Emerging Infections 9 | CDC EID

EID Journal Home > Volume 17, Number 6–June 2011

Volume 17, Number 6–June 2011
Book Review
Emerging Infections 9
W. Michael Scheld, M. Lindsay Grayson, and James M. Hughes, editors
ASM Press, Washington, DC, USA, 2010
ISBN: 978-1-55581-525-7
Pages: 380; Price: US $154.95


Suggested citation for this article

This book is the ninth in the Emerging Infections series from the American Society for Microbiology. The 18 chapters cover the following diseases and pathogens: influenza in 2009, human adenovirus 14, Acanthamoeba polyphaga mimivirus as a cause of pneumonia, hepatitis E, lymphocytic choriomeningitis virus-like arenavirus infections, human T-lymphotropic virus type 1 infections in indigenous populations, cytomegalovirus infection after transplantation, malignancies and HIV infection, Arcobacter sp. and food, multidrug-resistant gram-negative bacilli, sepsis in Africa, Buruli ulcer, Plasmodium knowlesi malaria, neglected tropical diseases, infections of long-term care, emerging infectious diseases in mobile populations, the One Health concept, and emerging infections of plants.

The book starts with a discussion of pandemic (H1N1) 2009 virus in Australia. In the state of Victoria, a major effort was made to limit the spread of the infection but had little success. Ultimately, 15%–20% of the Victorian population showed evidence of infection, despite a reproduction number computed as ≈1.6. The chapter on Buruli ulcer describes some findings from recent work in Australia on the disease. There is a discussion of a small new epidemic focus where evidence suggests mosquito-borne transmission, including genetic material identified from mosquitoes and evidence of protection from the use of mosquito repellent.

Infections of some special populations are discussed. It struck me that pneumonia and urinary tract infections in residents of long-term care are hardly emerging infections. However, the chapter rightly focuses on demographic shifts and changing effects of antimicrobial drugs. Another group mentioned is mobile populations. The authors discuss hepatitis E that is associated with refugee camps, but it might have been helpful to also emphasize that the risk of communicable diseases in these settings is primarily of outbreaks of diseases of the urban poor. The One Health concept is itself an emerging idea, resting on the interdependence of human and animal health and the implications for disease control.

Overall, this is a worthwhile book. It is not comprehensive but aims to update readers on specific areas in infectious diseases. The text does this quite well, but it has a heavy microbiological and clinical focus, and the public health aspects of the topics could, in general, be expanded. For the reader with an interest in the chapter topics, it is worth perusing.

Robert Hall
Author affiliation: Monash University, Melbourne, Victoria, Australia

Suggested Citation for this Article
Hall R. Emerging Infections 9 [book review]. Emerg Infect Dis [serial on the Internet]. 2011 Jun [date cited]. http://www.cdc.gov/EID/content/17/6/1155.htm

DOI: 10.3201/eid1706.110444


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

Robert Hall, School of Public Health and Preventive Medicine, Monash University, Department of Epidemiology and Preventive Medicine, 99 Commercial Rd, Melbourne,
VIC 3004, Australia; email: robert.hall@monash.edu


Emerging Infections 9 | CDC EID

Rabies Postexposure Prophylaxis, France | CDC EID

EID Journal Home > Volume 17, Number 6–June 2011

Volume 17, Number 6–June 2011
Letter
Effect of Media Warnings on Rabies Postexposure Prophylaxis, France
Philippe Gautret, Caroline Labreuil, Mohamadou Seyni, Jean Delmont, Philippe Parola, and Philippe Brouqui
Author affiliation: Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France

Suggested citation for this article

To the Editor: Rabies was officially declared eliminated in nonflying mammals in metropolitan France during 2001–2008 by the World Organisation for Animal Health; the last case of rabies was believed to occur in a fox in 1998. However, rabies remained a public health concern because of the risk of translocation of infected dogs from enzootic areas and the natural circulation of bat rabies–associated lyssaviruses (BRALVs). In 2008, France temporarily lost its rabies-free status following evidence of an indigenous case of rabies in a dog, linked to an index case in a dog infected in Morocco. In 2007, a domestic cat was found infected with a BRALV, an indication that, although bats are the primary hosts of this pathogen, other mammals may be infected. (1). Rabies is a tragic and frightening disease, and bats have a sinister image. Therefore, possible transmission of rabies from bats to humans represents a particularly terrifying threat in which emotional distortion may play a key role in public responses. Patient demand for rabies postexposure prophylaxis (RPEP) has been associated with media-communicated health alerts in France (2,3) and French Guiana (4).

We compared the number of RPEP treatments in humans after bat-related exposures in the south of France with newspaper reports about rabies-related events over an 8-year period. In France, primary health care management of patients seeking RPEP is delivered through an official network of antirabies medical centers. All centers in the southern half of France were asked to provide the number of RPEP treatments that followed bat-related exposures in mainland France during 2002 through 2009. Of 22 centers, 18 participated in the study, reporting 326 RPEP treatments (Figure). Two marked peaks were observed: in September 2004 and in September 2008. The number of patients reporting bat-related exposures that occurred during the summer period (June–September) showed marked annual variations with a 2.1-fold increase in 2004 (44 cases) and a 4.7-fold increase in 2008 (96 cases) compared with the 2002–2009 average of 20.5 cases/summer (range 7–31). Most cases in 2008 were reported by the Marseille and Bordeaux centers. In 2004, 3 cases of illegally imported dogs with rabies were observed in France, in February, May, and August (2,5). Newspapers reported extensively on the third case, with 54 articles published in the 3 major national newspapers (Le Monde, Le Figaro, Libération) (2), after an alert was issued in late August (Figure). On July 30, 2008, in response to a familial cluster of RPEP following bat bites near Marseille, a media-communicated health alert was organized by the Marseille center in the major regional newspaper (La Provence) to warn people about the potential risk of rabies after bat-related exposures and the necessity of seeking advice when such events occur. The alert was developed by the Agence France Presse, released by the majority of national and regional newspapers, and included in a large number of websites (Figure). On August 28, 2008, an additional alert was released in Bordeaux because of 2 BRALV-infected bats in the region (Figure). The alert was published in the regional newspaper (Sud-Ouest) (3). No other rabies-related events were intensively reported in French media during the study period.

The pattern of spikes in RPEP in the south of France seen after bat-rabies media reports supports the results of other studies that found effective newspaper reporting increases patient demand for RPEP (2–4). However, the increase is of short duration. Our results may indicate that media reports bring out the worried well who were not truly exposed but still request RPEP. The results may also indicate that bat-related injuries or contacts are underreported in the absence of media events.

Classical rabies virus has been transmitted to humans by bats in South America (6). In Europe, European bat lyssavirus type 1 (EBLV-1) has been isolated from bats in Germany, France, the Netherlands, Denmark, Yugoslavia, Spain, and Poland and EBLV-2 from bats in the Netherlands, United Kingdom, Switzerland, Germany, and Finland (6,7). Only 3 cases of rabies in humans caused by bat bites have been reported in Europe (6). In France, health authorities recommend that all cases of confirmed bat-related exposures (bites, scratches, exposures to a mucous membrane) receive RPEP with both vaccine and immunoglobulin (8), based on World Health Organization guidelines (9). Whether RPEF is needed for other types of exposures is subject to considerable debate (10). The centers in southern France are directed to provide RPEP only for known exposures.

Based on results of study we conducted in 2008 when RPEP increased 4.7 fold after 2 media releases within several weeks, it is possible that only 20% of persons with bat exposure typically seek RPEP in periods without media reports. Although the risk of human rabies acquired through exposure to European bats is rare, information should be provided to the French public to avoid direct contact with bats, including handling when found inside homes during the summertime. When available, bats should be submitted for rabies testing to determine whether RPEP is needed. Following these procedures should minimize both the potential risk for transmission and the number of expensive RPEP treatments.

Acknowledgments
We thank the personnel of the Anti-rabies Medical Centres in Annecy, Annonay, Aurillac, Bastia, Bordeaux, Chambéry, Grenoble, Le Puy en Velay, Limoges, Lyon, Nice, Pau, Perpignan, Poitiers, Roanne, Saint-Etienne, and Toulouse for providing data.

full-text:
Rabies Postexposure Prophylaxis, France | CDC EID


Suggested Citation for this Article
Gautret P, Labreuil C, Seyni M, Delmont J, Parola P, Brouqui P. Effect of media warnings on rabies postexposure prophylaxis, France [letter]. Emerg Infect Dis [serial on the Internet] 2011 Jun [date cited]. http://www.cdc.gov/EID/content/17/6/1131.htm

DOI: 10.3201/eid1706.101962


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

Philippe Gautret, Service des Maladies Infectieuses et Tropicales, Hôpital Nord, AP-HM, 13015 Marseille, France; email: philippe.gautret@club-internet.fr

Rabies Immunization Status of Dogs, Beijing, China | CDC EID

EID Journal Home > Volume 17, Number 6–June 2011

Volume 17, Number 6–June 2011
Letter
Rabies Immunization Status of Dogs, Beijing, China
Chao Wang, Ying Wang, Xiaoyan Du, Lin Zeng, Gang Dong, Yanhua Wu, Jing Lu, Deyou Wei, Xi Zhu, Guosheng Liu, Taiyun Zhao, and Zhenwen Chen
Author affiliations: Capital Medical University, Beijing, People's Republic of China (C. Wang, Y. Wang, X. Du, Y. Wu, J. Lu, Z. Chen); Academy of Military Medical Sciences, Beijing (L. Zeng, T. Zhao), Chinese People's Liberation Army Center for Disease Control and Prevention, Beijing (G. Dong), Animal Health Inspection Office of Fengtai District, Beijing (D. Wei); and Disease Control and Prevention Center of Fengtai District, Beijing (X. Zhu, G. Liu)

Suggested citation for this article

To the Editor: In the People's Republic of China, >3,000 persons die of rabies each year; most were infected by dog bites (1). Since 2000, the dog population in Beijing has increased dramatically, and the exact vaccination coverage and immunization status of dogs are not known.

During 2006–2009, to assist with governmental rabies control, Fengtai District was selected as a geographically representative area in Beijing in which to conduct a survey of rabies antibody titers in domestic dogs. Blood samples were randomly collected from 4,775 dogs in Fengtai District, which account for 3% of all registered dogs in the district. Rabies virus neutralization antibody (VNA) titers were detected by fluorescent antibody virus neutralization (2). In brief, VNA titers >0.5 IU indicated positive immunization, implying that the dog had an adequate level of antibody, and VNA <0.5 IU indicated negative immunization (3). The data were analyzed by 2-tailed χ2 test; p<0.05 was considered significant. Vaccination coverage and antibody levels were categorized either by dog's function (guard or pet) or residence (urban or suburban) (Figure). Most dogs with a history of vaccination were positively immunized (68.1%) (Figure, bar A), compared with 16.4% in the unvaccinated group (Figure, bar B), demonstrating that compulsory immunization is crucial to rabies control (4). Of 944 dogs with unclear vaccination history, 221 (23.4%) (Figure, bar C) had adequate antibody levels, possibly from undocumented vaccination or contact with rabies hosts. However, for 2006, 2007, 2008, and 2009, immunization coverage in the district was 55.0%, 53.8%, 67.4%, and 54.4%, respectively, all below the >70% criterion recommended by the World Health Organization (5). The results imply that much work still needs to be done by the Beijing government, not only to meet the World Health Organization immunization baseline but also to keep risk for a rabies epidemic in Beijing low.

Immunization coverage ratios differed significantly (p<0.05) between guard (39.3%) and pet dogs (69.5%) (Figure, bars D, E) and between urban (81.7%) and suburban areas (27.6%) (Figure, bars F, G). Consequently, the number of negatively immunized guard dogs was 1.68× lower than that for pet dogs (Figure, bars D, E) (p<0.05), and the number of positively immunized dogs in urban areas was 2.5× higher than that in suburban areas (Figure, bars F, G) (p<0.05). In Beijing, guard dogs are usually raised by villagers to protect the house, whereas pet dogs are usually raised by city dwellers who treat dogs as friends. As a result, in urban areas dogs are registered and vaccinated in a timely manner by authorized pet hospitals (6). In suburban areas, however, dog management is deficient. For example, guard dogs in suburban areas are sometimes not vaccinated because the owner or veterinarian cannot safely restrain the dog for vaccination. According to our study, >10% of unregistered dogs with no clear history of vaccination are not vaccinated during yearly vaccination programs. In Beijing during 2007–2009, of 9 cases of rabies in humans, 6 were associated with stray dogs (7), and most stray dogs were found in suburban areas. Hence, strategies to either reduce stray dogs in the city or to get such dogs under official management (e.g., include stray dogs in compulsory annual vaccination programs) are urgently needed.

In our opinion, policies related to dog registration, vaccination recording, and vaccination strategies need improvement in Beijing, especially in suburban areas. Although our report only focused on the Fengtai District, the findings could be helpful for the Beijing government for establishing strategies to control the rabies epidemic in the entire city.

Acknowledgments
We thank Youxin Wang for assistance with data analysis.

This work was funded by Key Projects in the National Science and Technology Pillar Program (no. 2009BAI83B02) and the Program of Excellent Talents in Beijing (no. 2009D005018000007).

full-text:
Rabies Immunization Status of Dogs, Beijing, China | CDC EID


Suggested Citation for this Article
Wang C, Wang Y, Du X, Zeng L, Dong G, Wu Y, et al. Rabies immunization status of dogs, Beijing, China. Emerg Infect Dis [serial on the Internet]. 2011 Jun [date cited]. http://www.cdc.gov/EID/content/17/6/1129.htm

DOI: 10.3201/eid1706.101590


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

Zhenwen Chen, School of Basic Medical Science, Capital Medical University, Youanmenwai Xitoutiao No.10, Fengtai, Beijing 100069, People's Republic of China; email: czwen@ccmu.edu.cn

Mimivirus-like Particles in Sewage Sludge | CDC EID

EID Journal Home > Volume 17, Number 6–June 2011

Volume 17, Number 6–June 2011
Letter
Mimivirus-like Particles in Acanthamoebae from Sewage Sludge
William H. Gaze, Gina Morgan, Lihong Zhang, and Elizabeth M.H. Wellington
Author affiliation: University of Warwick, Coventry, UK


Suggested citation for this article

To the Editor: Mimivirus is a giant, double-stranded DNA virus. Its 650-nm diameter and 1.2-Mb genome make it the largest known virus (1). In 2003, mimivirus was isolated from a water cooling tower in Bradford, UK, after a pneumonia outbreak and was reported to infect Acanthamoeba polyphaga amebae (2). Subsequently, a small number of additional isolates have been reported (3).

Mimivirus has been associated with pneumonia, and this association was strengthened after antibodies to mimivirus were found in serum samples from patients with community- and hospital-acquired pneumonia and after mimivirus DNA was found in bronchoalveolar lavage specimens (4). More direct evidence of pathogenicity was illustrated when a pneumonia-like disease developed in a laboratory technician who worked with mimivirus and showed seroconversion to 23 mimivirus-specific proteins (5).

We report finding mimivirus-like particles during our molecular study of Acanthamoeba spp. abundance and diversity in final-stage conventionally treated sewage sludge from a wastewater treatment plant in the West Midlands, UK. Using metagenomic DNA extracted from the sludge (6), we estimated the abundance of Acanthamoeba spp. by using real-time PCR (7) and found it to be ≈1 × 102/g sludge. To assess species diversity, we amplified an Acanthamoeba spp.–specific 18S rRNA target, which resulted in products of ≈450 bp (8). PCR products were cloned and sequenced, revealing low Acanthamoeba spp. diversity with a predominance of clones most similar to A. palestinensis (22/25 clones), which fall within the T6 clade according to the classification of Stothard et al. (9). A small number (3/25) of clones showed closest similarity to acanthamoebae belonging to the T4 clade, which includes strains considered to be human pathogens, including some A. polyphaga strains.

full-text:
Mimivirus-like Particles in Sewage Sludge | CDC EID


Suggested Citation for this Article
Gaze WH, Morgan G, Zhang L, Wellington EMH. Mimivirus-like particles in acanthamoebae from sewage sludge [letter]. Emerg Infect Dis [serial on the Internet]. 2011 Jun [date cited]. http://www.cdc.gov/EID/content/17/6/1127.htm

DOI: 10.3201/eid1706.101282


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

William H. Gaze, University of Warwick–Biological Sciences, Gibbet Hill Campus, Coventry, Warwickshire CV47AL, UK; email: w.h.gaze@warwick.ac.uk

Diagnosis of Invasive Pneumococcal Disease | CDC EID

EID Journal Home > Volume 17, Number 6–June 2011

Volume 17, Number 6–June 2011
Letter
Easy Diagnosis of Invasive Pneumococcal Disease
Laura Selva, Xavier Krauel, Roman Pallares, and Carmen Muñoz-Almagro
Author affiliations: University Hospital Sant Joan de Déu, Barcelona, Spain (L. Selva, X. Krauel, C. Muñoz-Almagro); Saint John of God Hospital, Lunsar, Sierra Leone (X. Krauel); Bellvitge Hospital, Barcelona (R. Pallares); and University of Barcelona, Barcelona (R. Pallares)


Suggested citation for this article

To the Editor: Invasive pneumococcal disease (IPD) causes many cases of severe disease and death among children <5 years of age, mostly in developing countries (1,2). Before conjugate vaccines can be introduced in developing countries, information about disease epidemiology is urgently needed. The lack of laboratories equipped to perform pneumococcal serotyping leads to the need to send isolates to reference laboratories. Good sample preservation is necessary to prevent samples from arriving at the laboratory in poor condition. We evaluated the usefulness of multiplex real-time PCR from strains and blood samples kept at room temperature on dried blood spot (DBS) filter paper for detecting and serotyping Streptococcus pneumoniae. DBS screening is a reliable method that requires only a small amount of blood; it is used for the diagnosis of several human diseases (3,4). To validate the technique, we selected 15 pneumococcus clinical isolates representing 15 serotypes (1, 5, 19A, 19F, 14, 3, 7F, 4, 6A, 6B, 8, 9N, 18C, 23A, 23F) obtained during 2009 from patients at Hospital Sant Joan de Déu, in Barcelona. These isolates, used as controls, had been serotyped by quellung reaction at the Instituto de Salud Carlos III, Majadahonda-Madrid, Spain. These strains were cultured overnight at 35°C in 5% carbon dioxide on Columbia agar plates with 5% sheep blood (bioMérieux SA, Marcy l'Etoile, France). A suspension of each strain was adjusted to match a 0.5 McFarland standard (equivalent to 108 colony-forming units (CFU)/mL). Stock solutions of pneumococcus culture for each previously identified serotype were injected into blood previously extracted from 2 healthy volunteers. Serial dilutions of 100,000 CFU/mL to 1,000 CFU/mL (1,000 to 10 CFU equivalents/PCR) were performed. A total of 100 μL of blood was applied to DBS filter paper, and another 100 μL was used for DNA extraction from fresh blood. All DBS samples were air dried for 1 week. The procedure was also performed on negative control blood samples. DNA was extracted from DBS and fresh blood samples by using the NucliSense easyMAG automated extraction platform (bioMérieux, Boxtel, the Netherlands) according to the manufacturer's instructions. DNA detection of the pneumolysin (ply) gene by real-time PCR was performed according to a published assay (5). In addition, we performed a multiplex real-time PCR for molecular serotype detection of serotypes 1, 3, 5, 4, 6A, 6B, 7FA, 8, 9VANL, 14, 15BC, 18CB, 19A, 19FBC, 23F, 23A and the conserved capsular gene wzg as described by Tarrago et al. (6). DNA extracts were amplified with the Applied Biosystems 7300 Real-time PCR System (Applied Biosystems, Foster City, CA, USA). Negative results were defined as those with cycle threshold >40.

To evaluate the reliability obtained with this in vivo approach, we performed identification and serotyping of S. pneumoniae in 25 DBS samples from 25 children at Saint John of God Hospital in Mabesseneh-Lunsar, Sierra Leone. This hospital does not perform blood cultures. IPD was confirmed when DNA of a pneumolysin (ply) gene and an additional capsular gene of S. pneumoniae were detected by multiplex real-time PCR of DBS samples.

Detection of ply, wzg, and the specific gene for molecular serotype showed that both fresh blood and DBS samples yielded correctly positive results from the 10-fold serial dilutions analyzed (Table). With respect to the 25 (11 female and 14 male) patients from Sierra Leone who had suspected IPD, the median age was 25.71 months (range 15 days to 96 months); all had a diagnosis of fever without apparent source, and 16 also had malaria. Of these 25 children, DBS samples from 15 (60%) yielded a positive result for the ply and wzg genes, so they were considered confirmed episodes of IPD. A serotype included in 13-valent conjugate vaccine was detected in 6 (40%) of 15 positive samples: serotypes 3, 7FA, 19A, 6A, 6B, and 9VNL (1 sample each). In the remaining 9 samples, the results for ply gene and wzg gene were positive, but none of the 24 tested serotypes was detected.

This preliminary study enabled us to demonstrate that DBS screening is a reliable and easy method for diagnosing IPD and also for epidemiologic surveillance of the more frequent serotypes. The main limitation of our study is the small number of DBS samples sent from Saint John of God Hospital in Sierra Leone.

In conclusion, the DBS technique enables reproducible transport of samples for identification and serotyping of S. pneumoniae by multiplex PCR. The use of DBS on filter paper is an attractive alternative method for storing samples at room temperature and easily transporting them. Additional studies, including evaluation of the relative sensitivity of this method compared to direct culture, are necessary.

Acknowledgments
We thank members of the Sponsor the Treatment of a Child in Sierra Leone Foundation for taking care of patients and collecting samples for serotyping.

This study was supported by a grant from the Caja Navarra Foundation.

full-text:
Diagnosis of Invasive Pneumococcal Disease | CDC EID


Suggested Citation for this Article
Selva L, Krauel X, Pallares R, Muñoz-Almagro C. Easy diagnosis of invasive pneumococcal disease [letter]. Emerg Infect Dis [serial on the Internet]. 2011 Jun [date cited]. http://www.cdc.gov/EID/content/17/6/1125.htm

DOI: 10.3201/eid1706.100997


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

Carmen Muñoz-Almagro, Molecular Microbiology Department, University Hospital Sant Joan de Déu, P° Sant Joan de Déu, nº 2, 08950 Esplugues, Barcelona, Spain; email: cma@hsjdbcn.org

V. cholerae in Traveler from Haiti to Canada | CDC EID

EID Journal Home > Volume 17, Number 6–June 2011

Volume 17, Number 6–June 2011
Letter
Vibrio cholerae in Traveler from Haiti to Canada
Matthew W. Gilmour, Valérie Martel-Laferrière, Simon Lévesque, Christiane Gaudreau, Sadjia Bekal, Céline Nadon, and Anne-Marie Bourgault
Author affiliations: Public Health Agency of Canada, Winnipeg, Manitoba, Canada (M.W. Gilmour, C. Nadon); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (V. Martel-Laferrière, C. Gaudreau, A.-M. Bourgault); and Institut National de Santé Publique du Québec, Ste-Anne-de-Bellevue, Quebec (S. Lévesque, S. Bekal, A.-M. Bourgault)


Suggested citation for this article

To the Editor: A nationwide outbreak of cholera caused by Vibrio cholerae O1 serotype Ogawa began in Haiti in October 2010 and has since resulted in >200,000 illnesses and 4,000 deaths (1). Additional cases of cholera attributed to the outbreak strain have subsequently been reported in the neighboring Dominican Republic and in Florida and New Jersey in the United States. In these instances, illness was related to travel to Haiti or consumption of contaminated water on the island of Hispaniola (which is shared by Haiti and Dominican Republic).

In Canada, the province of Québec has a large Haitian immigrant population. In early November 2010, the Québec public health authorities provided clinicians and laboratories with recommendations regarding the diagnosis of V. cholerae infections. We report a case of V. cholerae O1 serotype Ogawa in Canada related to the outbreak in Haiti. It was diagnosed in Montréal, Québec, on January 5, 2011.

A 49-year-old Canadian woman traveled to Haiti with her 5 brothers and sisters during December 22–29, 2010, to attend her mother's funeral. While in Haiti, they stayed with family members. She came to the emergency department of the Centre Hospitalier de l'Université de Montréal on January 1, 2011, with abdominal cramps and diarrhea of moderate intensity that had started on December 29, the day she returned from Haiti. The patient was asthenic, but vital signs and results of a physical examination were normal. A complete blood count, levels of serum electrolytes and serum creatinine, and results of liver function tests were within reference ranges. A fecal sample was submitted and the patient received intravenous fluids and 1 dose (300 mg) of doxycycline. She improved rapidly and was discharged on January 3. The patient returned to the outpatient clinic on January 7, and she had recovered from her illness. Control fecal specimens obtained on January 9 and 10 were negative for V. cholerae. Family members that traveled with her did not get ill, and there were no secondary cases among her family members in Montréal.

The fecal culture of the sample provided on December 29 contained V. cholerae. The isolate was confirmed as toxigenic V. cholerae serogroup O1, serotype Ogawa, biotype El Tor, and matched the Haiti outbreak strain when tested by pulsed-field gel electrophoresis (PFGE). Antimicrobial drug susceptibility testing was performed by continuous gradient dilution (Etest; AB Biodisk, Solna, Sweden), and results were interpreted according to standard criteria (2). The strain was susceptible to azithromycin (0.25 mg/L), ciprofloxacin (0.5 mg/L), and tetracycline (1 mg/L) and resistant to trimethoprim/sulfamethoxazole (>32/608 mg/L).

Cases of diagnosed cholera are rare in Canada (0–3 laboratory-confirmed isolations of serogroup O1 and O139 V. cholerae per year (3). All cases in Canada have been associated with travel to cholera-endemic areas, including Africa and Southeast Asia. Monitoring of cholera in Canada is completed through the National Notifiable Diseases Program and through the public health laboratory network. Biochemical identification, serotyping, and PFGE testing are performed on all suspected V. cholerae isolates. Confirmed isolations of a serogroup O1 or O139 V. cholerae strain that produces cholera toxin are also reported through the International Health Regulations focal point.

Whole genome sequencing has been completed for several isolates to investigate the origin of the Haiti cholera outbreak (4,5). However, PFGE remains one of the primary tools for defining the outbreak strain (4). The highly standardized methods of PulseNet International for generating, analyzing, and comparing PFGE patterns are used worldwide to track the temporal and geographic distribution of V. cholerae (6,7).

FULL-TEXT:
V. cholerae in Traveler from Haiti to Canada | CDC EID



Suggested Citation for this Article
Gilmour MW, Martel-Laferrière V, Lévesque S, Gaudreau C, Bekal S, Nadon C, et al. Vibrio cholerae in traveler from Haiti to Canada [letter]. Emerg Infect Dis [serial on the Internet]. 2011 Jun [date cited]. http://www.cdc.gov/EID/content/17/6/1124.htm

DOI: 10.3201/eid1706.110161


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

Matthew W. Gilmour, National Microbiology Laboratory, Public Health Agency of Canada, 1015 Arlington St, Winnipeg, Manitoba R3E 3R2, Canada; email: matthew.gilmour@phac-aspc.gc.ca

Bedbugs as Vectors for Drug-Resistant Bacteria | CDC EID

EID Journal Home > Volume 17, Number 6–June 2011

Volume 17, Number 6–June 2011
Letter
Bedbugs as Vectors for Drug-Resistant Bacteria
Christopher F. Lowe and Marc G. Romney
Author affiliations: University of Toronto, Toronto, Ontario, Canada (C.F. Lowe); University of British Columbia, Vancouver, British Columbia, Canada (M.G. Romney); and St. Paul's Hospital, Providence Health Care, Vancouver (M.G. Romney)

Suggested citation for this article

To the Editor: Over the past 10 years in North America and western Europe, a resurgence of bedbugs (Cimex lectularius) has occurred (1). Although the basis for this resurgence is unclear, large bedbug infestations have been attributed to increased worldwide travel, altered insecticide management, and increased resistance to pesticides (2). Marginalized populations in large urban centers appear to be disproportionately affected; ≈30% of shelters in Toronto, Ontario, Canada, report bedbugs (1). We report recovery of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecium (VRE) from bedbugs in Vancouver, British Columbia.

Three patients, all residents of Vancouver's Downtown Eastside—an impoverished community in Vancouver with high rates of homelessness, poverty, HIV/AIDS, and injection drug use (3)—were hospitalized and found to be infested with bedbugs. Hypothesizing that these parasites may be vectors for the transmission of antimicrobial drug–resistant pathogens, we collected 5 bedbugs and tested them for drug-resistant organisms. The bedbugs were homogenized and streaked onto standard microbiological media, including 5% sheep blood agar. Bacterial colonies were identified by using conventional and automated microbiological methods, and susceptibility testing was performed in accordance with Clinical Laboratory Standards Institute guidelines (4). For 2 patients, VRE was isolated from 1 bedbug each. These bacterial isolates were also resistant to ampicillin, teicoplanin, and aminoglycosides but susceptible to linezolid, quinupristin/dalfopristin, and tetracycline. For 1 other patient, MRSA was isolated from 3 bedbugs. All MRSA isolates had susceptibility patterns consistent with pulsed-field gel electrophoresis type USA300 (susceptible to vancomycin, clindamycin, trimethoprim/sulfamethoxasole, tetracycline, and rifampin; resistant to erythromycin).

Despite investigations of transmissibility of numerous infectious agents, including transmissible blood-borne pathogens such as HIV and hepatitis B and C viruses, to our knowledge, no conclusive evidence has demonstrated disease transmission by bedbugs (5,6). Clinically, bedbug bites have been associated with cutaneous manifestations, most commonly pruritic wheals with a central hemorrhagic punctum (6). Excoriation at the site of a bite can cause further skin abrasion, thereby providing an entry point for colonizing bacteria, which can potentially result in folliculitic or cellulitic superinfections (5). S. aureus, which is commonly found on the skin and can cause cellulitis, has been reported to colonize the salivary glands of bedbugs for as long as 15 days (7). However, although transient and persistent forms of colonization may play a role in disease transmission, we did not differentiate these forms because the clinical bedbug specimens were processed at the time of receipt in the laboratory.

Similar to other cities worldwide, Vancouver has seen an alarming increase in bedbugs, particularly in the Downtown Eastside, where 31% of residents have reported bedbug infestation (8). Enterococci commensally occupy the gastrointestinal tract. The recovery of VRE from bedbugs could result from the relatively unhygienic living conditions encountered in the Downtown Eastside and the high level of interconnectedness between St. Paul's Hospital (where a large pool of patients with VRE colonization/infection reside) and the surrounding community.

MRSA is also a substantial problem in the Downtown Eastside; it has been cultured from 54.8% of skin and soft tissue infections of patients seen at the emergency department of St. Paul's Hospital (9). More recently, among wound infections in injection drug users in this community, 43% were colonized or infected with MRSA consistent with USA300, the predominant community-associated MRSA strain in Vancouver (10). The phenotype of the MRSA recovered from the bedbugs was consistent with community-associated MRSA and identical to that found on antibiograms from patients with MRSA infection who reside in this community. Given the high prevalence of MRSA (particularly USA300) in hotels and rooming houses in Vancouver's Downtown Eastside, bedbugs may become colonized with community-associated MRSA. Consequently, these insects may act as a hidden environmental reservoir for MRSA and may promote the spread of MRSA in impoverished and overcrowded communities.

Bedbugs carrying MRSA and/or VRE may have the potential to act as vectors for transmission. Further studies are needed to characterize the association between S. aureus and bedbugs. Bedbug carriage of MRSA, and the portal of entry provided through feeding, suggests a plausible potential mechanism for passive transmission of bacteria during a blood meal. Because of the insect's ability to compromise the skin integrity of its host, and the propensity for S. aureus to invade damaged skin, bedbugs may serve to amplify MRSA infections in impoverished urban communities.

full-text:
Bedbugs as Vectors for Drug-Resistant Bacteria | CDC EID


Suggested Citation for this Article
Lowe CF, Romney MG. Bedbugs as vectors for drug-resistant bacteria [letter]. Emerg Infect Dis [serial on the Internet]. 2011 Jun [date cited].
http://www.cdc.gov/EID/content/17/6/1132.htm

DOI: 10.3201/eid1706.101978


Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:

Marc G. Romney, St. Paul's Hospital/Providence Health Care, 1081 Burrard St, Vancouver, BC, Canada V6Z 1Y6; email: mromney@providencehealth.bc.ca