Seroepidemiology and genotyping of hepatitis E virus in Singapore reveal rise in number of cases and similarity of human strains to those detected in pig livers.

Hepatitis E virus (HEV) causes 20 million infections worldwide yearly, of which only about 3.3 million are symptomatic. In developed Asian countries, HEV strains detected in human sera and in food sources were genetically similar, suggesting that indigenous HEV infections may be largely food-borne. To assess the burden of hepatitis E in Singapore, we performed a seroepidemiologic study of the infection. Additionally, we carried out HEV genotyping on archived, residual HEV IgM-positive serum samples collected between 2014 and 2016 (n = 449), and on pig liver samples (n = 36) purchased from wet markets and supermarkets. Our study shows a rise in hepatitis E incidence (IgM) from 1.7 to 4.1 cases per 100,000 resident population from 2012 to 2016 and an increase in hepatitis E IgG positivity rate among residents from 14% in 2007 to 35% in 2016. Other findings also suggest the epidemiology of hepatitis E in Singapore has shifted, from it being mainly a disease imported from the Indian subcontinent, to one that is now increasingly prevalent in our resident population. Genotypes obtained from 143 human samples identified the majority to be genotype 3 (n = 121), 21 to be genotype 1 and one to be genotype 4. Further phylogenetic analyses suggest genotype 3a to be the cause of indigenous infections in residents, which showed genetic similarity to the genotype 3a strains detected in pig livers. This link between the strains in the majority of human samples and those in pig livers consumed by the public suggests a possible food-borne route of HEV infection in Singapore.

Sick pets as potential reservoirs of antibiotic-resistant bacteria in Singapore.

An analysis of 186 diagnostic reports collected from a veterinary clinic in Singapore between 2014 to 2016 showed that sick companion animals can carry bacteria that are of significance to human health. Among the 186 specimens submitted, 82 showed polymicrobial growth (45%, 82/186) and in total, 359 bacteria were isolated. Of the 359 bacteria reported, 45% (162/359) were multi-drug resistant and 18% (66/359) were extended-spectrum-beta-lactamase species. Resistance to broad-spectrum antibiotics were also observed among individual species. Namely, methicillin-resistance among Staphylococcus pseudintermedius (63%, 32/51) and Staphylococcus aureus (50%, 4/8); fluoroquinolone-resistance among Escherichia coli (40%, 17/42) and carbapenem-resistance among Klebsiella pneumoniae (7%, 2/30) were noted. Our analysis suggests that sick pets may contribute to the pool of clinically relevant antibiotic-resistant bacteria and play a role in the spread of antibiotic resistance in Singapore. A more extensive study to better understand the extent of distribution and the factors affecting transmission of antibiotic-resistant bacteria to and from pets is necessary.

Group B Streptococcus Infections Caused by Improper Sourcing and Handling of Fish for Raw Consumption, Singapore, 2015-2016.

We assessed microbial safety and quality of raw fish sold in Singapore during 2015-2016 to complement epidemiologic findings for an outbreak of infection with group B Streptococcus serotype III sequence type (ST) 283 associated with raw fish consumption. Fish-associated group B Streptococcus ST283 strains included strains nearly identical (0-2 single-nucleotide polymorphisms) with the human outbreak strain, as well as strains in another distinct ST283 clade (57-71 single-nucleotide polymorphisms). Our investigations highlight the risk for contamination of freshwater fish (which are handled and distributed separately from saltwater fish sold as sashimi) and the need for improved hygienic handling of all fish for raw consumption. These results have led to updated policy and guidelines regarding the sale of ready-to-eat raw fish dishes in Singapore.

Microbial survey of ready-to-eat salad ingredients sold at retail reveals the occurrence and the persistence of Listeria monocytogenes Sequence Types 2 and 87 in pre-packed smoked salmon.

BACKGROUND: As the preparation of salads involves extensive handling and the use of uncooked ingredients, they are particularly vulnerable to microbial contamination. This study aimed to determine the microbial safety and quality of pre-packed salads and salad bar ingredients sold in Singapore, so as to identify public health risks that could arise from consuming salads and to determine areas for improvement in the management of food safety. RESULTS: The most frequently encountered organism in pre-packed salad samples was B. cereus, particularly in pasta salads (33.3%, 10/30). The most commonly detected organism in salad bar ingredients was L. monocytogenes, in particular seafood ingredients (44.1%, 15/34), largely due to contaminated smoked salmon. Further investigation showed that 21.6% (37/171) of the pre-packed smoked salmon sold in supermarkets contained L. monocytogenes. Significantly higher prevalence of L. monocytogenes and higher Standard Plate Count were detected in smoked salmon at salad bars compared to pre-packed smoked salmon in supermarkets, which suggested multiplication of the organism as the products move down the supply chain. Further molecular analysis revealed that L. monocytogenes Sequence Type (ST) 2 and ST87 were present in a particular brand of pre-packed salmon products over a 4-year period, implying a potential persistent contamination problem at the manufacturing level. CONCLUSIONS: Our findings highlighted a need to improve manufacturing and retail hygiene processes as well as to educate vulnerable populations to avoid consuming food prone to L. monocytogenes contamination.

Diarrheagenic pathogens in adults attending a hospital in Singapore.

BACKGROUND: Singapore's diarrhoeal notification system is based on specific pathogens. Official data may thus be skewed towards notifiable diseases. Limited information is available on the profiles of aetiological agents responsible for acute gastroenteritis (AGE) cases, especially among the adult population. To understand the frequency and distribution of potential causative agents of diarrheal disease in Singapore, we screened adults' stool samples collected from a large public hospital. METHODS: The stool samples were screened for 18 diarrheagenic pathogens using a combination of commercial multiplex polymerase chain reaction (PCR), in-house singleplex PCR and immunochromatographic assays. One hundred adult faecal samples that were collected from October 2013 to January 2014 for routine diagnostic purposes and submitted for culture at Tan Tock Seng Hospital, Singapore were used. RESULTS: Pathogens were detected in 32% of the samples. The predominant organisms encountered were norovirus genogroup II (11%), Aeromonas spp. (9%) and Campylobacter spp. (5%). One sample was positive for both verocytotoxigenic E. coli (VTEC) and E. coli O157:H7. Two other samples were positive for VTEC only, and one other sample was positive for E. coli O157:H7 only. Astrovirus, C. perfringens, Shigella spp. and toxigenic C. difficile were each detected in 2% of the samples. Cryptosporidium parvum, Giardia lamblia, group A rotavirus, Salmonella spp. and Vibrio spp. were each detected in 1% of the samples. No L. monocytogenes, Y. enterocolitica, enteric adenovirus, or norovirus genogroup I were detected. CONCLUSION: Our preliminary findings suggest that pathogens causing non-notifiable diseases might have contributed considerably to the adult hospitalised AGE cases. However, as the samples were from an adult hospital, the data obtained may not be representative of the whole community. Thus, a larger study to collect clinical samples and risk exposure data from primary healthcare clinics and children hospital is planned for, to gain a more holistic perspective on the epidemiology of AGE in Singapore. A larger study may also offer valuable insights for improving the approach of microbiological surveillance of food, as well as strategizing inspection efforts along the food supply chain by public health authorities.

MICROBIOLOGICAL SAFETY ASSESSMENT AND RISK MITIGATION OF INDIAN ROJAK (DEEP FRIED READYTO-EAT FOOD) IN SINGAPORE.

We conducted a microbiological assessment of Indian Rojak, a popular deep fried food in Singapore to evaluate its overall microbial quality, assess the effectiveness of reheating and identify key food items that could contribute to the microbial load of the dish. In 2009, an outbreak of foodborne illness associated with this food led to 154 reported cases of acute gastroenteritis, 48 were hospitalized and 2 died. Vibrio parahaemolyticus was isolated from the patients. We evaluated 455 Indian Rojak ingredients from 35 stalls; no Salmonella spp, Vibrio cholerae/parahaemolyticus or Escherichia coli O157:H7 were recovered from the studied samples. The reheating by the food handlers significantly reduced the overall median Standard Plate Count (SPC) of food from 4.5 to 2.7 log colony forming units (CFU)/g (p<0.05). The cooked ingredients with the highest microbial loads were tofu and fish cake, with those purchased from wet markets having significantly higher bacterial loads than those purchased from supermarkets (p<0.05). The Rojak gravy had the lowest median bacterial load (1.9 log CFU/g). Raw, ready-to-eat vegetables, namely green chillis, cucumbers and onions had higher levels ranging from 5.9 to 6.1 log CFU/g. Contamination with E. coli, Staphylococcus aureus, and Bacillus cereus was seen with some of the ready-to-eat raw vegetables. Repeated education of food handlers with emphasis on good hygiene practices should be conducted to reduce the risk of foodborne illnesses.

Non-uniform depth scanning for proton therapy systems employing active energy variation.

In proton scanning systems that employ active energy variation for depth modulation, a switch of the particle energy might typically require 1-2 s. For plans comprising many energy slices, these seconds could sum up to a non-negligible fraction of the total treatment duration. We have applied the Nyquist-Shannon sampling theorem to determine an efficient spatial arrangement of Bragg peaks in a target volume. This pre-determined schedule of increasing energy spacing with higher energy allows us to reduce the number of used energy slices without compromising the physical dosimetric quality of a plan. Our results suggest that the advantage of such a simple implementation would be especially significant for larger, deep-seated tumors such as the prostate; the number of energy slices was cut by a factor of 2-6.

Demonstration of scan path optimization in proton therapy.

A three-dimensional (3D) intensity modulated proton therapy treatment plan to be delivered by magnetic scanning may comprise thousands of discrete beam positions. This research presents the minimization of the total scan path length by application of a fast simulated annealing (FSA) optimization algorithm. Treatment plans for clinical prostate and head and neck cases were sequenced for continuous raster scanning in two ways, and the resulting scan path lengths were compared: (1) A simple back-and-forth, top-to-bottom (zigzag) succession, and (2) an optimized path produced as a solution of the FSA algorithm. Using a first approximation of the scanning dynamics, the delivery times for the scan sequences before and after path optimization were calculated for comparison. In these clinical examples, the FSA optimization shortened the total scan path length for the 3D target volumes by approximately 13%-56%. The number of extraneous spilled particles was correspondingly reduced by about 13%-54% due to the more efficient scanning maps that eliminated multiple crossings through regions of zero fluence. The relative decrease in delivery time due to path length minimization was estimated to be less than 1%, due to both a high scanning speed and time requirements that could not be altered by optimization (e.g., time required to change the beam energy). In a preliminary consideration of application to rescanning techniques, the decrease in delivery time was estimated to be 4%-20%.

Selective IgA immune unresponsiveness to Proteus mirabilis fumarate reductase A-chain in rheumatoid arthritis.

OBJECTIVE: To determine if selective immune unresponsiveness to microbial antigens is associated with predisposition to rheumatoid arthritis (RA). METHODS: Proteins from Proteus mirabilis lysate were isolated by SDS-PAGE and examined by Western blotting for antibody responses in sera from patients with RA compared to healthy subjects and patients with psoriatic arthritis (PsA). RESULTS: Although RA patients had marked IgA immune responses to many P. mirabilis proteins compared to healthy subjects, selective unresponsiveness was found in RA to a 66 kDa protein identified as fumarate reductase A-chain (FRD-A) by mass spectroscopy. This was confirmed in Western blots with recombinant FRD-A from P. mirabilis. IgA unresponsiveness to FRD-A was found in 21/59 (35.6%) RA patients compared to 7/63 (11.1%) healthy individuals (p < 0.01) and 6/52 (11.5%) patients with PsA (p < 0.01). IgA unresponsiveness to FRD-A was present in 20/46 (43.5%) RA patients with IgA rheumatoid factors (RF) compared to 1/13 (7.7%) without RF (p < 0.025). CONCLUSION: Our results identify a selective hole in the IgA immune repertoire for P. mirabilis FRD-A in a subset of IgA RF-positive patients with RA.