Temporal and geographical distributions of reported cases of Escherichia coli O157:H7 infection in Ontario

Temporal, spatial and space-time distribution of infections caused by five major enteric pathogens, Ontario, Canada, 2010-2017

AIMS

In Canada, enteric diseases pose substantial health and economic burdens. The distribution of these diseases is uneven across both geography and time and understanding these patterns is therefore important for the prevention of future outbreaks. We evaluated temporal, spatial and space-time clustering of laboratory-confirmed cases of Campylobacter spp. (n = 28,728), non-typhoidal Salmonella spp. (n = 22,640), Shiga toxin-producing Escherichia coli (STEC; n = 1340), Yersinia spp. (n = 1674) and Listeria monocytogenes (n = 471) infections, reported between 2010 and 2017 inclusive in Ontario, the most populous province in Canada (population ~ 13,500,000 in 2016).

METHODS AND RESULTS

For each enteric pathogen, we calculated the mean incidence rates (IRs) for Ontario's 35 public health unit (PHU) areas and visualized them using choropleth maps. We identified temporal, spatial and space-time high infection rate clusters using retrospective Poisson scan statistics. Campylobacter and Salmonella infections had the highest IRs, while Listeria infections had the lowest. Campylobacter, Salmonella, STEC and Listeria mostly clustered temporally in the spring/summer and sometimes extended into fall, while Yersinia showed a less clear seasonal pattern. The IR visualizations and spatial and space-time scan statistics showed geographic heterogeneity of infection rates with high infection rate clusters detected mainly in PHUs across the southwestern and central-western regions of Ontario for Campylobacter, Salmonella and STEC infections, and mainly in PHUs located in the central-eastern regions for Yersinia and Listeria. A high proportion of cases in some of the significant Salmonella, STEC and Listeria infection clusters were linked to disease outbreaks.

CONCLUSIONS

Results from this study will inform heightened public health surveillance, and prevention and control programmes, in populations and regions of high infection rates. Further research is needed to determine the pathogen-specific socioeconomic, environmental and agricultural risk factors that may be related to the temporal and spatial disease patterns we observed in our study.

Differences in risk factors for transmission among Shiga toxin-producing Escherichia coli serogroups and stx profiles

OBJECTIVES

Trends in the incidence of O157 and non-O157 serogroups of Shiga toxin-producing Escherichia coli (STEC) infections have markedly diverged. Here, we estimate the extent to which STEC serogroups share the same transmission routes and risk factors, potentially explaining these trends.

METHODS

With 3048 STEC cases reported in Minnesota from 2010 to 2019, we used lasso penalized regression to estimate pooled odds ratios (pOR) for the association between STEC risk factors and specific STEC serogroups and Shiga toxin gene profiles. We used random forests as a confirmatory analysis.

RESULTS

Across an extended period of time, we found evidence for person-to-person transmission associated with the O26 serogroup, relative to other serogroups (pOR = 1.32 for contact with an individual with diarrhea). Rurality was less associated with non-O157 serogroups than O157 (pOR = 1.21 for each increasing level of rurality). We also found an association between unpasteurized juice and strains carrying only stx1 (pOR = 1.41).

CONCLUSIONS

Collectively, these results show differences in risk factors across STEC types, which suggest differences in the most effective routes of transmission. Serogroup-specific disease control strategies should be explored. Specifically, preventative measures for non-O157 STEC need to extend beyond those we have employed for O157 STEC.

Seropositivity to Shiga toxin 2 among Argentinian urban and rural residents. Association with sociodemographic and exposure factors

BACKGROUND

Shiga toxin-producing Escherichia coli (STEC) are enteric pathogens that cause hemolytic-uremic syndrome (HUS). Ruminants, especially cattle, are their main reservoir. This study describes the seroepidemiology of STEC in rural and urban populations in Argentina, a country with a high HUS incidence.

METHODS

A cross-sectional study was performed in patients without gastrointestinal symptoms. IgG antibodies against Stx2 were detected by western blotting.

RESULTS

Anti-Stx2 antibodies were detected in 14.56% of serum samples, more frequently in rural (19.38%) than urban residents (12%). Seropositivity was associated with lower socioeconomic status (SES). Among the other variables considered, thawing homemade hamburgers before cooking them, and the lack of knowledge about HUS were also associated with seropositivity. A multivariate logistic regression analysis performed with the variables that were statistically significant showed that only the SES index remained significant. As SES was measured based on several variables, we further analyzed each one of them and found that the lack of a high education level was statistically associated with seropositivity.

CONCLUSIONS

The present findings have implications for STEC prevention efforts, highlighting the importance of considering SES and risks factors linked to different SES levels when targeting consumer-level public health interventions.

Incidence, Demographic, and Seasonal Risk Factors of Infections Caused by Five Major Enteric Pathogens, Ontario, Canada, 2010-2017

In Canada, enteric infections cause significant health and economic burden. We evaluated the individual characteristics of laboratory-confirmed cases of Campylobacter spp. (n = 28,728), non-typhoidal Salmonella spp. (n = 22,640), Yersinia spp. (n = 1674), Verotoxin-producing Escherichia coli (VTEC; n = 1340), and Listeria monocytogenes (n = 471), reported between 2010 and 2017 inclusive, in Ontario, Canada (population ∼13,500,000). We calculated overall and pathogen-specific annual and mean incidence rates (IRs) for Ontario. We used multivariable Poisson and negative binomial regression models to estimate incidence rate ratios (IRRs) for years, seasons, age groups, and sexes, and we included two-way age and sex interaction terms in the models. Campylobacter and Salmonella infections had the highest IRs whereas Listeria infections had the lowest IRs. None of the infections showed long-term trends over the 8-year study period; however, rates of all five infections were elevated in the summer. More Salmonella, VTEC, and Listeria infections were linked to disease outbreaks than were Campylobacter and Yersinia infections. Overall, mean IRs of Campylobacter, Salmonella, Yersinia, and VTEC infections were highest in children 0-4 years old, whereas Listeria IRs peaked in adults 60 years and older. Higher mean IRs of Campylobacter were observed in males. No other differences by sex were statistically significant. The same mean rate was observed in both sexes for Listeria. Adjusting for all other factors, significant age- and sex-specific differences in IRs were observed in Campylobacter, Salmonella, and VTEC infection rates. No significant interactions of age and sex were found for Yersinia and Listeria infections. Future research should focus on the pathogen-specific socioeconomic, environmental, or agricultural risk factors that might be responsible for these infections.

Area-Level Clustering of Shiga Toxin-Producing Escherichia coli Infections and Their Socioeconomic and Demographic Factors in Ontario, Canada: An Ecological Study

Shiga toxin-producing Escherichia coli (STEC) infections are an important health burden for human populations in Ontario and worldwide. We assessed 452 STEC cases that were reported to Ontario's reportable disease surveillance system between 2015 and 2017. A retrospective scan statistic using a Poisson model was used to detect high-rate STEC clusters at the forward sortation area (FSA; the first three digits of a postal code) level. A significant spatial cluster in the southwest region of Ontario was identified. A case-case logistic regression analysis was applied to compare FSA-level socioeconomic and demographic characteristics among STEC cases included inside the spatial cluster with cases outside of the cluster. Cases included in the spatial cluster had higher odds of living in FSAs with a low median family income, low proportion of lone-parent families, and low proportion of the visible minority population. In addition, STEC cases inside the cluster had higher odds of coming from rural FSAs. Our study demonstrated that STEC cases were spatially clustered in Ontario and their clustering was associated with FSA-level socioeconomic and demographic determinants of cases.

Using multi-threshold regression techniques to assess river fecal pollution in the highly urbanized Tamsui River watershed

Rivers are an important urban water resource. This study adopted multivariate linear regression (MLR) and logistic regression (LR) with multiple thresholds to assess river fecal pollution in the Tamsui River watershed using auxiliary environmental data. First, environmental data between 2015 and 2017 on land use, antecedent precipitation, population density, sewerage infrastructure, and river water quality were obtained using geographic information systems and served as explanatory variables. River fecal coliforms (FC), the dependent variable, were also collected for the same period. Then, MLR was used to establish an overall prediction model after validation, and to determine significant factors influencing the level of river fecal pollution. Finally, after stratifying the fecal pollution as low, medium, and high levels, LR with multiple thresholds was employed to explore key factors affecting different FC pollution levels. The study results revealed that land use type and river water quality (other than FC) strongly affected river FC pollution. The discharge of household sewage and wastewater from urban areas was a major source of river FC pollution, particularly for low and medium pollution levels, while farmland land use was negatively correlated with the medium and high levels of river FC pollution in the highly urbanized watershed. Biochemical oxygen demand and suspended solids were highly correlated with medium and high pollution levels in river water.

Evaluating the risks associated with Shiga-toxin-producing Escherichia coli (STEC) in private well waters in Canada

Shiga-toxin-producing Escherichia coli (STEC) represent a major concern for waterborne disease outbreaks associated with consumption of contaminated groundwater. Over 4 million people rely on private groundwater systems as their primary drinking water source in Canada; many of these systems do not meet current standards for water quality. This manuscript provides a scoping overview of studies examining STEC prevalence and occurrence in groundwater, and it includes a synopsis of the environmental variables affecting survival, transport, persistence, and overall occurrence of these important pathogenic microbes in private groundwater wells used for drinking purposes.

Geogenomic Segregation and Temporal Trends of Human Pathogenic Escherichia coli O157:H7, Washington, USA, 2005-20141

The often-noted and persistent increased incidence of Escherichia coli O157:H7 infections in rural areas is not well understood. We used a cohort of E. coli O157:H7 cases reported in Washington, USA, during 2005–2014, along with phylogenomic characterization of the infecting isolates, to identify geographic segregation of and temporal trends in specific phylogenetic lineages of E. coli O157:H7. Kernel estimation and generalized additive models demonstrated that pathogen lineages were spatially segregated during the period of analysis and identified a focus of segregation spanning multiple, predominantly rural, counties for each of the main clinical lineages, Ib, IIa, and IIb. These results suggest the existence of local reservoirs from which humans are infected. We also noted a secular increase in the proportion of lineage IIa and IIb isolates. Spatial segregation by phylogenetic lineage offers the potential to identify local reservoirs and intervene to prevent continued transmission.

The Distribution of Enteric Infections Utilizing Stool Microbial Polymerase Chain Reaction Testing in Clinical Practice

BACKGROUND

Gastrointestinal infection is a major cause of morbidity. We sought to characterize the pathogenic etiologies of gastrointestinal infection to identify seasonal patterns and predictors of specific infections utilizing a multiplex PCR assay in clinical practice.

METHODS

We performed a cross-sectional study of 9403 patients who underwent 13,231 stool tests with a FilmArray gastrointestinal pathogen PCR panel during an episode of diarrhea from March 2015 to May 2017. Our primary outcome was the presence of a positive panel. Logistic regression was used to test for associations between season and infections.

RESULTS

A positive result was found in 3426 tests (25.9%) in 2988 patients (31.8%), yielding 4667 pathogens consisting of 1469 viruses (31.5%), 2925 bacteria (62.7%), and 273 parasites (5.8%). Age less than 50 years was associated with a higher prevalence of pathogens compared to age ≥ 50 (p < 0.0001). The overall prevalence of a positive result for bacteria peaked in the summer (635, 29.2%), and the prevalence of viruses peaked in the winter (446, 31.8%). Compared to the winter, testing in the summer yielded a higher prevalence of bacteria (OR 1.52, 95% CI 1.33, 1.73, p < 0.0001) and lower odds of viruses (OR 0.69, 95% CI 0.58, 0.81, p < 0.0001), primarily driven by E. coli species and norovirus.

CONCLUSIONS

Season was a major determinant in detecting specific pathogens. Our substantially lower positivity rate than previous reports in the literature on multiplex PCR assays may more accurately reflect true clinical practice. Recognizing the temporal distribution of enteric pathogens may help facilitate empiric treatment decisions in certain clinical situations.

Total coliform and Escherichia coli contamination in rural well water: analysis for passive surveillance

With increasing stress on our water resources and recent waterborne disease outbreaks, understanding the epidemiology of waterborne pathogens is crucial to build surveillance systems. The purpose of this study was to explore techniques for describing microbial water quality in rural drinking water wells, based on spatiotemporal analysis, time series analysis and relative risk mapping. Tests results for Escherichia coli and coliforms from private and small public well water samples, collected between 2004 and 2012 in Alberta, Canada, were used for the analysis. Overall, 14.6 and 1.5% of the wells were total coliform and E. coli-positive, respectively. Private well samples were more often total coliform or E. coli-positive compared with untreated public well samples. Using relative risk mapping we were able to identify areas of higher risk for bacterial contamination of groundwater in the province not previously identified. Incorporation of time series analysis demonstrated peak contamination occurring for E. coli in July and a later peak for total coliforms in September, suggesting a temporal dissociation between these indicators in terms of groundwater quality, and highlighting the potential need to increase monitoring during certain periods of the year.

Health conditions in rural areas with high livestock density: Analysis of seven consecutive years

Previous studies investigating health conditions of individuals living near livestock farms generally assessed short time windows. We aimed to take time-specific differences into account and to compare the prevalence of various health conditions over seven consecutive years. The sample consisted of 156,690 individuals registered in 33 general practices in a (rural) area with a high livestock density and 101,015 patients from 23 practices in other (control) areas in the Netherlands. Prevalence of health conditions were assessed using 2007-2013 electronic health record (EHR) data. Two methods were employed to assess exposure: 1) Comparisons between the study and control areas in relation to health problems, 2) Use of individual estimates of livestock exposure (in the study area) based on Geographic Information System (GIS) data. A higher prevalence of chronic bronchitis/bronchiectasis, lower respiratory tract infections and vertiginous syndrome and lower prevalence of respiratory symptoms and emphysema/COPD was found in the study area compared with the control area. A shorter distance to the nearest farm was associated with a lower prevalence of upper respiratory tract infections, respiratory symptoms, asthma, COPD/emphysema, allergic rhinitis, depression, eczema, vertiginous syndrome, dizziness and gastrointestinal infections. Especially exposure to cattle was associated with less health conditions. Living within 500m of mink farms was associated with increased chronic enteritis/ulcerative colitis. Livestock-related exposures did not seem to be an environmental risk factor for the occurrence of health conditions. Nevertheless, lower respiratory tract infections, chronic bronchitis and vertiginous syndrome were more common in the area with a high livestock density. The association between exposure to minks and chronic enteritis/ulcerative colitis remains to be elucidated.

A geostatistical investigation of agricultural and infrastructural risk factors associated with primary verotoxigenic E. coli (VTEC) infection in the Republic of Ireland, 2008-2013

Ireland reports the highest incidence of verotoxigenic Escherichia coli (VTEC) infection in Europe. This study investigated potential risk factors for confirmed sporadic and outbreak primary VTEC infections during 2008-2013. Overall, 989 VTEC infections including 521 serogroup O157 and 233 serogroup O26 were geo-referenced to 931 of 18 488 census enumeration areas. The geographical distribution of human population, livestock, unregulated groundwater sources, domestic wastewater treatment systems (DWWTS) and a deprivation index were examined relative to notification of VTEC events in 524 of 6242 rural areas. Multivariate modelling identified three spatially derived variables associated with VTEC notification: private well usage [odds ratio (OR) 6·896, P < 0·001], cattle density (OR 1·002, P < 0·001) and DWWTS density (OR 0·978, P = 0·002). Private well usage (OR 18·727, P < 0·001) and cattle density (OR 1·001, P = 0·007) were both associated with VTEC O157 infection, while DWWTS density (OR 0·987, P = 0·028) was significant within the VTEC O26 model. Findings indicate that VTEC infection in the Republic of Ireland is particularly associated with rural areas, which are associated with a ubiquity of pathogen sources (cattle) and pathways (unregulated groundwater supplies).

Factors Associated with Shiga Toxin-Producing Escherichia coli Shedding by Dairy and Beef Cattle

Shiga toxin-producing Escherichia coli (STEC) is an important foodborne pathogen that can cause hemorrhagic colitis and hemolytic-uremic syndrome. Cattle are the primary reservoir for STEC, and food or water contaminated with cattle feces is the most common source of infections in humans. Consequently, we conducted a cross-sectional study of 1,096 cattle in six dairy herds (n = 718 animals) and five beef herds (n = 378 animals) in the summers of 2011 and 2012 to identify epidemiological factors associated with shedding. Fecal samples were obtained from each animal and cultured for STEC. Multivariate analyses were performed to identify risk factors associated with STEC positivity. The prevalence of STEC was higher in beef cattle (21%) than dairy cattle (13%) (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.25, 2.47), with considerable variation occurring across herds (range, 6% to 54%). Dairy cattle were significantly more likely to shed STEC when the average temperature was >28.9°C 1 to 5 days prior to sampling (OR, 2.5; 95% CI, 1.25, 4.91), during their first lactation (OR, 1.8; 95% CI, 1.1, 2.8), and when they were <30 days in milk (OR, 3.9; 95% CI, 2.1, 7.2). These data suggest that the stress or the negative energy balance associated with lactation may result in increased STEC shedding frequencies in Michigan during the warm summer months. Future prevention strategies aimed at reducing stress during lactation or isolating high-risk animals could be implemented to reduce herd-level shedding levels and avoid transmission of STEC to susceptible animals and people.

IMPORTANCE

STEC shedding frequencies vary considerably across cattle herds in Michigan, and the shedding frequency of strains belonging to non-O157 serotypes far exceeds the shedding frequency of O157 strains, which is congruent with human infections in the state. Dairy cattle sampled at higher temperatures, in their first lactation, and early in the milk production stage were significantly more likely to shed STEC, which could be due to stress or a negative energy balance. Future studies should focus on the isolation of high-risk animals to decrease herd shedding levels and the potential for contamination of the food supply.

A descriptive analysis of the spatio-temporal distribution of enteric diseases in New Brunswick, Canada

Background

Enteric diseases affect thousands of Canadians annually and several large outbreaks have occurred due to infection with enteric pathogens. The objectives of this study were to describe the spatial and temporal distributions of reportable Campylobacter, Escherichia coli, Giardia, Salmonella and Shigella from 1994 to 2002 in New Brunswick, Canada. By examining the spatial and temporal distributions of disease incidence, hypotheses as to potential disease risk factors were formulated.

Methods

Time series plots of monthly disease incidence were examined for seasonal and secular trends. Seasonality of disease incidence was evaluated using the temporal scan statistic and seasonal–trend loess (STL) decomposition methods. Secular trends were evaluated using negative binomial regression modeling. The spatial distribution of disease incidence was examined using maps of empirical Bayes smoothed estimates of disease incidence. Spatial clustering was examined by multiple methods, which included Moran’s I and the spatial scan statistic.

Results

The peak incidence of Giardia infections occurred in the spring months. Salmonella incidence exhibited two peaks, one small peak in the spring and a main peak in the summer. Campylobacter and Escherichia coli O157 disease incidence peaked in the summer months. Moran’s I indicated that there was significant positive spatial autocorrelation for the incidence of Campylobacter, Giardia and Salmonella. The spatial scan statistic identified clusters of high disease incidence in the northern areas of the province for Campylobacter, Giardia and Salmonella infections. The incidence of Escherichia coli infections clustered in the south-east and north-east areas of the province, based on the spatial scan statistic results. Shigella infections had the lowest incidence rate and no discernable spatial or temporal patterns were observed.

Conclusions

By using several different spatial and temporal methods a robust picture of the spatial and temporal distributions of enteric disease in New Brunswick was produced. Disease incidence for several reportable enteric pathogens displayed significant geographic clustering indicating that a spatially distributed risk factor may be contributing to disease incidence. Temporal analysis indicated peaks in disease incidence, including previously un-reported peaks.

The impact of meteorology on the occurrence of waterborne outbreaks of vero cytotoxin-producing Escherichia coli (VTEC): a logistic regression approach

This study analyses the relationship between meteorological phenomena and outbreaks of waterborne-transmitted vero cytotoxin-producing Escherichia coli (VTEC) in the Republic of Ireland over an 8-year period (2005-2012). Data pertaining to the notification of waterborne VTEC outbreaks were extracted from the Computerised Infectious Disease Reporting system, which is administered through the national Health Protection Surveillance Centre as part of the Health Service Executive. Rainfall and temperature data were obtained from the national meteorological office and categorised as cumulative rainfall, heavy rainfall events in the previous 7 days, and mean temperature. Regression analysis was performed using logistic regression (LR) analysis. The LR model was significant (p < 0.001), with all independent variables: cumulative rainfall, heavy rainfall and mean temperature making a statistically significant contribution to the model. The study has found that rainfall, particularly heavy rainfall in the preceding 7 days of an outbreak, is a strong statistical indicator of a waterborne outbreak and that temperature also impacts waterborne VTEC outbreak occurrence.

Estimating the burden of acute gastrointestinal illness due to Giardia, Cryptosporidium, Campylobacter, E. coli O157 and norovirus associated with private wells and small water systems in Canada

Waterborne illness related to the consumption of contaminated or inadequately treated water is a global public health concern. Although the magnitude of drinking water-related illnesses in developed countries is lower than that observed in developing regions of the world, drinking water is still responsible for a proportion of all cases of acute gastrointestinal illness (AGI) in Canada. The estimated burden of endemic AGI in Canada is 20·5 million cases annually – this estimate accounts for under-reporting and under-diagnosis. About 4 million of these cases are domestically acquired and foodborne, yet the proportion of waterborne cases is unknown. There is evidence that individuals served by private systems and small community systems may be more at risk of waterborne illness than those served by municipal drinking water systems in Canada. However, little is known regarding the contribution of these systems to the overall drinking water-related AGI burden in Canada. Private water supplies serve an estimated 12% of the Canadian population, or ~4·1 million people. An estimated 1·4 million (4·1%) people in Canada are served by small groundwater (2·6%) and surface water (1·5%) supplies. The objective of this research is to estimate the number of AGI cases attributable to water consumption from these supplies in Canada using a quantitative microbial risk assessment (QMRA) approach. This provides a framework for others to develop burden of waterborne illness estimates for small water supplies. A multi-pathogen QMRA of Giardia, Cryptosporidium, Campylobacter, E. coli O157 and norovirus, chosen as index waterborne pathogens, for various source water and treatment combinations was performed. It is estimated that 103 230 AGI cases per year are due to the presence of these five pathogens in drinking water from private and small community water systems in Canada. In addition to providing a mechanism to assess the potential burden of AGI attributed to small systems and private well water in Canada, this research supports the use of QMRA as an effective source attribution tool when there is a lack of randomized controlled trial data to evaluate the public health risk of an exposure source. QMRA is also a powerful tool for identifying existing knowledge gaps on the national scale to inform future surveillance and research efforts.

Comanaging fresh produce for nature conservation and food safety

In 2006, a deadly Escherichia coli O157:H7 outbreak in bagged spinach was traced to California's Central Coast region, where >70% of the salad vegetables sold in the United States are produced. Although no definitive cause for the outbreak could be determined, wildlife was implicated as a disease vector. Growers were subsequently pressured to minimize the intrusion of wildlife onto their farm fields by removing surrounding noncrop vegetation. How vegetation removal actually affects foodborne pathogens remains unknown, however. We combined a fine-scale land use map with three datasets comprising ∼250,000 enterohemorrhagic E. coli (EHEC), generic E. coli, and Salmonella tests in produce, irrigation water, and rodents to quantify whether seminatural vegetation surrounding farmland is associated with foodborne pathogen prevalence in California's Central Coast region. We found that EHEC in fresh produce increased by more than an order of magnitude from 2007 to 2013, despite extensive vegetation clearing at farm field margins. Furthermore, although EHEC prevalence in produce was highest on farms near areas suitable for livestock grazing, we found no evidence of increased EHEC, generic E. coli, or Salmonella near nongrazed, seminatural areas. Rather, pathogen prevalence increased the most on farms where noncrop vegetation was removed, calling into question reforms that promote vegetation removal to improve food safety. These results suggest a path forward for comanaging fresh produce farms for food safety and environmental quality, as federal food safety reforms spread across ∼4.5 M acres of US farmland.

Diversity and Persistence of Salmonella enterica Strains in Rural Landscapes in the Southeastern United States

Salmonellosis cases in the in the United States show distinct geographical trends, with the southeast reporting among the highest rates of illness. In the state of Georgia, USA, non-outbreak associated salmonellosis is especially high in the southern low-lying coastal plain. Here we examined the distribution of Salmonella enterica in environmental waters and associated wildlife in two distinct watersheds, one in the Atlantic Coastal Plain (a high case rate rural area) physiographic province and one in the Piedmont (a lower case rate rural area). Salmonella were isolated from the two regions and compared for serovar and strain diversity, as well as distribution, between the two study areas, using both a retrospective and prospective design. Thirty-seven unique serovars and 204 unique strain types were identified by pulsed-field gel electrophoresis (PFGE). Salmonella serovars Braenderup, Give, Hartford, and Muenchen were dominant in both watersheds. Two serovars, specifically S. Muenchen and S. Rubislaw, were consistently isolated from both systems, including water and small mammals. Conversely, 24 serovars tended to be site-specific (64.8%, n = 37). Compared to the other Salmonella serovars isolated from these sites, S. Muenchen and S. Rubislaw exhibited significant genetic diversity. Among a subset of PFGE patterns, approximately half of the environmental strain types matched entries in the USA PulseNet database of human cases. Ninety percent of S. Muenchen strains from the Little River basin (the high case rate area) matched PFGE entries in PulseNet compared to 33.33% of S. Muenchen strains from the North Oconee River region (the lower case rate area). Underlying the diversity and turnover of Salmonella strains observed for these two watersheds is the persistence of specific Salmonella serovars and strain types that may be adapted to these watersheds and landscapes.

Identification and characterization of a peculiar vtx2-converting phage frequently present in verocytotoxin-producing Escherichia coli O157 isolated from human infections

Certain verocytotoxin-producing Escherichia coli (VTEC) O157 phage types (PTs), such as PT8 and PT2, are associated with severe human infections, while others, such as PT21, seem to be restricted to cattle. In an attempt to delve into the mechanisms underlying such a differential distribution of PTs, we performed microarray comparison of human PT8 and animal PT21 VTEC O157 isolates. The main differences observed were in the vtx2-converting phages, with the PT21 strains bearing a phage identical to that present in the reference strain EDL933, BP933W, and all the PT8 isolates displaying lack of hybridization in some regions of the phage genome. We focused on the region spanning the gam and cII genes and developed a PCR tool to investigate the presence of PT8-like phages in a panel of VTEC O157 strains belonging to different PTs and determined that a vtx2 phage reacting with the primers deployed, which we named Φ8, was more frequent in VTEC O157 strains from human disease than in bovine strains. No differences were observed in the production of the VT2 mRNA when Φ8-positive strains were compared with VTEC O157 possessing BP933W. Nevertheless, we show that the gam-cII region of phage Φ8 might carry genetic determinants downregulating the transcription of the genes encoding the components of the type III secretion system borne on the locus of enterocyte effacement pathogenicity island.

National patterns of Escherichia coli O157 infections, USA, 1996-2011

US public health laboratories began reporting Escherichia coli O157 isolates to CDC in 1996. We describe temporal and geographical patterns of isolates reported from 1996 to 2011 and demographics of persons whose specimens yielded isolates. We calculated annual E. coli O157 isolation rates/100 000 persons by patient's state of residence, county of residence, age, and sex using census data. The average annual isolation rate was 0·84. The average isolation rate in northern states (1·52) was higher than in southern states (0·43). Counties with ⩾76% rural population had a lower isolation rate (0·67) than counties with ⩽25%, 26-50%, and 51-75% rural populations (0·81, 0·92, and 0·81, respectively). The highest isolation rate (3·19) was in children aged 1-4 years. Infections were seasonal with 49% of isolates collected during July to September. Research into reasons for higher incidence in northern states and for seasonality could guide strategies to prevent illnesses.

Transmission of Escherichia coli O157:H7 in cattle is influenced by the level of environmental contamination

A pen infection-transmission experiment was conducted to elucidate the role of pathogen strain and environmental contamination in transmission of Escherichia coli O157:H7 (ECO157) in cattle. Five steers were inoculated with a three-strain mixture of ECO157 and joined with five susceptible steers in each of two experimental replicates. Faecal and environmental samples were monitored for ECO157 presence over 30 days. One ECO157 strain did not spread. Transmission rates for the other two strains were estimated using a generalized linear model developed based on a modified ‘Susceptible–Infectious–Susceptible’ mathematical model. Transmission rates estimated for the two strains (0·11 and 0·14) were similar. However, the rates significantly (P = 0·0006) increased 1·5 times for every 1-unit increase in the level of environmental contamination measured as log₁₀ c.f.u. Depending on the level of environmental contamination, the estimated basic reproduction numbers varied from <1 to 8. The findings indicate the importance of on-farm measures to reduce environmental contamination for ECO157 control in cattle that should be validated under field conditions.

Verotoxigenic Escherichia coli: costs of illness in Canada, including long-term health outcomes

The main objective of this study was to provide cost estimates of human Escherichia coli O157 infection to facilitate future assessment of the benefits and costs of alternative preventive strategies to reduce illness. We investigated the costs of illness to Canadians from primary human infection by verotoxigenic E. coli O157 (also called Shiga toxin-producing E. coli O157) using data from the National Notifiable Diseases Registry. We used relative risk information from peer-reviewed publications to estimate the burden of illness and associated costs for eight long-term health outcomes. National estimates of the number of cases (mean and 5th and 95th percentiles), associated costs, and a rank correlation test to identify which outcomes were associated with the highest per capita costs were calculated. An estimated 22,344 cases of primary infections occur in Canada annually, costing $26.7 million. There are 37,867 additional on-going long-term health outcomes costing $377.2 million each year. Our analysis indicated that the annual cost for primary and long-term illness is $403.9 million. The analysis supports evaluation of alternative control and prevention measures and the development and implementation of policy and practices aimed at safe food production.

Weather and livestock risk factors for Escherichia coli O157 human infection in Alberta, Canada

This study investigated the extent to which proximity to cattle and weather events in Alberta predispose human populations to E. coli O157 disease. Cases of human E. coli O157 infection in Alberta between 2004 and 2011 were obtained from the province's Communicable Disease Reporting System and Discharge Abstract Database. Regression models based on spatial area incorporated human infection data with livestock and weather covariates. A variety of regression models were applied (i.e. least squares, spatial lag/error, Poisson, negative binomial) to test the most appropriate approach. Ratios for the total number of calves, bulls and beef cows to human population were highlighted as significant cattle density variables in all final best-fitting models. Weather variables were not significant in final regression models averaged over the full study period. Our results provide evidence of a significant association between measures of cattle density and human E. coli O157 disease in Alberta.

Evaluation of land use and water quality in an agricultural watershed in the USA indicates multiple sources of bacterial impairment

Pathogens are the number one cause of impairments of assessed rivers and streams in the USA and pose a significant human health hazard. The Dry Run Creek Watershed in Northeast Iowa has been designated as impaired by the State of Iowa because of high levels of Escherichia coli bacteria. To investigate the nature of this impairment, land use and stream bank assessments were coupled with comprehensive water quality monitoring. Physical, chemical, and biological parameters were measured at 13 different sites in the watershed, including pH, temperature, conductivity, dissolved oxygen, turbidity, total Kjeldahl nitrogen, ammonia-N, nitrate + nitrite-N, total phosphorus, and E. coli. In addition, benthic macroinvertebrate communities were analyzed at seven sites, and optical brightener tests were performed late in the season. Results identified segments of the watershed that were more prominent contributors of E. coli, and correlations were observed between levels of E. coli and several chemical parameters, including ammonia-N, total Kjeldahl nitrogen, and total phosphorus. Interestingly, distinct sites emerged as more prominent contributors of these elements during rain vs. non-rain events, suggesting different types of sources. Both the amount of rainfall and the time elapsed between the rain event and the sampling influenced E. coli levels during wet weather conditions. Nitrate + nitrite-N displayed a unique response to rain events compared with the other parameters, suggesting a different delivery route. Analyses of benthic macroinvertebrate communities were consistent with pollution trends. Collectively, these data suggest distinct agriculturally related E. coli contributions, as well as specific areas and practices for water quality improvement strategies. This study can serve as a resource for evaluating agricultural watersheds that are impaired for bacteria.

A prospective case-control and molecular epidemiological study of human cases of Shiga toxin-producing Escherichia coli in New Zealand

Background

Shiga toxin-producing Escherichia coli (STEC) O157:H7 and related non-O157 STEC strains are enteric pathogens of public health concern worldwide, causing life-threatening diseases. Cattle are considered the principal hosts and have been shown to be a source of infection for both foodborne and environmental outbreaks in humans. The aims of this study were to investigate risk factors associated with sporadic STEC infections in humans in New Zealand and to provide epidemiological information about the source and exposure pathways.

Methods

During a national prospective case–control study from July 2011 to July 2012, any confirmed case of STEC infection notified to regional public health units, together with a random selection of controls intended to be representative of the national demography, were interviewed for risk factor evaluation. Isolates from each case were genotyped using pulsed-field gel electrophoresis (PFGE) and Shiga toxin-encoding bacteriophage insertion (SBI) typing.

Results

Questionnaire data from 113 eligible cases and 506 controls were analysed using multivariate logistic regression. Statistically significant animal and environmental risk factors for human STEC infections were identified, notably 'Cattle livestock present in meshblock’ (the smallest geographical unit) (odds ratio 1.89, 95% CI 1.04–3.42), 'Contact with animal manure’ (OR 2.09, 95% CI 1.12–3.90), and 'Contact with recreational waters’ (OR 2.95, 95% CI 1.30–6.70). No food-associated risk factors were identified as sources of STEC infection. E. coli O157:H7 caused 100/113 (88.5%) of clinical STEC infections in this study, and 97/100 isolates were available for molecular analysis. PFGE profiles of isolates revealed three distinctive clusters of genotypes, and these were strongly correlated with SBI type. The variable 'Island of residence’ (North or South Island of New Zealand) was significantly associated with PFGE genotype (p = 0.012).

Conclusions

Our findings implicate environmental and animal contact, but not food, as significant exposure pathways for sporadic STEC infections in humans in New Zealand. Risk factors associated with beef and dairy cattle suggest that ruminants are the most important sources of STEC infection. Notably, outbreaks of STEC infections are rare in New Zealand and this further suggests that food is not a significant exposure pathway.

Passive immunization by recombinant ferric enterobactin protein (FepA) from Escherichia coli O157

BACKGROUND AND OBJECTIVES

Enterohemorrhagic Escherichia coli (EHEC) O157:H7 has been recognized as a major food borne pathogen responsible for frequent hemorrhagic colitis and hemolytic uremic syndrome in humans. Cattle are important reservoirs of E. coli O157:H7, in which the organism colonizes the intestinal tract and is shed in the feces.

OBJECTIVE

Vaccination of cattle has significant potential as a pre-harvest intervention strategy for E. coli O157:H7. The aim of this study was to evaluate active and passive immunization against E. coli O157:H7 using a recombinant protein.

MATERIALS AND METHODS

The recombinant FepA protein induced by IPTG was purified by nickel affinity chromatography. Antibody titre was determined by ELISA in FepA immunized rabbits sera. Sera collected from vaccinated animals were used for bacterial challenge in passive immunization studies.

RESULTS

The results demonstrate that passive immunization with serum raised against FepA protects rabbits from subsequent infection.

CONCLUSION

Significant recognition by the antibody of ferric enterobactin binding protein may lead to its application in the restriction of Enterobacteriaceae propagation.

How to choose geographical units in ecological studies: proposal and application to campylobacteriosis

In spatial epidemiology, the choice of an appropriate geographical unit of analysis is a key decision that will influence most aspects of the study. In this study, we proposed and applied a set of measurable criteria applicable for orienting the choice of geographical unit. Nine criteria were selected, covering many aspects such as biological relevance, communicability of results, ease of data access, distribution of exposure variables, cases and population, and shape of unit. These criteria were then applied to compare various geographical units derived from administrative, health services, and natural frameworks that could be used for the study of the spatial distribution of campylobacteriosis in the province of Quebec, Canada. In this study, municipality was the geographical unit that performed the best according to our assessment and given the specific objectives and time period of the study. Future research areas for optimizing the choice of geographical unit are discussed.

Risk of infectious gastroenteritis in young children living in Québec rural areas with intensive animal farming: results of a case-control study (2004-2007)

This study was designed to evaluate the epidemiology of severe gastroenteritis in children living in Québec rural areas with intensive livestock activities. From September 2005 through June 2007, 165 cases of gastroenteritis in children aged from 6 months to 5 years, hospitalized or notified to the public health department were enrolled, and 326 eligible controls participated. The parents of cases and controls were asked questions about different gastroenteritis risk factors. The quality of the drinking water used by the participants was investigated for microbial indicators as well as for four zoonotic bacterial pathogens (Campylobacter spp, Escherichia coli, Salmonella spp and Yersinia spp) and two enteric parasites (Cryptosporidium spp and Giardia spp). From 134 stool specimen analysed, viruses were detected in 82 cases (61%), while 28 (21%) were found with at least one of the bacteria investigated, and five cases were infected by parasites. Campylobacteriosis was the main bacterial infection (n = 15), followed by Salmonella sp (n = 7) and E. coli O157:H7 (n = 5) among cases with bacterial gastroenteritis. No significant difference was found between cases and controls regarding the quality of water consumed; the frequency of faecal contamination of private wells was also similar between cases and controls. Considering the total cases (including those with a virus), no link was found between severe gastroenteritis and either being in contact with animals or living in a municipality with the highest animal density (4th quartile). However, when considering only cases with a bacterial or parasite infection (n = 32), there was a weak association with pig density that was not statistically significant after adjusting for potential confounders. Contact with domestic, zoo or farm animals were the only environmental factor associated with the disease.

Population-based estimate of the burden of acute gastrointestinal illness in Jiangsu province, China, 2010-2011

To determine the burden and distribution of acute gastrointestinal illness (AGI) in the population, a cross-sectional, monthly face-to-face survey of 10 959 residents was conducted in Jiangsu province between July 2010 and June 2011. The adjusted monthly prevalence was 4.7% with 0.63 AGI episodes/person per year. The prevalence was the highest in children aged <5 years and lowest in persons aged ≥ 65 years. A bimodal seasonal distribution was observed with peaks in summer and winter. Regional difference of AGI prevalence was substantial [lowest 0.5% in Taicang, highest 15.1% in Xinqu (Wuxi prefecture)]. Healthcare was sought by 38.4% of the ill respondents. The use of antibiotics was reported by 65·2% of the ill respondents and 38.9% took antidiarrhoeals. In the multivariable model, gender, education, season, sentinel site and travel were significant risk factors of being a case of AGI. These results highlight the substantial burden of AGI and the risk factors associated with AGI in Jiangsu province, China.

Spatial and temporal drivers of zoonotic pathogen contamination of an agricultural watershed

In regions where animal agriculture is prominent, such as southern Alberta, higher rates of gastrointestinal illness have been reported when compared with nonagricultural regions. This difference in the rate of illness is thought to be a result of increased zoonotic pathogen exposure through environmental sources such as water. In this study, temporal and spatial factors associated with bacterial pathogen contamination of the Oldman River, which transverses this region, were analyzed using classification and regression tree analysis. Significantly higher levels of fecal indicators; more frequent isolations of Campylobacter spp., Escherichia coli O157:H7, and Salmonella enterica spp.; and higher rates of detection of pig-specific Bacteroides markers occurred at downstream sites than at upstream sites, suggesting additive stream inputs. Fecal indicator densities were also significantly higher when any one of these three bacterial pathogens was present and where there were higher total animal manure units; however, occasionally pathogens were present when fecal indicator levels were low or undetectable. Overall, Salmonella spp., Campylobacter spp., and E. coli O157:H7 presence was associated with season, animal manure units, and total rainfall on the day of sampling and 3 d in advance of sampling. Several of the environmental variables analyzed in this study appear to influence pathogen prevalence and therefore may be useful in predicting water quality and safety and in the improvement of watershed management practices in this and other agricultural regions.

Agricultural, socioeconomic and environmental variables as risks for human verotoxigenic Escherichia coli (VTEC) infection in Finland

Background

Verotoxigenic E. coli (VTEC) is the cause of severe gastrointestinal infection especially among infants. Between 10 and 20 cases are reported annually to the National Infectious Disease Register (NIDR) in Finland. The aim of this study was to identify explanatory variables for VTEC infections reported to the NIDR in Finland between 1997 and 2006. We applied a hurdle model, applicable for a dataset with an excess of zeros.

Methods

We enrolled 131 domestically acquired primary cases of VTEC between 1997 and 2006 from routine surveillance data. The isolated strains were characterized by virulence type, serogroup, phage type and pulsed-field gel electrophoresis. By applying a two-part Bayesian hurdle model to infectious disease surveillance data, we were able to create a model in which the covariates were associated with the probability for occurrence of the cases in the logistic regression part and the magnitude of covariate changes in the Poisson regression part if cases do occur. The model also included spatial correlations between neighbouring municipalities.

Results

The average annual incidence rate was 4.8 cases per million inhabitants based on the cases as reported to the NIDR. Of the 131 cases, 74 VTEC O157 and 58 non-O157 strains were isolated (one person had dual infections). The number of bulls per human population and the proportion of the population with a higher education were associated with an increased occurrence and incidence of human VTEC infections in 70 (17%) of 416 of Finnish municipalities. In addition, the proportion of fresh water per area, the proportion of cultivated land per area and the proportion of low income households with children were associated with increased incidence of VTEC infections.

Conclusions

With hurdle models we were able to distinguish between risk factors for the occurrence of the disease and the incidence of the disease for data characterised by an excess of zeros. The density of bulls and the proportion of the population with higher education were significant both for occurrence and incidence, while the proportion of fresh water, cultivated land, and the proportion of low income households with children were significant for the incidence of the disease.

Combining risk assessment and epidemiological risk factors to elucidate the sources of humanE. coliO157 infection

E. coliO157 can be transmitted to humans by three primary (foodborne, environmental, waterborne) and one secondary (person-to-person transmission) pathways. A regression model and quantitative microbiological risk assessments (QMRAs) were applied to determine the relative importance of the primary transmission pathways in NE Scotland. Both approaches indicated that waterborne infection was the least important but it was unclear whether food or the environment was the main source of infection. The QMRAs over-predicted the number of cases by a factor of 30 and this could be because allE. coliO157 strains may not be equally infective and/or the level of infectivity in the dose–response model was too high. The efficacy of potential risk mitigation strategies to reduce human exposure toE. coliO157 using QMRAs was simulated. Risk mitigation strategies focusing on food and environment are likely to have the biggest impact on infection figures.

Spread of E. coli O157 infection among Scottish cattle farms: stochastic models and model selection

Identifying risk factors for the presence of Escherichia coli O157 infection on cattle farms is important for understanding the epidemiology of this zoonotic infection in its main reservoir and for informing the design of interventions to reduce the public health risk. Here, we use data from a large-scale field study carried out in Scotland to fit both "SIS"-type dynamical models and statistical risk factor models. By comparing the fit (assessed using maximum likelihood) of different dynamical models we are able to identify the most parsimonious model (using the AIC statistic) and compare it with the model suggested by risk factor analysis. Both approaches identify 2 key risk factors: the movement of cattle onto the farm and the number of cattle on the farm. There was no evidence for a role of other livestock species or seasonality, or of significant risk of local spread. However, the most parsimonious dynamical model does predict that farms can infect other farms through routes other than cattle movement, and that there is a nonlinear relationship between the force of infection and the number of infected farms. An important prediction from the most parsimonious model is that although only approximately 20% farms may harbour E. coli O157 infection at any given time approximately 80% may harbour infection at some point during the course of a year.

Geographical association between livestock density and human Shiga toxin-producing Escherichia coli O157 infections

Shiga toxin-producing Escherichia coli (STEC) bacteria can cause outbreaks and sporadic cases of gastroenteritis in humans. Ruminants are seen as the main reservoir. The aim of this study was to evaluate the spatial association between reported human STEC O157 infections in The Netherlands and different livestock densities. Data were collected at the municipality level and a spatial regression analysis was performed. Between April 1999 and December 2008, 409 symptomatic sporadic cases were registered. Adding an interaction term between season, age, and livestock density showed an increased risk of STEC cases in summer for living in areas with cattle, in particular for young children. In conclusion, cattle, but not pigs or poultry, are indicated as an important source for human STEC O157 infections in rural areas. The association is probably due to direct or indirect contact with cattle, resulting in symptomatic infections, especially in young children.

The association between proximity to animal feeding operations and community health: a systematic review

BACKGROUND

A systematic review was conducted for the association between animal feeding operations (AFOs) and the health of individuals living near AFOs.

METHODOLOGY/PRINCIPAL FINDINGS

The review was restricted to studies reporting respiratory, gastrointestinal and mental health outcomes in individuals living near AFOs in North America, European Union, United Kingdom, and Scandinavia. From June to September 2008 searches were conducted in PUBMED, CAB, Web-of-Science, and Agricola with no restrictions. Hand searching of narrative reviews was also used. Two reviewers independently evaluated the role of chance, confounding, information, selection and analytic bias on the study outcome. Nine relevant studies were identified. The studies were heterogeneous with respect to outcomes and exposures assessed. Few studies reported an association between surrogate clinical outcomes and AFO proximity. A negative association was reported when odor was the measure of exposure to AFOs and self-reported disease, the measure of outcome. There was evidence of an association between self-reported disease and proximity to AFO in individuals annoyed by AFO odor.

CONCLUSIONS/SIGNIFICANCE

There was inconsistent evidence of a weak association between self-reported disease in people with allergies or familial history of allergies. No consistent dose response relationship between exposure and disease was observable.

Temporal and spatial patterns of bovine Escherichia coli O157 prevalence and comparison of temporal changes in the patterns of phage types associated with bovine shedding and human E. coli O157 cases in Scotland between 1998-2000 and 2002-2004

Background

Escherichia coli O157 is an important cause of acute diarrhoea, haemorrhagic colitis and, especially in children, haemolytic uraemic syndrome (HUS). Incidence rates for human E. coli O157 infection in Scotland are higher than most other United Kingdom, European and North American countries. Cattle are considered the main reservoir for E. coli O157. Significant associations between livestock related exposures and human infection have been identified in a number of studies.

Results

Animal Studies: There were no statistically significant differences (P = 0.831) in the mean farm-level prevalence between the two studies (SEERAD: 0.218 (95%CI: 0.141-0.32); IPRAVE: 0.205 (95%CI: 0.135-0.296)). However, the mean pat-level prevalence decreased from 0.089 (95%CI: 0.075-0.105) to 0.040 (95%CI: 0.028-0.053) between the SEERAD and IPRAVE studies respectively (P < 0.001). Highly significant (P < 0.001) reductions in mean pat-level prevalence were also observed in the spring, in the North East and Central Scotland, and in the shedding of phage type (PT) 21/28. Human Cases: Contrasting the same time periods, there was a decline in the overall comparative annual reported incidence of human cases as well as in all the major PT groups except 'Other' PTs. For both cattle and humans, the predominant phage type between 1998 and 2004 was PT21/28 comprising over 50% of the positive cattle isolates and reported human cases respectively. The proportion of PT32, however, was represented by few (<5%) of reported human cases despite comprising over 10% of cattle isolates. Across the two studies there were differences in the proportion of PTs 21/28, 32 and 'Other' PTs in both cattle isolates and reported human cases; however, only differences in the cattle isolates were statistically significant (P = 0.002).

Conclusion

There was no significant decrease in the mean farm-level prevalence of E. coli O157 between 1998 and 2004 in Scotland, despite significant declines in mean pat-level prevalence. Although there were declines in the number of human cases between the two study periods, there is no statistically significant evidence that the overall rate (per 100,000 population) of human E. coli O157 infections in Scotland over the last 10 years has altered. Comparable patterns in the distribution of PTs 21/28 and 32 between cattle and humans support a hypothesized link between the bovine reservoir and human infections. This emphasizes the need to apply and improve methods to reduce bovine shedding of E. coli O157 in Scotland where rates appear higher in both cattle and human populations, than in other countries.

DNA extraction from bovine faeces: current status and future trends

There is an increasing interest in the detection and enumeration of micro-organisms pathogenic for human and present in bovine faeces. This interest is because pollution of the environment by animal faeces may affect the safety of food and of drinking or recreational water. Detection and quantification of microbial pathogens carried out using DNA extracted from the faecal matrix are affected by the quality and the quantity of the DNA extracts, which are critical factors that limit the accuracy and sensitivity of molecular studies. This review compares published methods on DNA extraction from bovine faeces, focusing on the extent to which the success of DNA amplification is affected by issues related to the faeces. Following a general discussion on the DNA extraction methods used for faeces, we focus particularly on issues related to the faecal environment itself. The objective is to identify information that can be used to improve the sensitivity of those PCR methods used after direct DNA extraction.

Gene and antigen markers of shiga-toxin producing E. coli from Michigan and Indiana river water: occurrence and relation to recreational water quality criteria

The relation of bacterial pathogen occurrence to fecal indicator bacteria (FIB) concentrations used for recreational water quality criteria (RWQC) is poorly understood. This study determined the occurrence of Shiga-toxin producing Escherichia coli (STEC) markers and their relation to FIB concentrations in Michigan and Indiana river water. Using 67 fecal coliform (FC) bacteria cultures from 41 river sites in multiple watersheds, we evaluated the occurrence of five STEC markers: the Escherichia coli (EC) O157 antigen and gene, and the STEC virulence genes eaeA, stx1, and stx2. Simple isolations from selected FC cultures yielded viable EC O157. By both antigen and gene assays, EC O157 was detected in a greater proportion of samples exceeding rather than meeting FC RWQC (P < 0.05), but was unrelated to EC and enterococci RWQC. The occurrence of all other STEC markers was unrelated to any FIB RWQC. The eaeA, stx2, and stx1 genes were found in 93.3, 13.3, and in 46.7% of samples meeting FC RWQC and in 91.7, 0.0, and 37.5% of samples meeting the EC RWQC. Although not statistically significant, the percentage of samples positive for each STEC marker except stx1 was lower in samples that met, as opposed to exceeded, FIB RWQC. Viable STEC were common members of the FC communities in river water throughout southern Michigan and northern Indiana, regardless of FIB RWQC. Our study indicates that further information on the occurrence of pathogens in recreational waters, and research on alternative indicators of their occurrence, may help inform water-resource management and public health decision-making.

Occurrence and antibiotic resistance of Escherichia coli O157:H7 in a watershed in north-central Indiana

The Wildcat Creek in north-central Indiana is an impaired stream with historically high fecal coliform counts. This study evaluated the presence of both fecal coliforms and Escherichia coli O157:H7 at five sites in rural and urban areas in the eastern part of the Wildcat Creek watershed. Escherichia coli O157:H7 was isolated by immunomagnetic separation. Shiga-like toxin genes (stx1 and stx2) were detected in selected isolates by polymerase chain reaction (PCR) amplification. Isolates of E. coli O157:H7 were also tested by the Kirby-Bauer method for their resistance to eight different antibiotics. Fecal coliform counts were high at two sites located downstream from the city of Kokomo. Escherichia coli O157:H7 was found to be a common occurrence in both the urban and rural parts of the Wildcat Creek watershed, being detected at least twice from each site. This bacterium was also found at various times of the year. Additionally, isolates of antibiotic resistant E. coli O157:H7 were detected from various sites along the stream, especially in sites located in the city and downstream from the urban area, suggesting that human activities might be associated with the dissemination of these bacteria.

Differences between notifiable and administrative health information in the spatial-temporal surveillance of enteric infections

PURPOSE

The purpose of this study is to compare the spatial and temporal information generated from two distinct health data sources available for the surveillance of intestinal infections associated with Escherichia coli O157:H7.

METHODS

Our study area is the province of Alberta, Canada. Data are from two sources: a fee-for-service administrative health data system and a notifiable disease data reporting system. The study period is between 1999 and 2005. We compare the systems by observing correlations in the infections over time, the variability in the overall distribution of cases (as measured by a geographic dissimilarity index), and the relative locations of spatial-temporal clusters of infection.

RESULTS

Our results indicate considerable variability in information generated from these two systems. The geographic distribution of cases varies considerably, with annual indices of dissimilarity suggesting considerable variation in the geographic distribution of cases throughout the study period (D=0.445). The temporal patterns identified by these two sources of information are negatively correlated (-0.40, p<0.001). Notifiable disease clusters occur in the summer in southern regions of the province, whereas cases identified from administrative health data system cluster in the winter season, and further to the north.

CONCLUSIONS

Notifiable disease data may suffer from selection bias; administrative health data may be insufficiently precise without laboratory confirmation. Our results illustrate differences in the spatial and temporal information generated from these two systems of case identification. Future surveillance of gastrointestinal illness of infectious origin may benefit from case ascertainment algorithms based on both sources of data.

A multi-level approach for investigating socio-economic and agricultural risk factors associated with rates of reported cases of Escherichia coli O157 in humans in Alberta, Canada

Using negative binomial and multi-level Poisson models, the authors determined the statistical significance of agricultural and socio-economic risk factors for rates of reported disease associated with Escherichia coli O157 in census subdivisions (CSDs) in Alberta, Canada, 2000-2002. Variables relating to population stability, aboriginal composition of the CSDs, and the economic relationship between CSDs and urban centres were significant risk factors. The percentage of individuals living in low-income households was not a statistically significant risk factor for rates of disease. The statistical significance of cattle density, recorded at a higher geographical level, depended on the method used to correct for overdispersion, the number of levels included in the multi-level models, and the choice of using all reported cases or only sporadic cases. Our results highlight the importance of local socio-economic risk factors in determining rates of disease associated with E. coli O157, but their relationship with individual risk factors requires further evaluation.

Super-shedding and the link between human infection and livestock carriage of Escherichia coli O157

Cattle that excrete more Escherichia coli O157 than others are known as super-shedders. Super-shedding has important consequences for the epidemiology of E. coli O157 in cattle--its main reservoir--and for the risk of human infection, particularly owing to environmental exposure. Ultimately, control measures targeted at super-shedders may prove to be highly effective. We currently have only a limited understanding of both the nature and the determinants of super-shedding. However, super-shedding has been observed to be associated with colonization at the terminal rectum and might also occur more often with certain pathogen phage types. More generally, epidemiological evidence suggests that super-shedding might be important in other bacterial and viral infections.

Cattle density and Shiga toxin-producing Escherichia coli infection in Germany: increased risk for most but not all serogroups

Shiga toxin-producing Escherichia coli (STEC) cause severe gastroenteritis and life-threatening hemolytic-uremic syndrome. For STEC of serogroup O157, association between disease incidence and cattle contact has been established in some countries. For other (non-O157) serogroups, however, accounting for approximately 80% of notified STEC gastroenteritis in Germany, the role of cattle in human infection is less clear. For example, an association of non-O157 STEC infection and cattle density has not been investigated. The aim of this study was thus to investigate a potential association between STEC incidence and cattle density in Germany, with special attention to the non-O157 serogroups. We modeled district-level incidence of notified human STEC cases in relation to cattle density, utilizing German notification data from 2001 through 2003. Cattle numbers came from the national "Proof of Origin and Information Database for Animals." A Bayesian Poisson regression model was used, incorporating independent, as well as spatially correlated, district-level random effects into the analysis. We analyzed 3216 German STEC cases. Cattle density was positively associated with overall STEC incidence. The risk for STEC infection increased by 68% per 100 additional cattle/km(2). The magnitude of the risk estimates differed by serogroup and was greatest for O111. A positive association was found for all major disease-causing serogroups (O26, O103, O111, O128, O145, O157) except O91. The association with serogroup O26 (lowest median age of patients) was only borderline significant. Residual variation indicates that additional factors not under study may also be of importance, and that they may be serogroup- and region-specific, too. In conclusion, this study suggests that living in a cattle-raising region appears to imply risk not only for STEC O157, but also for most non-O157 serogroups. Furthermore, the varying magnitude of this risk and the residual variation found for different serogroups indicate that risk profiles for human STEC infection may be serogroup-specific. This needs to be taken into account in risk factor studies for non-O157 STEC, ideally by reporting risks separately by serogroup.

Surveillance of hemolytic uremic syndrome in children less than 15 years of age, a system to monitor O157 and non-O157 Shiga toxin-producing Escherichia coli infections in France, 1996-2006

BACKGROUND

Since the 1980s, Shiga toxin-producing Escherichia coli (STEC), especially E. coli O157:H7, has been an important cause of food borne disease in industrial countries. In France, as there was no routine screening for STEC in clinical laboratories, enhanced surveillance of hemolytic uremic syndrome (HUS) in children less than 15 years of age was established in 1996 to monitor trends in the incidence of STEC infections.

METHODS

The surveillance system was based on a voluntary national network of pediatricians of 31 pediatric nephrology units in public hospitals.

RESULTS

From 1996 to 2006, the mean annual incidence of HUS was 0.71 cases per 100,000 children less than 15 years of age and 1.87 cases per 100,000 children less than 5 years of age. STEC infections were confirmed in 66% of patients; STEC O157 was the most common serogroup identified in STEC-related HUS (83%). In this 11-year period, 96% of HUS cases were sporadic and only 2 outbreaks caused by STEC O157 and by a dual infection of STEC O26 and O80 were detected.

CONCLUSIONS

An evaluation of the surveillance of pediatric HUS showed that it is a simple and useful system for monitoring trends in STEC infections in France. It provides the information needed to measure the impact of new and changing vehicles of STEC transmission, and evaluate the effectiveness of prevention measures.