Magnitude, distribution, risk factors and care-seeking behaviour of acute, self-reported gastrointestinal illness among US Army Soldiers: 2015.

Throughout history, acute gastrointestinal illness (AGI) has been a significant cause of morbidity and mortality among US service members. We estimated the magnitude, distribution, risk factors and care seeking behaviour of AGI among the active duty US Army service members using a web-based survey. The survey asked about sociodemographic characteristics, dining and food procurement history and any experience of diarrhoea in the past 30 days. If respondents reported diarrhoea, additional questions about concurrent symptoms, duration of illness, medical care seeking and stool sample submission were asked. Univariable and multivariable logistic regression were used to identify the factors associated with AGI and factors associated with seeking care and submitting a stool sample. The 30-day prevalence of AGI was 18.5% (95% CI 16.66-20.25), the incidence rate was 2.24 AGI episodes per person-year (95% CI 2.04-2.49). Risk factors included a region of residence, eating at the dining facility and eating at other on-post establishments. Individuals with AGI missed 2.7-3.7 days of work, which costs approximately $ 847 451 629 in paid wages. Results indicate there are more than 1 million cases of AGI per year among US Army Soldiers, which can have a major impact on readiness. We found that care-seeking behaviours for AGI are different among US Army Service Members than the general population. Army Service Members with AGI report seeking care and having a stool sample submitted less often, especially for severe (bloody) diarrhoea. Factors associated with seeking care included rank, experiencing respiratory symptoms (sore throat, cough), experiencing vomiting and missing work for their illness. Factors associated with submitting a stool sample including experiencing more than five loose stools in 24 h and not experiencing respiratory symptoms. US Army laboratory-based surveillance under-estimates service members with both bloody and non-bloody diarrhoea. To our knowledge, this is the first study to estimate the magnitude, distribution, risk factors and care-seeking behaviour of AGI among Army members. We determined Army service members care-seeking behaviours, AGI risk factors and stool sample submission rates are different than the general population, so when estimating burden of AGI caused by specific foodborne pathogens using methods like Scallan et al. (2011), unique multipliers must be used for this subset of the population. The study legitimises not only the importance of AGI in the active duty Army population but also highlights opportunities for public health leaders to engage in simple strategies to better capture AGI impact so more modern intervention strategies can be implemented to reduce burden and indirectly improve operational readiness across the Enterprise.

Estimate of the annual burden of foodborne illness in nondeployed active duty US Army Service Members: five major pathogens, 2010-2015.

In this study, we estimate the burden of foodborne illness (FBI) caused by five major pathogens among nondeployed US Army service members. The US Army is a unique population that is globally distributed, has its own food procurement system and a food protection system dedicated to the prevention of both unintentional and intentional contamination of food. To our knowledge, the burden of FBI caused by specific pathogens among the US Army population has not been determined. We used data from a 2015 US Army population survey, a 2015 US Army laboratory survey and data from FoodNet to create inputs for two model structures. Model type 1 scaled up case counts of Campylobacter jejuni, Shigella spp., Salmonella enterica non-typhoidal and STEC non-O157 ascertained from the Disease Reporting System internet database from 2010 to 2015. Model type 2 scaled down cases of self-reported acute gastrointestinal illness (AGI) to estimate the annual burden of Norovirus illness. We estimate that these five pathogens caused 45 600 (5%-95% range, 30 300-64 000) annual illnesses among nondeployed active duty US Army Service members. Of these pathogens, Norovirus, Campylobacter jejuni and Salmonella enterica non-typhoidal were responsible for the most illness. There is a tremendous burden of AGI and FBI caused by five major pathogens among US Army Soldiers, which can have a tremendous impact on readiness of the force. The US Army has a robust food protection program in place, but without a specific active FBI surveillance system across the Department of Defence, we will never have the ability to measure the effectiveness of modern, targeted, interventions aimed at the reduction of specific foodborne pathogens.

'One Health' investigation: outbreak of human Salmonella Braenderup infections traced to a mail-order hatchery - United States, 2012-2013.

Human salmonellosis linked to contact with live poultry is an increasing public health concern. In 2012, eight unrelated outbreaks of human salmonellosis linked to live poultry contact resulted in 517 illnesses. In July 2012, PulseNet, a national molecular surveillance network, reported a multistate cluster of a rare strain of Salmonella Braenderup infections which we investigated. We defined a case as infection with the outbreak strain, determined by pulsed-field gel electrophoresis, with illness onset from 25 July 2012-27 February 2013. Ill persons and mail-order hatchery (MOH) owners were interviewed using standardized questionnaires. Traceback and environmental investigations were conducted. We identified 48 cases in 24 states. Twenty-six (81%) of 32 ill persons reported live poultry contact in the week before illness; case-patients named 12 different MOHs from eight states. The investigation identified hatchery D as the ultimate poultry source. Sampling at hatchery D yielded the outbreak strain. Hatchery D improved sanitation procedures and pest control; subsequent sampling failed to yield Salmonella. This outbreak highlights the interconnectedness of humans, animals, and the environment and the importance of industry knowledge and involvement in solving complex outbreaks. Preventing these infections requires a 'One Health' approach that leverages expertise in human, animal, and environmental health.

Risk factors associated with clinical signs of vesicular stomatitis and seroconversion without clinical disease in Colorado horses during the 2014 outbreak.

Vesicular stomatitis (VS) is caused by a contagious rhabdovirus that affects horses, cattle, and swine. Clinical signs of vesicular stomatitis virus (VSV) infection in pigs and cattle are indistinguishable from foot-and-mouth disease (FMD), a foreign animal disease and reportable disease in the United States (Rodriguez et al., 2000). A VS epidemic occurred in the Rocky Mountain region in 2014-15. A study was conducted in Colorado to evaluate horse- and management-level factors associated with VS. For a horse to be considered a clinical VS horse, there were two requirements. First, clinical VS horses had to have clinical signs consistent with VS, including one or more of the following: vesicles, ulcers, erosions or crusting on the muzzle, nares, lips, oral or nasal mucosa, ears, ventrum, udder or penile sheath, or coronary band lesions. Second, clinical VS horses had to have laboratory confirmation of VSV exposure via virus isolation from lesions or a positive complement fixation test performed on sera. All non-clinical horses residing on VSV-affected premises enrolled in the study were evaluated for exposure (i.e., seroconversion) to VSV. Overall, management and housing data were collected from 334 horses on 48 premises in Colorado. Approximately one-third (31.4%) of enrolled horses were clinical cases and two-thirds (68.6%) were controls. Three premises-matched logistic regression models were constructed in SAS using backward elimination (P-value < 0.05) after univariate screening of a priori-selected variables (P-value < 0.20). Model outcomes included differences in characteristics and management of 1) clinical and nonclinical horses, 2) exposed and unexposed horses, and 3) exposed nonclinical and unexposed nonclinical horses. Overall, factors most strongly associated with risk of being a VS clinical horse were access to pasture (P-value = 0.002), and pregnancy status (P-value = 0.001). Factors most strongly associated with VSV exposure among horses were access to pasture (P-value = 0.003) and lack of any insect control (P-value = 0.001). The only factor associated with VSV-exposed nonclinical horses compared with unexposed VSV horses was contact with clinical horses (P-value = 0.013). There were no associations identified regarding clinical horses compared with exposed nonclinical horses. With regard to severity of lesions (severe vs. moderate or mild), no variables met the criteria for inclusion in the multivariable model. Results of this study provide evidence that pasture access and fly control are important factors associated with VSV exposure.

Locally delivered lovastatin nanoparticles enhance fracture healing in rats.

Statins stimulate bone formation in vitro and in vivo and, when given in large doses or by prolonged infusions, stimulate biomechanical strength of murine long bones with healing fractures. However, administration of statins by large oral doses or prolonged infusions to a fracture site is not a feasible therapeutic approach to hasten healing of human fractures. We administered lovastatin in biodegradable polymer nanobeads of poly(lactic-co-glycolide acid) to determine if lovastatin delivered in low doses in nanoparticles of a therapeutically acceptable scaffold could increase rates of healing in a standard preclinical model of femoral fracture. We found that these nanobeads: (1) stimulated bone formation in vitro at 5 ng/mL, (2) increased rates of healing in femoral fractures when administered as a single injection into the fracture site, and (3) decreased cortical fracture gap at 4 weeks as assessed by microcomputed tomography. These preclinical results suggest that lovastatin administered in a nanobead preparation may be therapeutically useful in hastening repair of human fractures.

Evaluation of environmental sampling and culture to determine Mycobacterium avium subspecies paratuberculosis distribution and herd infection status on US dairy operations.

The objectives of this study were to determine the distribution of Mycobacterium avium subspecies paratuberculosis (MAP) in the environment and assess the relationship between the culture status of MAP in the farm environment and herd infection status. The National Animal Health Monitoring System's Dairy 2002 study surveyed dairy operations in 21 states. One component of the study involved collection and culturing of environmental samples for MAP from areas on farms where manure accumulated from a majority of a herd's cows. Operations were selected for inclusion based on perceived risk factors for MAP infection identified in a previously administered questionnaire. Individual animal and environmental samples were collected and used to determine the efficiency of environmental sampling for determination of herd infection status. Individual animal fecal, serum, and milk samples were used to classify herds as infected or not infected based on the presence of at least one test-positive animal in the herd. A total of 483 environmental samples (approximately 5 per farm) were collected, and 218 (45.1%) were culture-positive for MAP. A similar percentage of environmental cultures collected from all designated areas were positive [parlor exits (52.3%), floors of holding pens (49.1%), common alleyways (48.8%), lagoons (47.4%), manure spreaders (42.3%), and manure pits (41.5%)]. Of the 98 operations tested with the environmental sample culture, 97 had individual serum ELISA results, 60 had individual fecal culture results, and 34 had individual milk ELISA results. Sixty-nine of the 98 operations (70.4%) had at least one environmental sample that was culture-positive. Of the 50 herds classified as infected by fecal culture, 38 (76.0%) were identified by environmental culture. Two of the 10 operations classified as not infected based on individual animal fecal culture were environmental culture-positive. Of the 80 operations classified as infected based on serum ELISA-positive results, 61 (76.3%) were identified as environmental-positive, whereas 20 of the 28 (71.4%) operations identified as infected based on milk ELISA were detected by environmental sampling. Environmental sample culturing is less costly than individual animal sampling, does not require animal restraint, and identified more than 70% of infected operations. Environmental sampling is another diagnostic tool that veterinarians and dairy producers can use to determine herd infection status for MAP.

Salmonella in dairy operations in the United States: prevalence and antimicrobial drug susceptibility.

Salmonella serotypes are important foodborne pathogens of humans that can be acquired through consumption of contaminated meat and dairy products. Salmonella infection also can be a significant animal health issue. As part of a national study of U.S. dairy operations conducted between March and September 2002, fecal samples were collected from representative cows in 97 dairy herds in 21 states and were cultured to determine the prevalence of Salmonella shedding. Salmonella was recovered from the feces of at least one cow in 30.9% of the herds. Overall, 7.3% of fecal samples were culture positive for Salmonella. The three most frequently recovered serotypes were Salmonella Meleagridis (24.1%), Salmonella Montevideo (11.9%), and Salmonella Typhimurium (9.9%). The susceptibilities of Salmonella isolates recovered were determined using a panel of 16 antimicrobial drugs. Salmonella isolates recovered from dairy cows had relatively little resistance to these antimicrobial agents; 83.0% of the isolates were susceptible to all antimicrobials tested. This study provides updated information on the prevalence and susceptibility patterns of Salmonella in dairy herds and on cow and herd characteristics. These data contribute to our understanding of the ecology of Salmonella in the dairy farm environment.

Prevalence of Salmonella enterica in bulk tank milk from US dairies as determined by polymerase chain reaction.

Samples of bulk tank milk from dairies across the United States, taken as part of the National Animal Health Monitoring System Dairy 2002 survey, were analyzed for the presence of Salmonella enterica using a commercially available real-time polymerase chain reaction (PCR) kit. Samples from 854 farms in 21 states were collected and enriched in tetrathionate broth to amplify any salmonellae present, and DNA was isolated from the resulting biomass. One hundred one samples (11.8%) were shown to contain Salmonella enterica using the real-time PCR assay, whereas conventional culture techniques detected the pathogen in only 22 (2.6%) of the samples. A conventional PCR assay targeting a different gene from Salmonella enterica confirmed the presence of the organism in 94 of the real-time PCR-positive samples. Thus, assay of milk samples by real-time PCR indicates that the prevalence of Salmonella enterica in US bulk tank milk is substantially higher than previously reported.

Review of the 2012 Epizootic Hemorrhagic Disease Outbreak in Domestic Ruminants in the United States.

An unusually large number of cases of Epizootic hemorrhagic disease (EHD) were observed in United States cattle and white-tailed deer in the summer and fall of 2012. USDA APHIS Veterinary Services area offices were asked to report on foreign animal disease investigations and state diagnostic laboratory submissions which resulted in a diagnosis of EHD based on positive PCR results. EHD was reported in the following species: cattle (129 herds), captive white-tailed deer (65 herds), bison (8 herds), yak (6 herds), elk (1 herd), and sheep (1 flock). A majority of the cases in cattle and bison were found in Nebraska, South Dakota, and Iowa. The majority of cases in captive white-tailed deer were found in Ohio, Iowa, Michigan, and Missouri. The most common clinical sign observed in the cattle and bison herds was oral lesions. The major observation in captive white-tailed deer herds was death. Average within-herd morbidity was 7% in cattle and bison herds, and 46% in captive white-tailed deer herds. The average within-herd mortality in captive white-tailed deer herds was 42%.

Clothing and exercise. II. Influence of clothing during exercise/work in environmental extremes.

Thermoregulatory studies often investigate thermal responses without considering the influences of clothing. These studies have expanded our understanding of basic human responses to various environmental conditions. However, human thermoregulation is variable and modified by heat transfer interactions between skin surface area, clothing and environment. Much of the original work on the influence of clothing on work performance was the result of ergonomic concerns. Currently, the importance of clothing and the influence of new clothing technology aimed at minimising thermal stress has spawned a new interest. For hot climates, new fabrics have been developed with improved wicking properties to keep the wearer cooler and drier, and to enhance heat transfer from the body while providing greater comfort. In contrast, the challenge of cold environments requires a different approach to clothing, which tries to minimise the free movement of air and water along the skin surface of the body. The materials used should also be able to absorb radiant heat from the environment and be nonconductive. In a cold climate, the wearer needs to balance the need for a clothing barrier for warmth with the potential for accumulating too much heat as the result of metabolic heat production from exercise. To counteract this potential problem, it is suggested that cold-weather clothing be worn in layers that can be removed during exercise and replaced during less active periods. Protective clothing for firefighters, hazardous waste workers and astronauts, and athletic protective gear, have specialised design requirements which may be influenced by considerations, for example, of environmental conditions, garment weight, the need for durability, impact forces.

Patterns of Cryptosporidium oocyst shedding in calves and a comparison of two diagnostic methods.

Cryptosporidium spp. oocyst shedding was observed in calves from approximately 1 to 30 days of age. Oocysts were detected by either the Kinyoun acid-fast staining technique (microscopic examination--ME) or a commercially produced enzyme immunoassay EIA). Test concordance between the two detection methods was determined. The mean (+/- SD) number of days to detection of cryptosporidial oocysts was 9.52 +/- 1.92 for the ME and 9.83 +/- 3.19 for the EIA. No significant difference between the means was found (P = 0.17). The period prevalence of cryptosporidiosis was 100% in calves from 1 to 30 days of age. The overall agreement between the ME and EIA was 72%, with a kappa value of 0.42 (SE +/- 0.05). McNemar's test indicated that the proportion of tests determined positive by the two methods was not equal (P < 0.01). The findings or this study indicate moderate agreement between the two diagnostic methods, with the EIA being the more sensitive of the two. However, in most cases the herd-level determination of cryptosporidiosis requires minimal sample sizes and is more economically and easily accomplished by the ME method of detection.

Climatic factors and the occurrence of vesicular stomatitis in New Mexico, United States of America.

Vesicular stomatitis (VS) outbreaks occurred in the southwestern United States of America in 1995, 1997 and 1998. The epidemiology of VS is not understood completely and some of the epidemiologic aspects of this disease are currently under investigation. In this study, daily maximum temperature, daily minimum temperature, daily mean temperature, daily mean relative humidity and daily total precipitation were collected at the Sevilleta Long Term Ecological Research site in central New Mexico. Discriminant analysis was used to identify the climatic variables best able to classify in which months VS would occur. The study found that the amounts of precipitation occurring two, ten, eleven and twelve months prior to the month in which cases were diagnosed, were the climatic variables that best described the occurrence of VS cases. The association of VS cases and precipitation suggests that, like numerous other arthropod-borne diseases, transmission of the disease-causing pathogen is linked to variations in climate.

Management factors affecting the risk for vesicular stomatitis in livestock operations in the western United States.

OBJECTIVE: To identify management factors affecting the risk of animals developing vesicular stomatitis (VS). DESIGN: Case-control study. ANIMALS: Horses, cattle, and sheep with suspected vesicular stomatitis on 395 premises in Colorado, New Mexico, Utah, and Arizona. PROCEDURE: Data were collected during the VS outbreak of 1997. Diagnosticians interviewed livestock owners and completed a supplemental questionnaire. Cases were defined as those premises that had a completed questionnaire and had > or = 1 animal positive for VS. Control premises were all premises investigated that had a completed questionnaire and on which the animals had been tested but VS was not detected. RESULTS: Animals that had access to a shelter or barn had a reduced risk of developing VS (OR, 0.6; 95% confidence interval [CI], 0.35 to 0.99). This effect was more pronounced for equine premises (OR, 0.5; 95% CI, 0.3 to 0.9). Conversely, during an adjusted analysis on equine premises, risk of developing disease was increased slightly where animals had access to pasture (OR, 2.01; 95% CI, 1.1 to 3.7). On all premises where owners reported insect populations were greater than normal, odds of developing disease were significantly increased (OR, 2.5; 95% CI, 1.47 to 4.47). Premises with animals housed < 0.25 miles from running water were more than twice as likely to have clinical signs of VS (OR, 2.6; 95% CI, 1.32 to 5.0). CONCLUSIONS AND CLINICAL RELEVANCE: These results support reports of others that suggest biting insects are a vector in VS virus transmission. Management practices to reduce exposure to biting insects might reduce the risk of VS.

Public veterinary medicine: public health. Serologic evaluation of vesicular stomatitis virus exposure in horses and cattle in 1996.

OBJECTIVE: To determine potential risk factors for vesicular stomatitis (VS) in Colorado livestock in 1995 and evaluate VS virus (VSV) exposure of Colorado livestock in 1996. DESIGN: Retrospective case-control study of VS risk factors and seroprevalence evaluation. SAMPLE POPULATION: Premises included 52 that had VS-positive animals and 33 that did not have VS-positive animals during the 1995 epidemic, and 8 in the vicinity of premises that had VS-positive animals during the 1995 epidemic. PROCEDURE: Layout and management data for premises were collected during site visits in 1996. Signalment and management data were collected for animals from which samples were obtained, and samples were tested by serologic examination and virus isolation. The VSV seroprevalence rate was estimated for Colorado, using serum obtained for equine infectious anemia testing and from the Market Cattle Identification program in Colorado. RESULTS: At least 1 animal was seropositive for VSV on 35 of 52 (67%) premises, and 71 of 228 (31%) animals tested were seropositive for VSV. Seroprevalence was 63 of 170 (37%) for horses and 8 of 54 (15%) for cattle. Seroprevalence of VSV in animals from non-study premises in Colorado in 1996 was estimated to be 1.1% in cattle and 0.8% in horses. CLINICAL IMPLICATIONS: Overall VSV seroprevalence in Colorado livestock was less than seroprevalence in epidemic areas, and seroprevalence rates in epidemic areas were greater for horses than cattle. Results may indicate that some animals had subclinical VSV infection during epidemics and that animals may be exposed to VSV between epidemics.

Financial impact of the 1995 outbreak of vesicular stomatitis on 16 beef ranches in Colorado.

OBJECTIVE: To determine financial impact of an outbreak of vesicular stomatitis in the San Luis Valley of southern Colorado. DESIGN: Survey and financial analysis. SAMPLE POPULATION: 16 ranchers whose beef herds were affected by the 1995 outbreak. PROCEDURE: Information concerning financial effects during the outbreak year was collected by personal interview of each rancher and examination of financial records. RESULTS: Affected herds ranged from 79 to 956 cows (mean, 345). Cow case-fatality rates ranged from 0 to 80%, with calf case-fatality rates ranging from 0 to 28% and overall case-fatality rates of 0 to 15%. Median financial loss was $7,818/ranch and mean financial loss was $15,565/ranch, excluding total financial losses associated with sale of calves. Primary financial losses for these beef herds were attributed to increased culling rates, death of pregnant cows, loss of income from calves, and costs for additional labor during the outbreak. Some costs were attributable to a decrease in market price for beef and a drought during the year after the outbreak. CLINICAL IMPLICATIONS: Financial losses for an outbreak of vesicular stomatitis can be attributed to effects of the disease and costs associated with imposed quarantines.

Oral vesicular lesions in horses without evidence of vesicular stomatitis virus infection.

OBJECTIVE: To report clinical and serologic findings in horses with oral vesicular lesions that were consistent with vesicular stomatitis (VS) but apparently were not associated with VS virus (VSV) infection. DESIGN: Serial case study. ANIMALS: 8 horses. PROCEDURE: Horses were quarantined after appearance of oral lesions typical of VS. Severity of clinical signs was scored every 2 to 5 days for 3 months. Serum samples were tested for antibodies by use of competitive ELISA (cELISA), capture ELISA for IgM, serum neutralization, and complement fixation (CF). Virus isolation was attempted from swab specimens of active lesions. RESULTS: 2 horses with oral vesicular lesions on day 1 had antibodies (cELISA and CF) against VSV; however, results of CF were negative by day 19. Five of the 6 remaining horses were seronegative but developed oral lesions by day 23. Virus isolation was unsuccessful for all horses. CONCLUSIONS AND CLINICAL RELEVANCE: Horses were quarantined for 75 days in compliance with state and federal regulations. However, evidence suggests that oral lesions were apparently not associated with VSV infection. The occurrence in livestock of a vesicular disease that is not caused by VSV could confound efforts to improve control of VS in the United States and could impact foreign trade. Vesicular stomatitis is of substantial economic and regulatory concern.

Out-of-hospital use of a pulse oximeter to determine systolic blood pressures.

STUDY OBJECTIVE: Blood pressure (BP) in the out-of-hospital setting is one of the most important diagnostic tools used by emergency medical services (EMS) providers. Conventional methods of palpation and auscultation can be time consuming, and the measurements often are inaccurate because of the adverse working conditions encountered. Pulse oximetry waveform systolic blood pressure (POWSBP) measurement has been used successfully in emergency departments to monitor BP. The objective of this study was to compare the accuracy of field POWSBP measurements obtained by noninvasive electronic BP measurement (NIBPM), auscultation, and palpation in the out-of-hospital environment. DESIGN: Blood pressure measurements used for this study were obtained by POWSBP, NIBPM (PROPAQ model 102; Protocol Systems, Beaverton, Oregon USA), auscultation, and palpation on patients in moving ambulances. Measurement of POWSBP was accomplished by observing the return of the waveform on the pulse oximeter at the time of cuff deflation. The order in which the readings were obtained as well as the arm chosen for measurement were randomized. SETTING AND PARTICIPANTS: Paramedics and emergency medical technicians in an urban, inner-city emergency medical services (EMS) system. MEASUREMENTS AND MAIN RESULTS: Blood pressure measurements were sampled from 69 patients. Regression analysis identified significant correlation between POWSBP and the four methods utilized, with r = 0.92 for NIPBM, r = 0.95 for auscultation, and r = 0.97 for palpation, all significant at p < 0.0001. CONCLUSIONS: The use of POWSBP measurement is a fast, easy, and accurate technique with which to measure systolic BP in the field. It may have special importance for noisy environments and moving vehicles in which conventional methods of auscultation or palpation may be difficult.

Mycobacterium bovis in California dairies: a case series of 2002-2013 outbreaks.

From 2002 to 2013, bovine tuberculosis (bTB) caused by Mycobacterium bovis (M. bovis) has been detected on numerous dairies in California. In total, twelve herds had bTB detected and are included in the case series which describes these recent outbreaks and discusses potential pathways of introduction. Epidemiological investigations to determine the initial source of bTB in each herd included obtaining data on likely pathways of pathogen introduction. Pathways included purchasing cattle, use of heifer-raising operations, commingling of cattle at greater risk of exposure to infected cattle with cattle destined for California dairies, contact with infected wildlife, exposure to humans with bTB infections, community and neighboring herds and others. Epidemiologic and molecular typing data confirmed the source of infection in 3 herds and probable sources of infection in 2 herds. In the 7 remaining herds described in this case series an epidemiologic link to a source could not be determined and molecular typing results did not associate M. bovis isolates acquired from these herds with another specific U.S. herd or U.S.-born animal. Preventing new introductions of M. bovis onto California dairies will require rigorous epidemiologic investigation of all the potential pathways of introduction discussed here. The root cause(s) of bTB on California dairies is certainly multifactorial with complex interactions of herd management practices, importation of cattle at greater risk of exposure to infected cattle, and the potential of human M. bovis exposure. The extensive use of molecular typing has improved epidemiologists' ability to narrow the scope of potential sources.