Norovirus outbreak associated with undercooked oysters and secondary household transmission.

During December 2009, over 200 individuals reported gastrointestinal symptoms after dining at a North Carolina restaurant. An outbreak investigation included a case-control study of restaurant patrons, a secondary household transmission study, environmental assessment of the restaurant facilities and operations, and laboratory analysis of stool and food samples. Illness was primarily associated with consumption of steamed oysters (odds ratio 12, 95% confidence interval 4·8-28) and 20% (8/41 households) reported secondary cases, with a secondary attack rate of 14% among the 70 susceptible household contacts. Norovirus RNA was detected in 3/5 stool specimens from ill patrons; sequencing of RT-PCR products from two of these specimens identified identical genogroup II genotype 12 sequences. Final cooked temperatures of the steamed oysters were generally inadequate to inactivate norovirus, ranging from 21°C to 74°C. Undercooked contaminated oysters pose a similar risk for norovirus illness as raw oysters and household contacts are at risk for secondary infection.

Hospital characteristics associated with colonization of water systems by Legionella and risk of nosocomial legionnaires' disease: a cohort study of 15 hospitals.

OBJECTIVE: To investigate an increase in reports of legionnaires' disease by multiple hospitals in San Antonio, Texas, and to study risk factors for nosocomial transmission of legionnaires' disease and determinants for Legionella colonization of hospital hot-water systems. SETTING: The 16 largest hospitals in the cities of San Antonio, Temple, and Austin, Texas. DESIGN: Review of laboratory databases to identify patients with legionnaires' disease in the 3 years prior to the investigation and to determine the number of diagnostic tests for Legionella performed; measurement of hot-water temperature and chlorine concentration and culture of potable water for Legionella. Exact univariate calculations, Poisson regression, and linear regression were used to determine factors associated with water-system colonization and transmission of Legionella. RESULTS: Twelve cases of nosocomial legionnaires' disease were identified; eight of these occurred in 1996. The rise in cases occurred shortly after physicians started requesting Legionella urinary antigen tests. Hospitals that frequently used Legionella urinary antigen tests tended to detect more cases of legionnaires' disease. Legionella was isolated from the water systems of 11 of 12 hospitals in San Antonio; the 12th had just experienced an outbreak of legionnaires' disease and had implemented control measures. Nosocomial legionellosis cases probably occurred in 5 hospitals. The number of nosocomial legionnaires' disease cases in each hospital correlated better with the proportion of water-system sites that tested positive for Legionella (P=.07) than with the concentration of Legionella bacteria in water samples (P=.23). Hospitals in municipalities where the water treatment plant used monochloramine as a residual disinfectant (n=4) and the hospital that had implemented control measures were Legionella-free. The hot-water systems of all other hospitals (n=11) were colonized with Legionella. These were all supplied with municipal drinking water that contained free chlorine as a residual disinfectant. In these contaminated hospitals, the proportion of sites testing positive was inversely correlated with free residual chlorine concentration (P=.01). In all hospitals, hot-water temperatures were too low to inhibit Legionella growth. CONCLUSIONS: The increase in reporting of nosocomial legionnaires' disease was attributable to increased use of urinary antigen tests; prior cases may have gone unrecognized. Risk of legionnaires' disease in hospital patients was better predicted by the proportion of water-system sites testing positive for Legionella than by the measured concentration of Legionella bacteria. Use of monochloramine by municipalities for residual drinking water disinfection may help prevent legionnaires' disease.

Development and application of a quantitative, specific assay for Cryptosporidium parvum oocyst detection in high-turbidity environmental water samples.

Chlorine-resistant Cryptosporidium parvum oocysts in drinking water play an important role in the epidemiology of cryptosporidiosis. Current methods of detecting these organisms in water are insensitive, labor-intensive, highly subjective, and severely limited by sample turbidity. We describe here an alternative technique utilizing electrochemiluminescence (ECL) technology for detecting C. parvum oocysts in environmental water samples. This method is quantitative, reproducible, and requires only minimal sample processing. Currently, the ECL assay can detect as few as one oocyst in one milliliter of concentrated test sample with sample turbidity of up to 10,000 nephelometric turbidity units. Water and sewer samples collected during a cryptosporidiosis outbreak were tested by ECL assay. Cryptosporidium parvum oocysts were found in the source water at the time of outbreak, and a sharply decreasing level of oocysts in sewer samples was observed over a three-month period following the outbreak.

Multistate outbreak of Listeria monocytogenes associated with Mexican-style cheese made from pasteurized milk among pregnant, Hispanic women.

Listeriosis is a severe infection caused by Listeria monocytogenes. Since 2004, the Centers for Disease Control and Prevention has requested that listeriosis patients be interviewed using a standardized Listeria Initiative (LI) questionnaire. In January 2009, states and the Centers for Disease Control and Prevention began investigating a multistate outbreak of listeriosis among pregnant, Hispanic women. We defined a case as an illness occurring between October 2008 and March 2009 with an L. monocytogenes isolate indistinguishable from the outbreak strain by pulsed-field gel electrophoresis. We conducted a multistate case-control study using controls that were selected from L. monocytogenes illnesses in non-outbreak-related pregnant, Hispanic women that were reported to the LI during 2004 to 2008. Eight cases in five states were identified. Seven of these were pregnant, Hispanic females aged 21 to 43 years, and one was a 3-year-old Hispanic girl, who was excluded from the study. Seven (100%) cases but only 26 (60%) of 43 controls had consumed Mexican-style cheese in the month before illness (odds ratio, 5.89; 95% confidence interval, 1.07 to ∞; P = 0.04). Cultures of asadero cheese made from pasteurized milk collected at a manufacturing facility during routine sampling by the Michigan Department of Agriculture on 23 February 2009 yielded the outbreak strain, leading to a recall of cheeses produced in the plant. Recalled product was traced to stores where at least three of the women had purchased cheese. This investigation highlights the usefulness of routine product sampling for identifying contaminated foods, of pulsed-field gel electrophoresis analysis to detect multistate outbreaks, and of the LI for providing timely exposure information for case-control analyses. Recalls of contaminated cheeses likely prevented additional illnesses.

Epidemiology of drug-resistant tuberculosis in Texas.

During 1987-1996, over 22,000 tuberculosis cases were reported in Texas, at an average annual incidence rate of 12.5 cases per 100,000 population. Counties with the highest rates were located along the Mexico-Texas border and in northwestern Texas. Nine percent of cases were resistant to at least one of the five first-line antituberculosis drugs used for treatment. Almost 5 percent (4.6%) were resistant to isoniazid, either alone or in combination with other antibiotics; 2.3% were resistant to rifampin; and only 1.3% were resistant to both isoniazid and rifampin. Being a recurrent case, being foreign-born, being 20-39 years of age, and residing in a Mexico-Texas border county were independent risk factors for isoniazid resistance and rifampin resistance. Tuberculosis patients with human immunodeficiency virus (HIV) infection were more likely to have rifampin resistance and less likely to have isoniazid resistance than patients without HIV infection. Factors associated with multi-drug-resistant tuberculosis included a history of previous tuberculosis (relative risk (RR) = 4.91, 95% confidence interval (CI) 3.5-6.8), non-US birth (RR = 2.69, 95% CI 2.1-3.5), age younger than 20 years (RR = 1.97, 95% CI 1.1-3.5), age 20-39 years (RR = 1.82, 95% CI 1.3-2.6), and residence in a Mexico-Texas border county (RR = 2.33, 95% CI 1.8-3.1).

A study of tuberculosis among foreign-born Hispanic persons in the U.S. States bordering Mexico.

In 1996, 10% of the 20,973 U.S. tuberculosis (TB) cases were among foreign-born (FB) Hispanic persons, with the four states bordering Mexico accounting for 83% of FBH cases. Limited information is available on this population's health care seeking and migration practices and on differences between FB Hispanic patients in border and nonborder areas. Therefore, we conducted interviews and record reviews for all consenting FB Hispanic TB patients from eight counties bordering Mexico (BC; n = 167) and seven urban nonborder counties (NBC; n = 158) in these States during 1995-1997. BC patients had resided in the U.S. longer than NBC patients (17.4 versus 10.8 yr; p < 0.01), had immigrated more often from Mexican border communities (62.4% versus 25.4%; p < 0.01), and had returned to Mexico more often in the past 12 mo (71.5% versus 47.3%; p < 0. 01). TB symptoms were present for >/= 6 mo in 37% of BC and 34% of NBC patients. Binational collaboration is essential for improving TB control in both countries and should extend beyond border areas of Mexico.

Tuberculosis outbreak in a Texas prison, 1994.

In 1994 a Texas prison containing a population of mentally retarded inmates experienced a large tuberculosis outbreak. Fifteen cases of tuberculosis were identified (8 confirmed by positive cultures for Mycobacterium tuberculosis) and more than 100 inmates became infected. The culture-confirmed patients were infected with an identical strain of tuberculosis as demonstrated by polymerase chain reaction (PCR) based DNA fingerprinting technique. The prison followed standard tuberculosis infection control policies, but these controls were inadequate to prevent tuberculosis transmission in this special population. Two hundred and thirty inmates (119 inmates showing evidence of new tuberculosis infection or active disease and 111 healthy controls) were enrolled in the investigation. Inmate cell assignments, job duties, and educational classes were identified and medical chart reviews were conducted on all inmates. Tuberculosis transmission was associated with residing on the D Wing of the prison (OR = 25.84, P < 0.01), attending school in Classroom A (OR = 8.34, P = 0.01) and working on the prison utility work crew (OR = 2.52, P < 0.01). The index case in the outbreak had been prescribed 6 months of isoniazid (INH) chemoprophylaxis in 1988.

Development of methods to detect "Norwalk-like viruses" (NLVs) and hepatitis A virus in delicatessen foods: application to a food-borne NLV outbreak.

"Norwalk-like viruses" (NLVs) and hepatitis A virus (HAV) are the most common causes of virus-mediated food-borne illness. Epidemiological investigations of outbreaks associated with these viruses have been hindered by the lack of available methods for the detection of NLVs and HAV in foodstuffs. Although reverse transcription (RT)-PCR methods have been useful in detecting NLVs and HAV in bivalve mollusks implicated in outbreaks, to date such methods have not been available for other foods. To address this need, we developed a method to detect NLVs and HAV recovered from food samples. The method involves washing of food samples with a guanidinium-phenol-based reagent, extraction with chloroform, and precipitation in isopropanol. Recovered viral RNA is amplified with HAV- or NLV-specific primers in RT-PCRs, using a viral RNA internal standard control to identify potential sample inhibition. By this method, 10 to 100 PCR units (estimated to be equivalent to 10(2) to 10(3) viral genome copies) of HAV and Norwalk virus seeded onto ham, turkey, and roast beef were detected. The method was applied to food samples implicated in an NLV-associated outbreak at a university cafeteria. Sliced deli ham was positive for a genogroup II NLV as determined by using both polymerase- and capsid-specific primers and probes. Sequence analysis of the PCR-amplified capsid region of the genome indicated that the sequence was identical to the sequence from virus detected in the stools of ill students. The developed method is rapid, simple, and efficient.

Rapid molecular genetic subtyping of serotype M1 group A Streptococcus strains.

Serotype M1 group A Streptococcus, the most common cause of invasive disease in many case series, generally have resisted extensive molecular subtyping by standard techniques (e.g., multilocus enzyme electrophoresis, pulsed-field gel electrophoresis). We used automated sequencing of the sic gene encoding streptococcal inhibitor of complement and of a region of the chromosome with direct repeat sequences to unambiguously differentiate 30 M1 isolates recovered from 28 patients in Texas with invasive disease episodes temporally clustered and thought to represent an outbreak. Sequencing of the emm gene was less useful for M1 strain differentiation, and restriction fragment length polymorphism analysis with IS1548 or IS1562 as Southern hybridization probes did not provide epidemiologically useful subtyping information. Sequence polymorphism in the direct repeat region of the chromosome and IS1548 profiling data support the hypothesis that M1 organisms have two main evolutionary lineages marked by the presence or absence of the speA2 allele encoding streptococcal pyrogenic exotoxin A2.

A foodborne outbreak of gastroenteritis associated with Norwalk-like viruses: first molecular traceback to deli sandwiches contaminated during preparation.

In March 1998, an outbreak of acute gastroenteritis occurred among students at a Texas university. Overall, 125 ill students sought medical care. Case-control studies revealed that illness was significantly associated with eating foods from the university's main cafeteria deli bar on 9 and 10 March. Stool specimens from 9 (50%) of 18 ill students and samples of deli ham showed evidence of Norwalk-like viruses (NLVs) by reverse-transcriptase (RT) polymerase chain reaction (PCR) assay. A food handler who prepared sandwiches for lunch on 9 March reported that her infant had been sick with watery diarrhea since just before the outbreak. A stool sample from the infant was positive for NLV by RT-PCR, and the sequence of the amplified product was identical to that of amplified product from deli ham and students' stool specimens. This is the first time RT-PCR and sequence analysis have successfully confirmed viral contamination of a food item likely to have been contaminated by a food handler.

Evidence from molecular fingerprinting of limited spread of drug-resistant tuberculosis in Texas.

To determine the contribution of recent transmission to spread of drug-resistant tuberculosis in Texas, we performed IS6110-based and pTBN12-based restriction fragment length polymorphism (RFLP) analyses on Mycobacterium tuberculosis isolates. Isolates collected from 201 patients in Texas between 1992 and 1994 were studied. The distribution of cases was strikingly focal. All cases were reported from 35 of the 254 counties in Texas, and 74% (148 of 201) were reported from only 9 counties. One hundred sixty-one (80%) of the patients had M. tuberculosis isolates with unique RFLP patterns, and 41 (20%) patients were in 20 clusters, each comprising 2 to 3 patients. The largest number of cases of drug-resistant tuberculosis were reported in counties bordering Mexico, but the percentage of clustered cases was highest in northeast Texas and in counties that included the cities of Dallas, Fort Worth, and Houston. Compared to nonclustered patients, clustered patients were more likely to be African American and to have been born in the United States. Clustered patients were significantly more likely to be from the same geographic area, and clustered patients from the same geographic area were more likely to have isolates with identical drug susceptibility patterns, suggesting that they were linked by recent transmission. In 11 of 20 clusters, clustered patients were from geographically separate regions, and most isolates did not have identical drug susceptibility patterns, suggesting that tuberculosis was contracted from a common source in the remote past. Based on the low percentage of clustered cases and the small cluster size, we conclude that there is no evidence for the extensive transmission of drug-resistant tuberculosis in Texas.