Two related outbreaks (in 2009 and 2012) of cryptosporidiosis in Norwegian schoolchildren during a stay at a remote holiday farm provided us with a natural experiment to investigate possible secondary transmission of Cryptosporidium parvum IIa A19G1R1. After the children had returned home, clinical data and stool samples were obtained from their household contacts. Samples were investigated for the presence of Cryptosporidium oocysts by immunofluorescence antibody test. We found both asymptomatic and symptomatic infections, which are likely to have been secondary transmission. Laboratory-confirmed transmission rate was 17% [4/23, 95% confidence interval (CI) 7·0–37·1] in the 2009 outbreak, and 0% (95% CI 0–16·8) in the 2012 outbreak. Using a clinical definition, the probable secondary transmission rate in the 2012 outbreak was 8% (7/83, 95% CI 4·1–16·4). These findings highlight the importance of hygienic and public health measures during outbreaks or individual cases of cryptosporidiosis. We discuss our findings in light of previous studies reporting varying secondary transmission rates of Cryptosporidium spp.

In some French départements, the eradication of bovine tuberculosis is incomplete and usual skin tests [single intradermal tuberculin test (SIT) and single intradermal comparative cervical test (SICCT)] have poor specificity due to cross-reactions with non-pathogenic mycobacteria, causing economic losses. In Côte d'Or (Burgundy, France), an experimental serial testing scheme based on the combination of SICCT and gamma-interferon (IFN-γ) tests has been initiated in order to shorten the interval between suspicion and its invalidation in herds with false-positive results to skin tests. Our aim was to assess the scheme's sensitivity and to compare it to the sensitivity of the screening scheme recommended by the European Commission. Our study included 1768 animals from Côte d'Or. The sensitivities of both schemes were estimated using a Bayesian approach. The individual sensitivity of the IFN-γ test [88·1%, 95% credibility interval (CrI) 72·8–97·5] was not significantly different from individual SICCT sensitivity (80·3%, 95% CrI 61·6–98·0) and individual SIT sensitivity (84·2%, 95% CrI 59·0–98·2). The individual specificity of the IFN-γ test was 62·3% (95% CrI 60·2–64·5). No significant difference could be demonstrated between the sensitivities of the serial testing scheme used in Côte d'Or (73·1%, 95% CrI 41·1–100) and the European Union serial testing scheme (70·1%, 95% CrI 31·5–100·0).

An individual's risk of infection from an infectious agent can depend on both the individual's own risk and protective factors and those of individuals in the same community. We hypothesize that an individual's exposure to an infectious agent is associated with the risks of infection of those living nearby, whether their risks are modified by pharmaceutical interventions or by other factors, because of the potential for transmission from them. For example, unvaccinated individuals living in a highly vaccinated community can benefit from indirect protection, or living near more children in a typhoid-endemic region (where children are at highest risk) might result in more exposure to typhoid. We tested this hypothesis using data from a cluster-randomized typhoid vaccine trial. We first estimated each individual's relative risk of confirmed typhoid outcome using their vaccination status and age. We defined a new covariate, potential exposure, to be the sum of the relative risks of all who live within 100 m of each person. We found that potential exposure was significantly associated with an individual's typhoid outcome, and adjusting for potential exposure affected estimates of vaccine efficacy. We suggest that it is useful and feasible to adjust for spatially heterogeneous distributions of individual-level risk factors, but further work is required to develop and test such approaches.

A total of 180 non-duplicate carbapenem-resistant Klebsiella pneumoniae isolates were recovered from patients hospitalized between December 2010 and January 2012 at a Chinese hospital. Eight KPC-2, four NDM-1, one VIM-2, and five KPC-2 plus IMP-4 producers were identified and all were multidrug resistant due to the presence of other resistance determinants, including extended-spectrum β-lactamases (CTX-M-15, SHV-12), 16S rRNA methylases (armA, rmtB) and plasmid-mediated quinolone-resistance determinants (qnrA, B, S, aac(6′)-Ib-cr). Nine K. pneumoniae clones (Kpn-A1/ST395, Kpn-A3/ST11, Kpn-A2/ST134, Kpn-B/ST263, Kpn-C/ST37, Kpn-D/ST39, Kpn-E/ST1151, Kpn-F/ST890, Kpn-G/ST1153) were identified. bla KPC-2 was located on transferable ~65 kb IncL/M (ST395, ST11, ST134, ST39) and ~100 kb IncA/C (ST37, ST1153, ST890) plasmids, respectively. On the other hand, bla NDM-1 was associated with a ~70 kb IncA/C plasmid (ST263). However, non-typable plasmids of ~40 kb containing bla VIM-2 were detected in the ST1151 clone. This work reports the first co-occurrence of four diverse types of carbapenemase of K. pneumoniae clones from a single hospital in China. IncA/C, IncL/M, and other successful plasmids may be important for the dissemination of carbapenemases, producing a complex epidemiological picture.

An unusually long-lasting community-acquired outbreak of Legionnaires’ disease (LD) occurred in the inhabitants of a town in northern Italy from 2005 to 2008. Overall, 43 cases were diagnosed including five deaths. Hundreds of water samples were collected for Legionella isolation but only two clinical samples were obtained. Clinical strains were ST23 as were environmental isolates detected in most Legionella-positive patients' homes and those from a public fountain. Although no Legionella was found in the municipal water mains, a continuous chlorination was applied in 2008. This action resulted in a halving of cases, although incidence remained tenfold higher than the Italian average incidence until the end of 2013, when it dropped to the expected rate. Retrospective analyses of prevalent wind direction suggested that a hidden cooling tower could have been the main cause of this uncommon outbreak, highlighting the importance of implementation of cooling tower registers in supporting LD investigations.

A survey of national animal influenza surveillance programmes was conducted to assess the current capacity to detect influenza viruses with zoonotic potential in animals (i.e. those influenza viruses that can be naturally transmitted between animals and humans) at regional and global levels. Information on 587 animal influenza surveillance system components was collected for 99 countries from Chief Veterinary Officers (CVOs) (n = 94) and published literature. Less than 1% (n = 4) of these components were specifically aimed at detecting influenza viruses with pandemic potential in animals (i.e. those influenza viruses that are capable of causing epidemic spread in human populations over large geographical regions or worldwide), which would have zoonotic potential as a prerequisite. Those countries that sought to detect influenza viruses with pandemic potential searched for such viruses exclusively in domestic pigs. This work shows the global need for increasing surveillance that targets potentially zoonotic influenza viruses in relevant animal species.

Leptospira interrogans, hantaviruses (particularly Seoul virus), hepatitis E virus (HEV), and Toxoplasma gondii are rat-associated zoonoses that are responsible for human morbidity and mortality worldwide. This study aimed to describe the infection patterns of these four pathogens in wild rats (Rattus norvegicus) across socioeconomic levels in neighbourhoods in Lyon, France. The infection or exposure status was determined using polymerase chain reaction or serology for 178 wild rats captured in 23 locations; additionally, confirmatory culture or mouse inoculation was performed. Multivariate logistic regression analyses were used to investigate whether morphological and socioeconomic data could predict the infection status of the rats. This study revealed that the rat colony's age structure may influence the prevalence of L. interrogans, hantavirus, and HEV. In addition, areas with high human population densities and low incomes may be associated with a greater number of infected rats and an increased risk of disease transmission.

This study describes the first large-scale serosurvey on West Nile virus (WNV) conducted in the equine population in Pakistan. Sera were collected from 449 equids from two provinces of Pakistan during 2012–2013. Equine serum samples were screened using a commercial ELISA kit detecting antibodies against WNV and related flaviviruses. ELISA-positive samples were further investigated using virus-specific microneutralization tests (MNTs) to identify infections with Japanese encephalitis virus (JEV), WNV and tick-borne encephalitis virus (TBEV). Anti-WNV antibodies were detected in 292 samples by ELISA (seroprevalence 65·0%) and WNV infections were confirmed in 249 animals by MNT. However, there was no animal found infected by JEV or TBEV. The detection of WNV-seropositive equines in Pakistan strongly suggests a widespread circulation of WNV in Pakistan.

A dengue vaccine is expected to be available within a few years. Once vaccine is available, policy-makers will need to develop suitable policies to allocate the vaccine. Mathematical models of dengue transmission predict complex temporal patterns in prevalence, driven by seasonal oscillations in mosquito abundance. In particular, vaccine introduction may induce a transient period immediately after vaccine introduction where prevalence can spike higher than in the pre-vaccination period. These spikes in prevalence could lead to doubts about the vaccination programme among the public and even among decision-makers, possibly impeding the vaccination programme. Using simple dengue transmission models, we found that large transient spikes in prevalence are robust phenomena that occur when vaccine coverage and vaccine efficacy are not either both very high or both very low. Despite the presence of transient spikes in prevalence, the models predict that vaccination does always reduce the total number of infections in the 15 years after vaccine introduction. We conclude that policy-makers should prepare for spikes in prevalence after vaccine introduction to mitigate the burden of these spikes and to accurately measure the effectiveness of the vaccine programme.

Pertussis or whooping cough is a highly contagious community disease mainly caused by Bordetella pertussis and B. parapertussis. We report a minor outbreak of whooping cough (2009–2010) in symptomatic subjects from Bisham, near Swat, Khyber Pukhtoonkhawa province, Pakistan. Interestingly, our results show that all the culture-positive isolates (n = 21) collected from children (average age 3·46 years), were identified as B. parapertussis after routine identification tests and PCR IS481, IS1001 and IS1002. Furthermore, in the affected patients, none had received immunization with diphtheria-pertussis-tetanus (DTPw) vaccine. Therefore, the possibility of the re-emergence of the disease due to limitation of basic health services as a result of the political unrest due to the 9/11 situation is also examined. Moreover, we discuss the importance of vaccinating both adults and children with DTPwPaw vaccine containing both organisms for better protection.

Reporting of percutaneous injuries (PIs) to the Chinese Exposure Prevention Information Network (EPINet) became mandatory for all public and tertiary referral hospitals in Taiwan in 2011. We have estimated the number of microbially contaminated PIs and the national PI incidence using a retrospective secondary data analysis approach to analyse 2011 data from the Chinese EPINet to determine the types of PI, mechanisms of occurrence and associated risks. The results revealed a national estimate of PIs between 6710 and 8319 in 2011. The most common incidents for physicians were disposable syringes, suture needles, and disposable scalpels; while for nurses they were disposable syringes, intravenous catheters, and lancets. About 13·0% of the source patients were seropositive for hepatitis B virus (HBV) surface antigen, 13·8% were seropositive for hepatitis C virus (HCV), and 1·1% seropositive for human immunodeficiency virus (HIV). From these results we estimate that annually 970 full-time healthcare workers (HCWs) would be exposed to HBV, 1094 to HCV, and 99 to HIV. This study improves our understanding of the mechanisms and risks of PIs and informs the development of more efficient preventive measures to protect HCWs from such injuries.

Two clusters of confirmed cryptosporidiosis infections were detected in Navarra, Spain, in the summer of 2012, in the context of an increased incidence in the region. Molecular subtyping of Cryptosporidium hominis determined that one cluster, occurring in an urban area, was due to the predominant circulating subtype IbA10G2R2 and the other cluster, with cases occurring in a rural area, was due to a rare subtype IaA18R3. No single exposure was associated with infection, although exposure to certain children's pools was reported by a majority of patients interviewed in each cluster. Genotyping tools were useful in the investigation and could aid investigation of cryptosporidiosis outbreaks in Spain in the future.

There is little known regarding the transmissibility of human papillomavirus (HPV) between different sites in men who have sex with men (MSM) and heterosexual individuals. We conducted a retrospective analysis investigating all new patients attending the Melbourne Sexual Health Centre in Australia between 2002 and 2013. We describe the prevalence and ratio of the first episode of anogenital warts in MSM and heterosexual males and females. The proportion of new MSM clients with anal and penile warts was 4·0% (362/8978) and 1·6% (141/8978), respectively; which gave an anal-to-penile wart ratio of 1:2·6. About 13·7% (1656/12112) of heterosexual males had penile warts and 10·0% (1121/11166) of females had vulval warts, which yielded a penile-to-vulval wart ratio of 1:0·7. Penile–anal transmission has a higher ratio than penile–vulval transmission, suggesting that the anal epithelium may be more susceptible to HPV infection than the vulval epithelium in females; these ratios are important in modelling the control of HPV in MSM.

Expansion of sandflies and increasing pet travel have raised concerns about canine leishmaniasis (CanL) spread to new areas of Europe. This study aimed to estimate the probability of CanL introduction and persistence following movements of infected dogs. Stochastic modelling was used to estimate the probabilities of (1) CanL infection during travels or imports of infected dogs (Pinf and PinfCA, respectively), (2) CanL persistence in a dog network with sandflies after introduction of an infected dog (Pper), and (3) persistence in a CanL-free region (Pper region) for N dogs moving between endemic and free regions. Different mitigation measures (MMs) were assessed. Pinf [7·8%, 95% predictive interval (PI) 2·6–16·4] and Pper (72·0%, 95% PI 67·8–76·0) were reduced by use of repellent, vaccine, prophylactic medication, and insecticide, in decreasing order of effectiveness. Testing and exclusion of positive dogs was most effective in reducing Pper region for a small N. The spread of CanL to CanL-free areas with sandflies is thus likely, but can be reduced by MMs.

A ‘black box’ paradigm has prevailed in which researchers have focused on the association between the total number of pathogens for which individuals are seropositive (i.e. total pathogen burden) and various chronic diseases, while largely ignoring the role that seropositivity for specific combinations of pathogens may play in the aetiology of such outcomes and consequently mortality. We examined the association between total pathogen burden as well as specific pathogen combinations and all-cause mortality in the United States. Data were from individuals aged ⩾25 years tested for cytomegalovirus (CMV), herpes simplex virus (HSV)-1, HSV-2 and Helicobacter pylori, with mortality follow-up to 31 December 2006 in the National Health and Nutrition Examination Survey (NHANES) III (N = 6522). We did not observe a statistically significant graded relationship between total pathogen burden level and all-cause mortality. Furthermore, compared to those seronegative for all four pathogens, the greatest statistically significant rate of all-cause mortality was for those CMV+/HSV-2+ (hazard ratio 1·95, 95% confidence interval 1·13–3·35) adjusting for age, gender, race/ethnicity, education level, body mass index (kg/m2) and smoking status. Interventions targeting prevention or treatment of particular pathogens may be more effective for reducing mortality than those focused solely on reducing overall pathogen burden.

In England, hospital admissions for severe staphylococcal boils and abscesses trebled between 1989 and 2004. We investigated this trend using routine data from primary and secondary care. We used The Health Improvement Network (THIN), a large primary-care database and national data on hospital admissions from Hospital Episode Statistics (HES). Time trends in the incidence of primary-care consultations for boils and abscesses were estimated for 1995–2010. HES data were used to calculate age-standardized hospital admission rates for boils, abscesses and cellulitis. The incidence of boil or abscess was 450 [95% confidence interval (CI) 447–452] per 100 000 person-years and increased slightly over the study period (incidence rate ratio 1·005, 95% CI 1·004–1·007). The rate of repeat consultation for a boil or abscess increased from 66 (95% CI 59–73) per 100 000 person-years in 1995 to peak at 97 (95% CI 94–101) per 100 000 person-years in 2006, remaining stable thereafter. Hospital admissions for abscesses, carbuncles, furuncles and cellulitis almost doubled, from 123 admissions per 100 000 in 1998/1999 to 236 admissions per 100 000 in 2010/2011. Rising hospitalization and recurrence rates set against a background of stable community incidence suggests increased disease severity. Patients may be experiencing more severe and recurrent staphylococcal skin disease with limited treatment options.

An unlinked anonymous study was conducted to estimate the prevalence of hepatitis C virus (HCV) infection in emergency department (ED) attendees at a London Hospital. Nine hundred and ninety-seven samples collected over a 12-day period were tested for HCV antibody (Ab) and reactive samples were further tested for HCV RNA. The HCV seroprevalence was 2·6% (26/997) with 1·2% (12/997) HCV RNA positive. A peak HCV RNA-positive prevalence of 4·8% (3/63) was found in males aged 35–44 years, this was compared to 0% (0/136) in males aged <35 years (P = 0·0614) and 1·4% (4/278) in males aged ⩾45 years (P = 0·2415). Assuming the cost for HCV Ab is £6 and HCV RNA is £40 per test, screening ED attendees aged 25–54 years would cost £360 per viraemic infection and identify 82% of those who were HCV RNA positive, yielding the most favourable cost/benefit ratio. HCV screening of ED attendees aged 25–54 years in this population could be an effective way of identifying patients and limit onward transmission.

Rheumatic fever (RF) is an important public health problem in New Zealand (NZ). There are three sources of RF surveillance data, all with major limitations that prevent NZ generating accurate epidemiological information. We aimed to estimate the likely RF incidence using multiple surveillance data sources. National RF hospitalization and notification data were obtained, covering the periods 1988–2011 and 1997–2011, respectively. Data were also obtained from four regional registers: Wellington, Waikato, Hawke's Bay and Rotorua. Coded patient identifiers were used to calculate the proportion of individuals who could be matched between datasets. Capture–recapture analyses were used to calculate the likely number of true RF cases for the period 1997–2011. A range of scenarios were used to correct for likely dataset incompleteness. The estimated sensitivity of each data source was calculated. Patients who were male, Māori or Pacific, aged 5–15 years and met the Jones criteria, were most likely to be matched between national datasets. All registers appeared incomplete. An average of 113 new initial cases occurred annually. Sensitivity was estimated at 80% for the hospitalization dataset and 60% for the notification dataset. There is a clear need to develop a high-quality RF surveillance system, such as a national register. Such a system could link important data sources to provide effective, comprehensive national surveillance to support both strategy-focused and control-focused activities, helping reduce the incidence and impact of this disease. It is important to remind clinicians that RF cases do occur outside the well-characterized high-risk group.

Ruminants are considered the main reservoir for transmission of Coxiella burnetii (Cb) to humans. The implementation of effective control measures against Cb in ruminants requires knowledge about potential risk factors. The objectives of this study were (i) to describe the spatial distribution of Q fever-infected dairy cattle herds in Sweden, (ii) to quantify the respective contributions of wind and animal movements on the risk of infection, while accounting for other sources of variation, and (iii) to investigate the possible protective effect of precipitation. A total of 1537 bulk milk samples were collected and tested for presence of Cb antibodies. The prevalence of test-positive herds was higher in the south of Sweden. For herds located in areas with high wind speed, open landscape, high animal densities and high temperature, the risk of being infected reached very high values. Because these factors are difficult to control, vaccination could be an appropriate control measure in these areas. Finally, the cumulated precipitation over 1 year was identified as a protective factor.