The distribution of Salmonella enterica serovars and subtypes in surface water from five agricultural regions across Canada.

Serovar prevalence of the zoonotic pathogen, Salmonella enterica, was compared among 1624 surface water samples collected previously from five different Canadian agricultural watersheds over multiple years. Phagetyping, pulsed field gel electrophoresis (PFGE), and antimicrobial resistance subtyping assays were performed on serovars Enteritidis, Typhimurium, and Heidelberg. Serovars and subtypes from surface water were compared with those from animal feces, human sewage, and serovars reported to cause salmonellosis in Canadians. Sixty-five different serovars were identified in surface water; only 32% of these were isolated from multiple watersheds. Eleven of the 13 serovars most commonly reported to cause salmonellosis in Canadians were identified in surface water; isolates of these serovars constituted >40% of the total isolates. Common phagetypes and PFGE subtypes of serovars associated with illness in humans such as S. Enteritidis and S. Typhimurium were also isolated from surface water and animal feces. Antimicrobial resistance was generally low, but was highest among S. Typhimurium. Monitoring of these rivers helps to identify vulnerable areas of a watershed and, despite a relatively low prevalence of S. enterica overall, serovars observed in surface water are an indication of the levels of specific S. enterica serovars present in humans and animals.

Comparative accessory gene fingerprinting of surface water Escherichia coli reveals genetically diverse naturalized population.

AIMS: To utilize comparative accessory gene fingerprinting to discriminate between naturalized and faecal Escherichia coli, with particular emphasis on strains from phylogroup B1. METHODS AND RESULTS: Fourteen accessory genes that were potentially ecotype-specific were selected on the basis of comparative genomic DNA sequence analysis between faecal and environmental strains and also using a literature-based strategy. PCR assays were designed for each gene, and used to screen 107 faecal strains from various hosts and 106 environmental strains from surface water and sediment. While none of the 14 accessory genes were ecotype-specific, six of the genes were ecotype-enriched. Specifically, toxin-antitoxin system genes were more abundant among faecal strains, whereas genes involved in iron acquisition, complement resistance/surface exclusion, and biofilm formation were more abundant among environmental strains. These six genes were used to form composite fingerprints which revealed the presence of several ecotype-specific and -enriched fingerprints. Notably, some of the environmental strain-specific or -enriched fingerprints consisted of strains putatively belonging to clade ET-1, which has been previously recognized as a naturalized subpopulation. CONCLUSIONS: Unlike single genes which did not reliably distinguish between faecal and naturalized phylogroup B1 E. coli strains, composite fingerprints of ecotype-enriched accessory genes may offer a novel method for distinguishing between these two populations. SIGNIFICANCE AND IMPACT OF THE STUDY: Accessory gene fingerprinting may have important practical implications for improving the specificity of methods that are widely used for quantifying and identifying the sources of faecal contamination in surface water.

Bacteria, viruses, and parasites in an intermittent stream protected from and exposed to pasturing cattle: prevalence, densities, and quantitative microbial risk assessment.

Over 3500 individual water samples, for 131 sampling times, targeting waterborne pathogens/fecal indicator bacteria were collected during a 7-year period from 4 sites along an intermittent stream running through a small livestock pasture system with and without cattle access-to-stream restriction measures. The study assessed the impact of cattle pasturing/riparian zone protection on: pathogen (bacterial, viral, parasite) occurrence, concentrations of fecal indicators, and quantitative microbial risk assessments (QMRA) of the risk of Cryptosporidium, Giardia and Escherichia coli O157:H7 infection in humans. Methodologies were developed to compute QMRA mean risks on the basis of water samples exhibiting potentially human infectious Cryptosporidium and E. coli based on genotyping Crytosporidium, and E. coli O157:H7 presence/absence information paired with enumerated E. coli. All Giardia spp. were considered infectious. No significant pasturing treatment effects were observed among pathogens, with the exception of Campylobacter spp. and E. coli O157:H7. Campylobacter spp. prevalence significantly decreased downstream through pasture treatments and E. coli O157:H7 was observed in a few instances in the middle of the unrestricted pasture. Densities of total coliform, fecal coliform, and E. coli reduced significantly downstream in the restricted pasture system, but not in the unrestricted system. Seasonal and flow conditions were associated with greater indicator bacteria densities, especially in the summer. Norovirus GII was detected at rates of 7-22% of samples for all monitoring sites, and rotavirus in 0-7% of samples for all monitoring sites; pasture treatment trends were not evident, however. Seasonal and stream flow variables (and their interactions) were relatively more important than pasture treatments for initially stratifying pathogen occurrence and higher fecal indicator bacteria densities. Significant positive associations among fecal indicator bacteria and Campylobacter spp. detection were observed. For QMRA, adjusting for the proportion of Cryptosporidium spp. detected that are infectious for humans reduces downstream risk estimates by roughly one order of magnitude. Using QMRA in this manner provides a more refined estimate of beneficial management practice effects on pathogen exposure risks to humans.

Investigation of an Escherichia coli environmental benchmark for waterborne pathogens in agricultural watersheds in Canada.

Canada's National Agri-Environmental Standards Initiative sought to develop an environmental benchmark for low-level waterborne pathogen occurrence in agricultural watersheds. A field study collected 902 water samples from 27 sites in four intensive agricultural watersheds across Canada from 2005 to 2007. Four of the sites were selected as reference sites away from livestock and human fecal pollution sources in each watershed. Water samples were analyzed for Campylobacter spp., Salmonella spp., Escherichia coli O157:H7, Cryptosporidium spp., Giardia spp., and the water quality indicator E. coli. The annual mean number of pathogen species was higher at agricultural sites (1.54 ± 0.07 species per water sample) than at reference sites (0.75 ± 0.14 species per water sample). The annual mean concentration of E. coli was also higher at agricultural sites (491 ± 96 colony-forming units [cfu] 100 mL(-1)) than at reference sites (53 ± 18 cfu 100 mL(-1)). The feasibility of adopting existing E. coli water quality guideline values as an environmental benchmark was assessed, but waterborne pathogens were detected at agricultural sites in 80% of water samples with low E. coli concentrations (<100 cfu 100 mL(-1)). Instead, an approach was developed based on using the natural background occurrence of pathogens at reference sites in agricultural watersheds to derive provisional environmental benchmarks for pathogens at agricultural sites. The environmental benchmarks that were derived were found to represent E. coli values lower than geometric mean values typically found in recreational water quality guidelines. Additional research is needed to investigate environmental benchmarks for waterborne pathogens within the context of the "One World, One Health" perspective for protecting human, domestic animal, and wildlife health.

Associations among pathogenic bacteria, parasites, and environmental and land use factors in multiple mixed-use watersheds.

Over a five year period (2004-08), 1171 surface water samples were collected from up to 24 sampling locations representing a wide range of stream orders, in a river basin in eastern Ontario, Canada. Water was analyzed for Cryptosporidium oocysts and Giardia cyst densities, the presence of Salmonella enterica subspecies enterica, Campylobacter spp., Listeria monocytogenes, and Escherichia coli O157:H7. The study objective was to explore associations among pathogen densities/occurrence and objectively defined land use, weather, hydrologic, and water quality variables using CART (Classification and Regression Tree) and binary logistical regression techniques. E. coli O157:H7 detections were infrequent, but detections were related to upstream livestock pasture density; 20% of the detections were located where cattle have access to the watercourses. The ratio of detections:non-detections for Campylobacter spp. was relatively higher (>1) when mean air temperatures were 6% below mean study period temperature values (relatively cooler periods). Cooler water temperatures, which can promote bacteria survival and represent times when land applications of manure typically occur (spring and fall), may have promoted increased frequency of Campylobacter spp. Fifty-nine percent of all Salmonella spp. detections occurred when river discharge on a branch of the river system of Shreve stream order = 9550 was >83 percentile. Hydrological events that promote off farm/off field/in stream transport must manifest themselves in order for detection of Salmonella spp. to occur in surface water in this region. Fifty seven percent of L. monocytogenes detections occurred in spring, relative to other seasons. It was speculated that a combination of winter livestock housing, silage feeding during winter, and spring application of manure that accrued during winter, contributed to elevated occurrences of this pathogen in spring. Cryptosporidium and Giardia oocyst and cyst densities were, overall, positively associated with surface water discharge, and negatively associated with air/water temperature during spring-summer-fall. Yet, some of the highest Cryptosporidium oocyst densities were associated with low discharge conditions on smaller order streams, suggesting wildlife as a contributing fecal source. Fifty six percent of all detections of ≥ 2 bacteria pathogens (including Campylobacter spp., Salmonella spp., and E. coli O157:H7) in water was associated with lower water temperatures (<∼ 14 °C; primarily spring and fall) and when total rainfall the week prior to sampling was >∼ 27 mm (62 percentile). During higher water temperatures (>∼ 14 °C), a higher amount of weekly rainfall was necessary to promote detection of ≥ 2 pathogens (primarily summer; weekly rainfall ∼>42 mm (>77 percentile); 15% of all ≥ 2 detections). Less rainfall may have been necessary to mobilize pathogens from adjacent land, and/or in stream sediments, during cooler water conditions; as these are times when manures are applied to fields in the area, and soil water contents and water table depths are relatively higher. Season, stream order, turbidity, mean daily temperature, surface water discharge, cropland coverage, and nearest upstream distance to a barn and pasture were variables that were relatively strong and recurrent with regard to discriminating pathogen presence and absence, and parasite densities in surface water in the region.

Molecular subtypes of Campylobacter spp., Salmonella enterica, and Escherichia coli O157:H7 isolated from faecal and surface water samples in the Oldman River watershed, Alberta, Canada.

Campylobacter spp., Salmonella enterica, and Escherichia coli O157:H7 isolated from 898 faecal, 43 sewage, and 342 surface water samples from the Oldman River were characterized using bacterial subtyping methods in order to investigate potential sources of contamination of the watershed. Among these pathogens, Campylobacter spp. were the most frequently isolated from faecal, sewage, and surface water samples (266/895, 11/43, and 91/342, respectively), followed by Salmonella (67/898, 8/43, and 29/342, respectively), and E. coli O157:H7 (16/898, 2/43, and 8/342, respectively). Salmonella Rubislaw was the most common serovar isolated from water. This serovar was also isolated from two wild bird species. Most other serovars isolated from water were either not isolated from animals or were isolated from multiple species. E. coli O157:H7 was predominantly isolated from cattle. The most common phage-types of this pathogen from cattle were also the most common among water isolates, and there were exact pulsed field gel electrophoresis and comparative genomic fingerprint matches between cattle, sewage, and water isolates. Campylobacters were commonly isolated from surface waters and faeces from most animal species. Restriction fragment length polymorphism of the Campylobacter flaA gene identified several location and host species-specific (cattle, goose, pig) fingerprints. Molecular subtyping of these bacterial pathogens shows considerable promise as a tool for determining the sources of faecal pollution of water.

Nosocomial Legionella pneumophila serogroup 5 outbreak associated with persistent colonization of a hospital water system.

An outbreak of infections caused by Legionella pneumophila serogroup 5 was detected in a university hospital, and nosocomial reservoirs of the legionella epidemic were examined. Clinical isolates from two patients who had been affected by the L. pneumophila serogroup 5 outbreak, and from another patient with a legionella infection caused by the same serogroup 3 years later, were compared to L. pneumophila serogroup 5 isolates from the hospital water supply by two molecular methods, amplified fragment length polymorphism (AFLP) analysis and random amplified polymorphic DNA analysis (RAPD). Genotyping confirmed the epidemiological linkage of the first two patients, and linked their infections with the hospital water supply. The third clinical strain, which was also linked to the hospital water, was very similar to the epidemic strain. Even though the water distribution system was sanitized (superheat and flush sanitation), the epidemic strain was shown to be persisting in the hospital water outlets several years after its initial discovery.

Microbial etiology of community-acquired pneumonia in the adult population of 4 municipalities in eastern Finland.

To determine the etiology of community-acquired pneumonia in the adult population of a defined area, specific antibody responses in paired serum samples, levels of circulating pneumococcal immune complexes in serum samples, and pneumococcal antigen in urine were measured. Samples (304 paired serum samples and 300 acute urine samples) were obtained from 345 patients > or =15 years old with community-acquired, radiologically confirmed pneumonia, which comprised all cases in the population of 4 municipalities in eastern Finland during 1 year. Specific infecting organisms were identified in 183 patients (including 49 with mixed infection), as follows: Streptococcus pneumoniae, 125 patients; Haemophilus influenzae, 12; Moraxella catarrhalis, 8; chlamydiae, 37 (of which, Chlamydia pneumoniae, 30); Mycoplasma pneumoniae, 30; and virus species, 27. The proportion of patients with pneumococcal infections increased and of those with Mycoplasma infections decreased with age, but for each age group, the etiologic profile was similar among inpatients and among outpatients. S. pneumoniae was the most important etiologic agent. The annual incidence of pneumococcal pneumonia per 1000 inhabitants aged > or =60 years was 8.0.

Chlamydia pneumoniae is an important cause of community-acquired pneumonia in school-aged children: serological results of a prospective, population-based study.

The aetiology of community-acquired pneumonia in childhood was studied in the total population of 8851 children in the area of 4 municipalities in eastern Finland. All cases of community-acquired pneumonia (n = 201) were registered during a surveillance period of 12 months between September 1, 1981 and August 31, 1982. The diagnosis of pneumonia was verified radiologically in all identified cases. The diagnosis of chlamydial infection was based on an antibody response measured by complement fixation (CF), by enzyme immunoassay (EIA; IgG or IgM) or by microimmunofluorescence (MIF; IgG or IgM), and the diagnosis of mycoplasmal infection on CF alone. In total, 29 cases of Chlamydia sp. infection were diagnosed; 20 were caused by Chlamydia pneumoniae. Thus, C. pneumoniae was an aetiological agent in 10%, of the 201 pneumonia cases: the proportion was 9% for children aged 5-9 y and 31% for those aged 10 y or more. In the study population, the total incidence of C. pneumoniae pneumonia was 2.3/1000/y. Mycoplasma pneumoniae serology (CF) was positive in 44 patients (22%); the total incidence of M. pneumoniae pneumonia was 5.0/1000/y. Serological evidence of both Chlamydiae and M. pneumoniae was detected in 9 (41%) patients. Our results indicate that C. pneumoniae is an important cause of community-acquired pneumonia in school-aged children. Diagnostic serological response to Chlamydia species or M. pneumoniae was found in 42% of pneumonia patients between 5 and 9 y of age and in 67% of patients aged 10 y or more. Thus, we suggest that macrolides should be considered as an empirical antimicrobial treatment for community-acquired pneumonia, especially in school-aged outpatients.

Etiology of childhood pneumonia: serologic results of a prospective, population-based study.

BACKGROUND: To investigate the etiology of pediatric community-acquired pneumonia, we conducted a prospective, population-based study covering the total population <15 years of age (n = 8851) in 4 municipalities in eastern Finland. MATERIALS AND METHODS: The number of patients was 201; chest radiographs were available for all cases and paired sera for serologic assays were available for >90% of cases. The methods included assays for antibody response to 3 pneumococcal antigens, specific pneumococcal immune complex assays and conventional antibody tests for mycoplasmal, chlamydial and viral infections. RESULTS: Serologic evidence of specific microbial etiology was obtained in 133 (66%) of the pneumonia patients. Bacterial infection was diagnosed in 102 cases (51%) and viral infection in 51 cases (25%). Streptococcus pneumoniae was the most common agent (57 cases; 28%), followed by Mycoplasma pneumoniae (44; 22%), respiratory syncytial virus (43; 21%) and Chlamydia spp. (29; 14%). Haemophilus influenzae was identified in only 6% and Moraxella catarrhalis in only 3% of the children. More than one specific infection was found in 51 patients (25%). The proportion of pneumococcal cases varied from 24 to 36% by age. Mycoplasma infections were seen mostly in patients > or =5 years and Chlamydia infections in patients > or =10 years of age. CONCLUSIONS: The results of our prospective, strictly population-based study confirm the importance of S. pneumoniae in the etiology of community-acquired pneumonia in children of all ages. M. pneumoniae and Chlamydia pneumoniae are important from the age of 5 years onwards.

Risk factors for community-acquired pneumonia in children: a population-based case-control study.

Risk factors for community-acquired pneumonia were studied by collecting data from all pneumonia patients (n = 201) in a defined child population between 3 months and 15 years of age during a surveillance period of 12 months, and from randomly selected healthy controls under 15 years of age (n = 250) from the same area. A structured questionnaire was used, with 409 (176 patients and 233 controls) families responding in total. The chi-square test, and the univariate and multivariate logistic regression analyses were used. The confounding effects of gender, age and place of acquisition were standardized, and the possible interactions between these variables and each individual risk factor were calculated. In the risk factor analysis, the responders were classified into 2 age groups: under 5 years and 5-14 years of age. In children under 5 years of age the significant risk factors were a history of recurrent respiratory infections during the past year [odds ratio (OR) 5.5], a history of wheezing episodes (OR 5.3), and a history of otitis media and tympanocentesis before the age of 2 years (OR 3.6). In the older children, the significant risk factors were a history of recurrent respiratory infections during the previous year (OR 3.0), and a history of wheezing periods at any age (OR 2.1). To sum up, a susceptibility to respiratory infections was found to be significantly associated with community-acquired pneumonia, and no interactions with age, gender or place of acquisition were significant. This trend was reflected by a history of wheezing and that of acute otitis media.

Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland.

Between September 1, 1981, and August 31, 1982, all patients with suspected or confirmed pneumonia among the 46,979 inhabitants of four municipalities in the province of Kuopio, Finland, were reported to a pneumonia register by their attending physicians. In addition, two study pathologists reported all cases of pneumonia found at autopsy, and two permanent registers were checked for retrospective identification of patients. Chest radiographs were obtained from 97% of all patients. The final diagnosis was based on radiologic or autopsy criteria. A total 546 patients (323 males and 223 females) had community-acquired pneumonia; of these, 37% were less than 15 years of age, and 31% were 60 years of age or older. Nineteen percent of the patients had defined chronic conditions, and 42% were admitted to hospital. The case fatality rate was 4%. The overall incidence of community-acquired pneumonia per 1,000 inhabitants per year was 11.6 (13.9 in males, 9.4 in females). The age-specific incidence per 1,000 inhabitants per year was as follows: age < 5 years, 36.0; age 5-14 years, 16.2; age 15-59 years, 6.0; age 60-74 years, 15.4; and age > or = 75 years, 34.2.

Outbreak of Mycoplasma pneumoniae infection among hospital personnel studied by a nucleic acid hybridization test.

An outbreak of Mycoplasma pneumoniae (MP) infection occurred during the period March-May 1989 among the personnel of the Accident and Emergency Department of the Kuopio University Hospital, Kuopio, Finland. The index patient was a young male orderly, who fell ill with severe pneumonia. His tracheal mucus sample proved to be strongly positive for MP when tested by a commercial DNA-RNA hybridization test (Gen-Probe). After the index patient two additional staff members (an orderly and a nurse) fell ill with pneumonia and 66 others showed symptoms of upper respiratory infection or fever. The most frequent symptoms were a sore throat, a cough, rhinitis and headaches. All 97 employees of the department were tested for the presence of MP in April-May 1989 using throat swabs as test material. Forty-three (44%) were found to be positive for MP by the 'Gen-Probe' test. Eight (19%) of the MP positive staff were completely asymptomatic. The MP positive staff were retested about 3 weeks later, whereupon 40 (93%) had become negative. Most of the persons involved in this outbreak suffered only from mild respiratory symptoms, suggesting that MP outbreaks like the present one may easily pass unnoticed.

Use of vaccines for respiratory infections. Strategies for influenza and pneumococcal vaccines.

Indications for use of influenza and pneumococcal vaccines are reviewed in view of current knowledge of the incidence, risk factors and etiology of pneumonia in adults. It appears that both vaccines contribute equally in an almost additive fashion to predicted benefits of vaccination; therefore, both should be used for maximum benefit. Target groups for vaccination include both elderly persons (e.g. 65 years and older) and younger ones who have medical risk factors that increase the likelihood or severity of pneumonia.

Significance of a terminal R wave in lead V1 of the electrocardiogram.

A terminal r wave in Lead V1 lower than 0.6 mV. was studied in the ECGs of four groups: (1) 104 healthy children, (2) 207 healthy young adults, (3) 171 patients with no autopsy evidence of a cardiopulmonary disease, and (4) 1,078 autopsy patients with a cardiopulmonary disease. Cases with a complete right bundle branch block were excluded. A terminal r wave occurred in 2.9 per cent healthy children, 1.4 per cent of healthy young adults, 0.6 per cent of patients without and in 5.9 per cent of patients with autopsy evidence of a cardiopulmonary disease. The occurrence of a terminal r wave was most common in pulmonary patients (10 per cent). But it was also found in patients with an anterior or a posterior myocardial infarction and in some cases of left ventricular hypertrophy. In the autopsy series RVH occurred in 57 per cent of patients with a Qr pattern, in 30 per cent of patients with a terminal r wave higher than the initial one, and in none of the patients with a terminal r wave lower than the initial one. It is concluded that the height of the terminal r wave has clinical significance. A terminal r wave higher than the initial one in Lead V1 is associated with a cardiopulmonary disease in subjects over 30 years of age, while an r wave lower than the initial one seems to be an innocent finding.