There has been no study exploring the prognostic values of neutrophil percentage-to-albumin ratio (NPAR). We hypothesised that NPAR is a novel marker of inflammation and is associated with all-cause mortality in patients with severe sepsis or septic shock. Patient data were extracted from the MIMIC-III V1.4 database. Only the data for the first intensive care unit (ICU) admission of each patient were used and baseline data were extracted within 24 h after ICU admission. The clinical endpoints were 30-, 90- and 365-day all-cause mortality in critically ill patients with severe sepsis or septic shock. Cox proportional hazards models and subgroup analyses were used to determine the relationship between NPAR and these clinical endpoints. A total of 2166 patients were eligible for this analysis. In multivariate analysis, after adjustments for age, ethnicity and gender, higher NPAR was associated with increased risk of 30-, 90- and 365-day all-cause mortality in critically ill patients with severe sepsis or septic shock. Furthermore, after adjusting for more confounding factors, higher NPAR remained a significant predictor of all-cause mortality (tertile 3 vs. tertile 1: HR, 95% CI: 1.29, 1.04–1.61; 1.41, 1.16–1.72; 1.44, 1.21–1.71). A similar trend was observed in NPAR levels stratified by quartiles. Higher NPAR was associated with increased risk of all-cause mortality in critically ill patients with severe sepsis or septic shock.

Outbreaks of foot-and-mouth disease persist in dairy cattle herds in Saudi Arabia despite revaccination at intervals of 4–6 months. Vaccine trials provide data on antibody responses following vaccination. Using this information we developed a mathematical model of the decay of protective antibodies with which we estimated the fraction of susceptible animals at a given time after vaccination. The model describes the data well, suggesting over 95% take with an antibody half-life of 43 days. Farm records provided data on the time course of five outbreaks. We applied a ‘SLIR’ epidemiological model to these data, fitting a single parameter representing disease transmission rate. The analysis provides estimates of the basic reproduction number, R0, which may exceed 70 in some cases. We conclude that the critical intervaccination interval which would provide herd immunity against FMDV is unrealistically short, especially for heterologous challenge. We suggest that it may not be possible to prevent foot-and-mouth disease outbreaks on these farms using currently available vaccines.

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that was caused by a novel bunyavirus, SFTSV. The study aimed to disclose the epidemiological and clinical characteristics of SFTSV infection in China so far. An integrated clinical database comprising 1920 SFTS patients was constructed by combining first-hand clinical information collected from SFTS sentinel hospitals (n = 1159) and extracted data (n = 761) from published literature. The considered variables comprised clinical manifestations, routine laboratory tests of acute infection, hospitalization duration and disease outcome. SFTSV-IgG data from 19 119 healthy subjects were extracted from the published papers. The key clinical variables, case-fatality rate (CFR) and seroprevalence were estimated by meta-analysis. The most commonly seen clinical manifestations of SFTSV infection were fever, anorexia, myalgia, chill and lymphadenopathy. The major laboratory findings were elevated lactate dehydrogenase, aminotransferase, followed by thrombocytopenia, lymphocytopenia, elevated alanine transaminase and creatine kinase. A CFR of 12·2% was estimated, significantly higher than that obtained from national reporting data, but showing no geographical difference. In our paper, the mortality rate was about 1·9 parts per million. Older age and longer delay to hospitalization were significantly associated with fatal outcome. A pooled seroprevalence of 3·0% was obtained, which increased with age, while comparable for gender. This study represents a clinical characterization on the largest group of SFTS patients up to now. A higher than expected CFR was obtained. A wider spectrum of clinical index was suggested to be used to identify SFTSV infection, while the useful predictor for fatal outcome was found to be restricted.

Cats and dogs being treated at two veterinary clinics were investigated for gastrointestinal carriage of Clostridium difficile using selective solid and en-richment media. Thirty-two (39.5%) of 81 stool samples yielded C. difficile. There were significant differences in isolation rates between clinics, 61.0% of animals being positive at one clinic compared to 17.5% at the other (Chi-square, P < 0.005). Of 29 animals receiving antibiotics, 15 (52.0%) harboured C. difficile while 11 (23.9%) of 46 animals not receiving antibiotics were positive (Chi-square, P < 0.01). There was no difference in carriage rate between cats (38.1%) and dogs (40.0%). The environment at both veterinary clinics was surveyed for the presence of C. difficile. Fifteen of 20 sites at one clinic were positive compared to 6 of 14 sites at the other clinic. Both cytotoxigenic and noncytotoxigenic isolates of C. difficile were recovered from animals and environmental sites. These findings suggest that household pets may be a potentially significant reservoir of infection with C. difficile.

Diarrhoeal diseases are primary contributors to millions of deaths annually. Yet, little is known about the evolutionary reasons for the differences in virulence among gastrointestinal pathogens. Applying the comparative, cost/benefit approach of evolutionary biology this paper proposes that waterborne transmission should favour evolution towards high virulence. This hypothesis is supported by a cross-specific test, which shows that waterborne transmission is strongly correlated with the virulence of bacterial gastrointestinal pathogens of humans. Alternative explanations of this correlation are not supported by available data. These findings bear on public health policy because they draw attention to a previously unrecognized long-range benefit gained from purification of water supplies: diarrhoeal pathogens may evolve to lower levels of virulence.

Klebsiella infection has been considered to be an uncommon cause of meningitis. To determine its incidence and clinical features, we reviewed the microbiologic records of cerebrospinal fluid (CSF) and blood cultures and the medical records of patients with bacterial meningitis admitted between 1981 and 1995. Klebsiella meningitis was diagnosed in 79 patients with 83 episodes. All patients had klebsiella isolated from CSF and/or blood and typical symptoms and signs of acute bacterial meningitis. Of these, 74 were over 16 years of age and 2 of the 5 children were infants. There was an increased prevalence rate of klebsiella meningitis after 1986. Of the 83 episodes, only 9 occurred between 1981 and 1986, accounting for 7·8% of 115 cases with CSF and/or blood culture-proven acute bacterial meningitis, whereas in 1987–95, there were 74 episodes accounting for 17·7% of 419 bacteriologically proven cases. K. pneumoniae accounted for 69 episodes, K. oxytoca, 11 episodes and K. ozaenae, 3 episodes. Male gender, diabetes mellitus and liver cirrhosis were commonly associated with K. pneumoniae meningitis. Neurosurgical procedures were frequently associated with K. oxytoca meningitis. All three patients with K. ozaenae meningitis had a primary disease of the nasopharyngeal pathway. The mortality rate due to K. pneumoniae was 48·5%, K. oxytoca, 10% and K. ozaenae, 0%. In patients with K. pneumoniae meningitis, poor prognostic factors included age over 60 years, diabetes mellitus, bacteremia and severe neurological deficits on the first day of treatment.

We describe an outbreak of skin lesions due to Mycobacterium chelonae subsp. abscessus associated with injections of lidocaine (lignocaine) given by a ‘bioenergetic’ (a practitioner of alternative medicine) in Colombia. The lidocaine carpules and the lesions of the patients yielded mycobacteria with identical biochemical characteristics.

Using the methodology of Sartwell and a case control design we examined the incubation period and assessed risk factors. Of 667 potentially exposed individuals, a total of 298 patients were interviewed, of whom 232 had skin lesions. The median incubation period was 30·5 days (range 15–59 days). Male sex (OR 2·85, 95% CI 1·26–6·51), increasing age (OR 1·25, 95% CI 1·03–1·53), subcutaneous injection route (OR 3·72, 95% CI 1·09–12·7) and number of injections (OR 1·01, 95% CI 1·00–1·03) were risk factors for disease.

To our knowledge, this is the largest reported outbreak of M. chelonae infection, the first in which the organism has been isolated from the putative vehicle of infection, and the first in which the incubation period could be determined.

A survey was made of serotype association and multiple antibiotic resistance in strains of Pseudomonas aeruginosa in Europe. Of 208 epidemiologically distinct strains from 16 laboratories in 10 countries, 48 were resistant to carbenicillin (MIC > 128 μg/ml) and gentamicin (MIC > 4 μ g/ml), and 12 of these strains were of serotvpe O 12. Representative O 12 strains from different countries were compared with two multiresistant O 12 strains isolated 5 years apart, from a British burns unit and the antibiotic sensitive serotype reference strain. All O 12 strains were similar by phage and pyocin typing but lysogenic phage profiles indicated that two strains (the later burns isolate and the serotype strain) were distinct from the others. Electrophoretic characterization of outer membrane proteins, lipopoly- saccharides and esterase enzymes corroborated the relationship of the strains and restriction fragment length polymorphism of DNA fragments hybridized with a cDNA probe copy of rRNA from P. aeruginosa provided further proof of their relatedness. We propose that the uniformity of characters of multiresistant O 12 P. aeruginosa in Europe is suggestive of a common origin for the strains.

In 2002, in The Netherlands a national study of gastroenteritis outbreaks was performed. Epidemiological information was collected by the Public Health Services (PHS) and the Food Inspection Services (FIS) using standardized questionnaires. Stool samples were collected for diagnostic testing. For foodborne outbreaks, food samples were taken. In total, 281 gastroenteritis outbreaks were included, mainly from nursing homes and homes for the elderly (57%), restaurants (11%), hospitals (9%) and day-care centres (7%). Direct person-to-person spread was the predominant transmission route in all settings (overall 78%), except for restaurant outbreaks where food was suspected in almost 90% (overall in 21% of outbreaks). The most common pathogen was norovirus (54%), followed by Salmonella spp. (4%), rotavirus group A (2%), Campylobacter spp. (1%) and only incidentally others. In conclusion, most outbreaks were reported from health and residential institutions, with norovirus as the dominant agent. Control should aim at reducing person-to-person spread. In foodborne outbreaks norovirus was common, due to contamination of food by food handlers. Salmonella, as the second foodborne pathogen, was mainly associated with raw shell eggs. These results stress the continuous need for food safety education, complementary to governmental regulation.

1. Features in the epidemiology of a spontaneous enteric gangrene in the Highlands of New Guinea are described.

2. The disease has been called pig-bel because of its firm association with the pig-feasting practices of the people, which occur in 3–7 year cycles.

3. Cl. welchii type C is believed to play an important role in the pathogenesis of the condition. Strains isolated were strongly toxigenic and uniform in their toxin production.

4. A food poisoning aetiology was not proved but circumstantial and immunological evidence suggest that pork may be a vector of the disease.

5. The source of Cl. welchii type C was not established.

A prospective longitudinal survey of cutaneous leishmaniasis (Leishmania peruviana) was carried out in Peru on a study population of 4716 persons living in 38 villages (Departments of Lima, Ancash and Piura). Demographic and clinical data were collected from all individuals, and a Montenegro skin test (MST) was carried out on 72% (3418) of the study population. Each household was revisited at 3-monthly intervals for up to 2 years to detect new leishmaniasis cases; 497 people received a second MST at the end of the study. Analysis of the epidemiological data indicated that (i) 17% (16/94) of all infections were subclinical, (ii) this percentage increased significantly with age, (iii) clinical infections led to 73·9 % protective immunity (95 % C.I. 53·0–85·5 %) and relatively permanent MST responsiveness (recovery rate = 0·0098/year; 95% C.I. 0·000–0·020/year), (iv) sub-clinical infections led to protective immunity, which was positively correlated with their MST induration size (increasing by 17·9% per mm; P < 0·0001), and a mean MST recovery rate of 0·114/year (4/421 man-months), and (v) recurrent leishmaniasis was dominated by reactivations, not by reinfections.

This study analysed the role of several risk factors for hospitalization due to community-acquired, respiratory syncytial virus (RSV) infection. The risk factors detected in infants hospitalized for RSV infection in the first 24 months of life were compared with those in the general infant population in our region. There were 361 episodes of hospitalization in 357 infants. Eighty per cent of the infants did not present underlying conditions for severe RSV infection and only 10 (3%) were candidates for palivizumab prophylaxis. In multivariate analysis, birthweight of <2500 g was independently associated with hospitalization for RSV infection and was the most commonly detected medical risk factor. Other risk factors were maternal age at delivery <25 years, birth in the second half of the year, prematurity, suburban residence and congenital heart disease. In conclusion, together with well-known risk factors, we found that low birthweight was an independent factor for severe RSV infection.

Brucellosis is a worldwide disease. Although it has been eradicated in some countries, it continues to be an important disease in many farming areas. Previous works have described the evolution and diffusion of brucellosis in antiquity through direct analysis of ancient human remains collected by the University Museum of Chieti, Italy, and by using paleopathological and historical data. The earliest published case was reported in a skeletal individual dated to the Middle Bronze Age. However, our research group has diagnosed vertebral brucellosis in the partial skeleton of the late Pliocene Australopithecus africanus, demonstrating that this infectious disease occasionally affected our direct ancestors 2·3–2·5 million years ago. The frequency of brucellosis increased during the Roman period, when the disease would almost certainly have been endemic in Roman society, and during the Middle Ages. Most paleopathological cases involve adult male skeletal individuals, and lumbar vertebrae and sacroiliac joints are most commonly involved.

The Belgian data for foodborne norovirus (NoV) outbreaks became available for the first time with the introduction of an extraction and detection protocol for NoV in the National Reference Laboratory for foodborne outbreaks in September 2006. In 2007, 10 NoV foodborne outbreaks were reported affecting 392 persons in Belgium. NoV became the most detected agent in foodborne outbreaks followed by Salmonella (eight foodborne outbreaks). The major implicated foods were sandwiches (4/10), where food handlers reported a history of gastroenteritis in two outbreaks. A food handler was implicated in the limited number of Belgian NoV outbreaks which is in accord with internationally recorded data. Forty foodborne and waterborne outbreak events due to NoV, epidemiological and/or laboratory confirmed, from 2000 to 2007 revealed that in 42·5% of the cases the food handler was responsible for the outbreak, followed by water (27·5%), bivalve shellfish (17·5%) and raspberries (10·0%).

Strongyloides stercoralis is rarely recognized as a major public health issue, probably because its burden is largely underestimated. We reviewed the literature (both PubMed and ‘grey’ literature) about the prevalence of strongyloidiasis in Latin America, an area of presumable high endemicity. There were finally 88 papers involved in the analysis, covering the period between 1981 and 2011. Studies were heterogeneous in several aspects, such as the populations screened and the diagnostic methods used. Most of the studies relied on direct coproparasitological examination, which has low sensitivity for the detection of S. stercoralis larvae. The following countries presented areas of high prevalence (>20%): Argentina, Ecuador, Venezuela, Peru and Brazil. Globally, for most of the included countries it was not possible to define reliable data because of paucity and/or inadequacy of studies. S. stercoralis requires specific diagnostic methods for its detection; therefore, surveys should be specifically designed in order to avoid underestimation of the infection.

This paper reports the first detection of Borrelia miyamotoi in UK Ixodes ricinus ticks. It also reports on the presence and infection rates of I. ricinus for a number of other tick-borne pathogens of public health importance. Ticks from seven regions in southern England were screened for B. miyamotoi, Borrelia burgdorferi sensu lato (s.l.), Anaplasma phagocytophilum and Neoehrlichia mikurensis using qPCR. A total of 954 I. ricinus ticks were tested, 40 were positive for B. burgdorferi s.l., 22 positive for A. phagocytophilum and three positive for B. miyamotoi, with no N. mikurensis detected. The three positive B. miyamotoi ticks came from three geographically distinct areas, suggesting a widespread distribution, and from two separate years, suggesting some degree of endemicity. Understanding the prevalence of Borrelia and other tick-borne pathogens in ticks is crucial for locating high-risk areas of disease transmission.

This paper uses a graph-theoretical approach to investigate the properties of the observed network of disease transmission in the 2001 foot-and-mouth epidemic in the United Kingdom. This analysis revealed both global and local heterogeneity in the contact pattern between the infected premises in the first 3 weeks of the disease. In particular, the global heterogeneity contributed to the failure of the culling strategy imposed by the UK government. However, a more effective strategy targeting selective deletion of key premises in the network was not available once the epidemic had begun. We recommend that post-hoc analyses of this sort should become part of preventative and proactive policy rather than part of a reaction to an ongoing crisis.

Yersinia enterocolitica biotype 1, serotype O.10K was isolated from 19 patients in the paediatric wards of a district general hospital over a period of 3 months. Fifteen cases were patients on the medical ward. Shortly afterwards. Y. enterocolitica biotype 1, serotype 0.6,30 was isolated from a further 17 patients on this ward in 1 month. The same serotypes of Y. enterocolitica were isolated from the pasteurized milk supplied to the ward. Epidemiological evidence indicated that contaminated pasteurized milk was the source of the yersinia organisms exereted by the patients.

In France surveillance underestimates the true burden of acute gastroenteritis (AG). We conducted a population-based, retrospective cross-sectional telephone survey between May 2009 and April 2010 in order to obtain more accurate estimates of the incidence and the burden of AG and to describe healthcare-seeking behaviour for AG. Of the 10 080 persons included in the survey, 260 respondents reported 263 episodes of AG. The incidence rate of AG was estimated at 0·33 cases/person-year (95% CI 0·28–0·37). It was highest in children aged <5 years and declined with age. Thirty-three percent (95% CI 27–40) of the AG cases consulted a physician and 76% (95% CI 70–82) used medication. Our results indicate that there are more than 21 million episodes of AG each year in France. These results allow a more accurate interpretation of the data derived from existing AG surveillance systems.

Livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) have been isolated from a number of livestock species and persons involved in animal production. We investigated the prevalence of LA-MRSA in fattening turkeys and people living on farms that house fattening turkeys. Eighteen (90%) of 20 investigated flocks were positive for MRSA, and on 12 of the farms 22 (37·3%) of 59 persons sampled were positive for MRSA. People with frequent access to the stables were more likely to be positive for MRSA. In most flocks MRSA that could be assigned to clonal complex (CC) 398 were detected. In five flocks MRSA of spa-type t002 that is not related to CC398 were identified. Moreover, other methicillin-resistant Staphylococcus spp. were detected on 11 farms and in eight people working on the farms.