chosen. These results confirm the need for careful selection of appropriate control groups and the need to carefully adjust for underlying severity of illness.

We used data from BioSense, a national electronic surveillance system, to describe pneumonia in hospitalized patients with influenza-like illness (ILI). Ninety-five hospitals from 20 states reported ICD-9-CM-coded inpatient final diagnosis data during the study period of September 2007 to February 2010. We compared the characteristics of persons with and without pneumonia among those with ILI-related hospitalizations. BioSense captured 26 987 ILI-related inpatient hospitalizations; 8979 (33%) had a diagnosis of pneumonia. Analysis of trends showed highest counts of pneumonia during the 2007–2008 season and the second 2009 pandemic wave. Pneumonia was more common with increasing age. Microbiology and pharmacy data were available for a subset of patients; 107 (5%) with pneumonia had a bloodstream infection and 17% of patients were prescribed antiviral treatment. Our findings demonstrate the potential utility of electronic healthcare data to track trends in ILI and pneumonia, identify risk factors for disease, identify bacteraemia in patients with pneumonia, and monitor antiviral use.

We examined the impact of the neonatal hepatitis B immunization programme, first provided to all neonates born to mothers screened positive for hepatitis B surface antigen (HBsAg) in late 1983, on the age-specific prevalence of HBsAg carriage in teenage mothers managed in 1998–2008. HBsAg carriage was found in 2·5%, 2·7%, 8·8% and 8·0% of mothers aged ⩽16, 17, 18, and 19 years, respectively (P = 0·004), which was also correlated with advancing age (P = 0·011). While neither difference nor correlation with age was found in mothers born before 1984, the prevalence of 1·2%, 1·5%, 7·1% and 8·3%, respectively, was significantly different among (P = 0·008) and correlated with (P = 0·002) age in mothers born 1984 onwards. Regression analysis indicated there was a significantly higher incidence of HBsAg carriage from age 17 onwards (adjusted odds ratio 2·55, 95% confidence interval 1·07–6·10, P = 0·035), suggesting that the protective effect of the vaccine declined in late adolescence.

Hypermucoviscous (HV) isolates of Klebsiella pneumoniae have been linked to virulence potential in experimental infections. We examined 33 isolates of K. pneumoniae from patients with bacteraemia for the HV phenotype on agar culture, and determined their virulence potential by screening for capsular (K) serotype by polymerase chain reaction and the presence of seven virulence factor genes. Fourteen (42·4%) isolates expressed the HV phenotype and 11 of these were serotype K1 or K2; these serotypes were not identified in HV-negative isolates. The genes rmpA, rmpA2, aerobactin, wabG and allS were significantly more frequent in HV than non-HV isolates. Multilocus sequence typing identified 21 sequence types (ST), eight of which were found in HV-positive isolates and the clonal relatedness of isolates of the most frequent types (ST23 and ST11) from different hospitals was confirmed by pulsed-field gel electrophoresis. The HV phenotype was more associated with community-acquired infection with a lower frequency of fatal underlying illness, but with significantly more focal infections, notably liver abscesses. Clinicians should be aware of such clinical impacts of the HV phenotype.

The behaviour of certain infected individuals within socially structured populations can have a disproportionately large effect on the spatio-temporal distribution of infection. Endemic infection with Mycobacterium bovis in European badgers (Meles meles) in Great Britain and Ireland is an important source of bovine tuberculosis in cattle. Here we quantify the risk of infection in badger cubs in a high-density wild badger population, in relation to the infection status of resident adults. Over a 24-year period, we observed variation in the risk of cub infection, with those born into groups with resident infectious breeding females being over four times as likely to be detected excreting M. bovis than cubs from groups where there was no evidence of infection in adults. We discuss how our findings relate to the persistence of infection at both social group and population level, and the potential implications for disease control strategies.

Canine influenza virus (CIV) is an emerging pathogen that causes acute respiratory disease in dogs. The aim of this study was to investigate the pathogenicity of A/canine/Jiangsu/06/2010 (H3N2) virus isolated in China. Nine dogs were inoculated intranasally with 107·95 of 50% egg infectious dose (EID50) of the virus. The onset of clinical signs and virus shedding was observed on day 1 post-infection (p.i.). The peak clinical score occurred between days 4 and 6 p.i. The experimentally infected dogs were found to shed virus not only via the respiratory tract but also via the digestive tract. Viral RNA could be detected in multiple organs including the trachea, lung, liver, spleen, kidney, brain and duodenum. All the sampled organs from infected dogs showed significant lesions and viral antigen staining. The results differed from those reporting using previous CIV strains; the Chinese isolate could induce extrapulmonary infection and cause extensive lesions in dogs.

In November 2009, we initiated a multistate investigation of Salmonella Montevideo infections with pulsed-field gel electrophoresis pattern JIXX01.0011. We identified 272 cases in 44 states with illness onset dates ranging from 1 July 2009 to 14 April 2010. To help generate hypotheses, warehouse store membership card information was collected to identify products consumed by cases. These records identified 19 ill persons who purchased company A salami products before onset of illness. A case-control study was conducted. Ready-to-eat salami consumption was significantly associated with illness (matched odds ratio 8·5, 95% confidence interval 2·1–75·9). The outbreak strain was isolated from company A salami products from an environmental sample from one manufacturing plant, and sealed containers of black and red pepper at the facility. This outbreak illustrates the importance of using membership card information to assist in identifying suspect vehicles, the potential for spices to contaminate ready-to-eat products, and preventing raw ingredient contamination of these products.

This study describes the epidemiology and symptoms in 271 cryptosporidiosis patients in Stockholm County, Sweden. Species/genotypes were determined by polymerase chain reaction–restriction fragment-length polymorphism (PCR–RFLP) of the Cryptosporidium oocyst wall protein (COWP) and 18S rRNA genes. Species were C. parvum (n=111), C. hominis (n=65), C. meleagridis (n=11), C. felis (n=2), Cryptosporidium chipmunk genotype 1 (n=2), and a recently described species, C. viatorum (n=2). Analysis of the Gp60 gene revealed five C. hominis allele families (Ia, Ib, Id, Ie, If), and four C. parvum allele families (IIa, IIc, IId, IIe). Most C. parvum cases (51%) were infected in Sweden, as opposed to C. hominis cases (26%). Clinical manifestations differed slightly by species. Diarrhoea lasted longer in C. parvum cases compared to C. hominis and C. meleagridis cases. At follow-up 25–36 months after disease onset, 15% of the patients still reported intermittent diarrhoea. In four outbreaks and 13 family clusters, a single subtype was identified, indicating a common infection source, which emphasizes the value of genotyping for epidemiological investigations.

Despite infection control measures, an important increase in the extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae incidence density occurred in our hospital from 2006 onwards. This study, focusing on the 2005–2007 period, was performed in an attempt to explain this increase. ESBLs were characterized, isolates were typed by ERIC2-PCR, and sequence type (ST) of clustered isolates was determined. Temporal-spatial relationships of patients were analysed to assess possible cross-contamination. Of the 74 ESBL-producing isolates, 30 (40%) were detected at admission, 53 (71·5%) produced CTX-M enzymes, 40 displayed unique ERIC2-PCR profiles and 34 were assigned into six clusters: ST16 (n = 21), ST101, ST48, ST35, ST13, and ST436. Relationships were identified in 22 of the 34 patients harbouring clustered isolates. This study highlights the complex epidemiology of ESBL-producing K. pneumoniae in the mid-2000s with potential cross-contamination for only 30% of the 74 patients in our hospital, and the emergence of clones that are currently spreading worldwide.

This study aimed to determine current seroprevalence of hepatitis A virus (HAV) antibody in subjects aged 0–30 years in Shanghai. A total of 5515 subjects were recruited through random clustering sampling in 2009. Basic clinical and demographic information and records of HAV vaccination were acquired by questionnaire interviews and review of immunization records. Serum samples were collected and tested for anti-HAV IgM and total anti-HAV. The overall seroprevalence of total anti-HAV was 52·9%. Subjects aged 20–24 years had the lowest (34·4%) anti-HAV seropositivity and subjects aged 5–9 years had the highest (74·6%) positivity. Seroprevalence was significantly greater in subjects from suburban areas than in subjects from urban areas. Subjects who had HAV immunizations had significantly greater seropositivity for total anti-HAV. Previous hepatitis A immunization policies had a significant impact on the presence of anti-HAV seroprevalence in a population aged 0–30 years from Shanghai.

A randomized control trial on verocytotoxigenic Escherichia coli (VTEC)-infected farms found evidence that: (1) keeping animals in the same group; (2) maintaining dry bedding; (3) preventing direct contact with neighbouring cattle; and (4) maintaining a closed herd, were associated with a reduced risk of infection in youngstock aged 3–18 months. This study evaluated these interventions using a cost-effectiveness framework for UK dairy farms. Keeping animals in the same group was considered to have negligible cost and was feasible for herds containing over 77 dairy cows. Assuming equal efficacy of the remaining interventions, preventing direct contact between neighbouring cattle is most cost-effective with a median annual cost of £2.76 per cow. This compares to £4.18 for maintaining dry bedding and £17.42 for maintaining a closed herd using quarantine procedures. Further model validation and exploration of other potential benefits are required before making policy decisions on VTEC control.