Surface sampling methods for Bacillus anthracis spore contamination

"Smart markets": harnessing the potential of new technologies for endemic and emerging infectious disease surveillance in traditional food markets

Emerging and endemic zoonotic diseases continue to threaten human and animal health, our social fabric, and the global economy. Zoonoses frequently emerge from congregate interfaces where multiple animal species and humans coexist, including farms and markets. Traditional food markets are widespread across the globe and create an interface where domestic and wild animals interact among themselves and with humans, increasing the risk of pathogen spillover. Despite decades of evidence linking markets to disease outbreaks across the world, there remains a striking lack of pathogen surveillance programs that can relay timely, cost-effective, and actionable information to decision-makers to protect human and animal health. However, the strategic incorporation of environmental surveillance systems in markets coupled with novel pathogen detection strategies can create an early warning system capable of alerting us to the risk of outbreaks before they happen. Here, we explore the concept of "smart" markets that utilize continuous surveillance systems to monitor the emergence of zoonotic pathogens with spillover potential.IMPORTANCEFast detection and rapid intervention are crucial to mitigate risks of pathogen emergence, spillover and spread-every second counts. However, comprehensive, active, longitudinal surveillance systems at high-risk interfaces that provide real-time data for action remain lacking. This paper proposes "smart market" systems harnessing cutting-edge tools and a range of sampling techniques, including wastewater and air collection, multiplex assays, and metagenomic sequencing. Coupled with robust response pathways, these systems could better enable Early Warning and bolster prevention efforts.

Taking Screenshots of the Invisible: A Study on Bacterial Contamination of Mobile Phones from University Students of Healthcare Professions in Rome, Italy

Mobile phones (MPs) are commonly used both in the personal and professional life. We assessed microbiological contamination of MPs from 108 students in healthcare professions (HPs), in relation to their demographic characteristics and MPs handling habits, collected by means of a questionnaire. Cultural and biochemical tests were performed, and statistical analyses were carried out. Staphylococci were present in 85% of MPs, Enterococci in 37%, Coliforms in 6.5%; E. coli was never detected. Staphylococcus epidermidis was the most frequently isolated staphylococcal species (72% of MPs), followed by S. capitis (14%), S. saprophyticus, S. warneri, S. xylosus (6%), and by S. aureus (4%). Heterotrophic Plate Counts (HPC) at 37 °C, ranged from 0 to 1.2 × 10⁴ CFU/dm² (mean = 362 CFU/dm²). In univariate analysis, the male gender only was significantly associated with higher HPCs and enterococcal contamination. Multiple linear regression models explained only 17% and 16% of the HPC 37 °C and staphylococcal load variability, respectively. Developing specific guidelines for a hygienic use of MPs in clinical settings, for preventing cross-infection risks, is advisable, as well as introducing specific training programs to HP students. MPs decontamination procedures could also be implemented in the community.

Microbiomes of China's Space Station During Assembly, Integration, and Test Operations

Sufficient evidence indicates that orbiting space stations contain diverse microbial populations, which may threaten astronaut health and equipment reliability. Understanding the composition of microbial communities in space stations will facilitate further development of targeted biological safety prevention and maintenance practices. Therefore, this study systematically investigated the microbial community of China's Space Station (CSS). Air and surface samples from 46 sites on the CSS and Assembly Integration and Test (AIT) center were collected, from which 40 bacteria strains were isolated and identified. Most isolates were cold- and desiccation-resistant and adapted to oligotrophic conditions. Bacillus was the dominant bacterial genus detected by both cultivation-based and Illumina MiSeq amplicon sequencing methods. Microbial contamination on the CSS was correlated with encapsulation staff activities. Analysis by spread plate and qPCR revealed that the CSS surface contained 2.24 × 10³-5.47 × 10³ CFU/100 cm² culturable bacteria and 9.32 × 10⁵-5.64 × 10⁶ 16S rRNA gene copies/100cm²; BacLight™ analysis revealed that the viable/total bacterial cell ratio was 1.98-13.28%. This is the first study to provide important systematic insights into the microbiome of the CSS during assembly that describes the pre-launch microbial diversity of the space station. Our findings revealed the following. (1) Bacillus strains and staff activities should be considered major concerns for future biological safety. (2) Autotrophic and multi-resistant microbial communities were widespread in the AIT environment. Although harsh cleaning methods reduced the number of microorganisms, stress-resistant strains were not completely removed. (3) Sampling, storage and analytical methods for the space station were thoroughly optimized, and are expected to be applicable to low-biomass environments in general. Microbiology-related future works will follow up to comprehensively understand the changing characteristics of microbial communities in CSS.

Experimental Study to Develop a Method for Improving Sample Collection to Monitor Laryngoscopes after Reprocessing

BACKGROUND/AIMS

The microbiological surveillance of endoscopes and automated flexible endoscope reprocessing have been proven to be two of the most difficult and controversial areas of infection control in endoscopy. The purpose of this study was to standardize a sampling method for assessing the effectiveness of standard reprocessing operating procedures for flexible fiberoptic laryngoscopes (FFLs).

METHODS

First, the sampling devices were directly inoculated with Bacillus atrophaeus spores; second, tissue non tissue (TNT) wipes were tested on artificially contaminated surfaces and on FFLs.

RESULTS

Comparison of the sponges, cellulose, and TNT wipes indicated that the TNT wipes were more effective in releasing spores (93%) than the sponges (49%) and cellulose wipes (52%). The developed protocol provides a high efficiency for both collection and extraction from the stainless steel surface (87% of the spores were removed and released) and from the FFL (85% of the spores were removed and released), with relatively low standard deviations for recovery efficiency, particularly for the analysis of the FFL.

CONCLUSION

TNT wipes are more efficient for sampling surface areas, thereby aiding in the accuracy and reproducibility of environmental surveillance.

A New Wipe-Sampling Instrument for Measuring the Collection Efficiency of Trace Explosives Residues

Trace explosives detection, a crucial component of many security screening environments, commonly employs wipe-sampling. Since collection of an explosive residue is necessary for detection, it is important to have a thorough understanding of the parameters that affect the efficiency of collection. Current wipe-sampling evaluation techniques for explosive particles have their limits: manual sampling (with fingers or a wand) is limited in its ability to isolate a single parameter and the TL-slip/peel tester is limited to a linear sample path. A new wipe-sampling instrument, utilizing a commercial off-the-shelf (COTS) 3D printer repurposed for its XYZ stage, was developed to address these limitations. This system allowed, for the first time, automated two-dimensional wipe-sampling patterns to be studied while keeping the force and speed of collection constant for the length of the sampling path. This new instrument is not only capable of investigating the same parameters as current technology (wipe materials, test surfaces, forces of collection, and linear sample patterns), it has added capabilities to investigate additional parameters such as directional wipe patterns (i.e. "L" and "U" shapes, square, and serpentine) and allowing for multiple lines to be sampled during a single collection without the need for adjustments by the user. In this work, parametric studies were completed using 1,3,5-trinitroperhydro-1,3,5-triazine (RDX) and the COTS 3D printer for wipe-sampling to establish collection efficiencies for numerous scenarios. Trace explosives detection in field screening environments could be greatly improved with the ability to comprehensively investigate how a wide range of parameters individually affect collection by wipe-sampling. A screener who knows how to properly interrogate any given surface will be much more efficient at detecting trace explosives.

Effect of Sterilants on Amplification and Detection of Target DNA from Bacillus cereus Spores

To conceal criminal activity of a bioterrorist or agroterrorist, the site of pathogen generation is often treated with sterilants to kill the organisms and remove evidence. As dead organisms cannot be analyzed by culture, this study examined whether DNA from sterilant-treated Bacillus cereus spores was viable for amplification. The spores were exposed to five common sterilants: bleach, Sterilox®, oxidizer foam (L-Gel), a peroxyacid (Actril®), and formaldehyde vapor. The spores were inoculated on typical surfaces found in offices and laboratories to test for environmental effects. It was found that the surface influenced the efficiency of recovery of the organisms. The DNA isolated from the recovered spores was successfully detected using RT-qPCR for all treatments except for formaldehyde, by amplifying the phosphatidylinositol phospholipase C and sphingomyelinase genes. The results demonstrated that evidence from sites treated with sterilants can still provide information on the uncultured organism, using DNA amplification.

Considerations for estimating microbial environmental data concentrations collected from a field setting

In the event of an indoor release of an environmentally persistent microbial pathogen such as Bacillus anthracis, the potential for human exposure will be considered when remedial decisions are made. Microbial site characterization and clearance sampling data collected in the field might be used to estimate exposure. However, there are many challenges associated with estimating environmental concentrations of B. anthracis or other spore-forming organisms after such an event before being able to estimate exposure. These challenges include: (1) collecting environmental field samples that are adequate for the intended purpose, (2) conducting laboratory analyses and selecting the reporting format needed for the laboratory data, and (3) analyzing and interpreting the data using appropriate statistical techniques. This paper summarizes some key challenges faced in collecting, analyzing, and interpreting microbial field data from a contaminated site. Although the paper was written with considerations for B. anthracis contamination, it may also be applicable to other bacterial agents. It explores the implications and limitations of using field data for determining environmental concentrations both before and after decontamination. Several findings were of interest. First, to date, the only validated surface/sampling device combinations are swabs and sponge-sticks on stainless steel surfaces, thus limiting availability of quantitative analytical results which could be used for statistical analysis. Second, agreement needs to be reached with the analytical laboratory on the definition of the countable range and on reporting of data below the limit of quantitation. Finally, the distribution of the microbial field data and statistical methods needed for a particular data set could vary depending on these data that were collected, and guidance is needed on appropriate statistical software for handling microbial data. Further, research is needed to develop better methods to estimate human exposure from pathogens using environmental data collected from a field setting.

Microbiological Food Safety Status of Commercially Produced Tomatoes from Production to Marketing

Tomatoes have been implicated in various microbial disease outbreaks and are considered a potential vehicle for foodborne pathogens. Traceback studies mostly implicate contamination during production and/or processing. The microbiological quality of commercially produced tomatoes was thus investigated from the farm to market, focusing on the impact of contaminated irrigation and washing water, facility sanitation, and personal hygiene. A total of 905 samples were collected from three largescale commercial farms from 2012 through 2014. The farms differed in water sources used (surface versus well) and production methods (open field versus tunnel). Levels of total coliforms and Escherichia coli and prevalence of E. coli O157:H7 and Salmonella Typhimurium were determined. Dominant coliforms were identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. No pathogens or E. coli were detected on any of the tomatoes tested throughout the study despite the high levels of coliforms (4.2 to 6.2 log CFU/g) present on the tomatoes at the market. The dominant species associated with tomatoes belonged to the genera Enterobacter, Klebsiella, and Citrobacter. Water used on the farm for irrigation considered not fit for purpose according to national agricultural irrigation standards, with high E. coli levels resulting from either a highly contaminated source water (river water at 3.19 log most probable number [MPN]/100 ml) or improper storage of source water (stored well water at 1.72 log MPN/100 ml). Salmonella Typhimurium was detected on two occasions on a contact surface in the processing facility of the first farm in 2012. Contact surface coliform counts were 2.9 to 4.8 log CFU/cm(2). Risk areas identified in this study were water used for irrigation and poor sanitation practices in the processing facility. Implementation of effective food safety management systems in the fresh produce industry is of the utmost importance to ensure product safety for consumers.

Biosecurity Programs and Assets

Chapter 12 explores the programs and assets that have been assembled internationally, nationally, and regionally to safeguard populations from the threat of biological agents. The programs and assets can be viewed with the framework of comprehensive emergency management, which is made up of mitigation, preparedness, response, and recovery. Nations have come together and taken a stance individually to mitigate the threat. For the most part, these programs produce policy and procedures that support the Biological and Toxin Weapons Convention of 1972. Responding to a biological disaster will be frustrating, confusing, and dangerous for first responders, first receivers, and public health officials. Developed countries are far better trained and equipped to deal with the release of a formulated biological agent than they were 15 years ago. Specific examples of programs and assets that match up with mitigation, preparedness, response, and recovery are discussed herein.

Complete genome sequences for 35 biothreat assay-relevant bacillus species

In 2011, the Association of Analytical Communities (AOAC) International released a list of Bacillus strains relevant to biothreat molecular detection assays. We present the complete and annotated genome assemblies for the 15 strains listed on the inclusivity panel, as well as the 20 strains listed on the exclusivity panel.

A genetic inventory of spacecraft and associated surfaces

Terrestrial organisms or other contaminants that are transported to Mars could interfere with efforts to study the potential for indigenous martian life. Similarly, contaminants that make the round-trip to Mars and back to Earth could compromise the ability to discriminate an authentic martian biosignature from a terrestrial organism. For this reason, it is important to develop a comprehensive inventory of microbes that are present on spacecraft to avoid interpreting their traces as authentic extraterrestrial biosignatures. Culture-based methods are currently used by NASA to assess spacecraft cleanliness but deliberately detect only a very small subset of total organisms present. The National Research Council has recommended that molecular (DNA)-based identification techniques should be developed as one aspect of managing the risk that terrestrial contamination could interfere with detection of life on (or returned from) Mars. The current understanding of the microbial diversity associated with spacecraft and clean room surfaces is expanding, but the capability to generate a comprehensive inventory of the microbial populations present on spacecraft outbound from Earth would address multiple considerations in planetary protection, relevant to both robotic and human missions. To this end, a 6-year genetic inventory study was undertaken by a NASA/JPL team. It was completed in 2012 and included delivery of a publicly available comprehensive final report. The genetic inventory study team evaluated the utility of three analytical technologies (conventional cloning techniques, PhyloChip DNA microarrays, and 454 tag-pyrosequencing) and combined them with a systematic methodology to collect, process, and archive nucleic acids as the first steps in assessing the phylogenetic breadth of microorganisms on spacecraft and associated surfaces.

A rapid and repeatable method to deposit bioaerosols on material surfaces

A simple method for repeatably inoculating surfaces with a precise quantity of aerosolized spores was developed. Laboratory studies were conducted to evaluate the variability of the method within and between experiments, the spatial distribution of spore deposition, the applicability of the method to complex surface types, and the relationship between material surface roughness and spore recoveries. Surface concentrations, as estimated by recoveries from wetted-wipe sampling, were between 5×10(3) and 1.5×10(4)CFUcm(-2) across the entire area (930cm(2)) inoculated. Between-test variability (Cv) in spore recoveries was 40%, 81%, 66%, and 20% for stainless steel, concrete, wood, and drywall, respectively. Within-test variability was lower, and did not exceed 33%, 47%, 52%, and 20% for these materials. The data demonstrate that this method is repeatable, is effective at depositing spores across a target surface area, and can be used to dose complex materials such as concrete, wood, and drywall. In addition, the data demonstrate that surface sampling recoveries vary by material type, and this variability can partially be explained by the material surface roughness index. This deposition method was developed for use in biological agent detection, sampling, and decontamination studies, however, is potentially beneficial to any scientific discipline that investigates surfaces containing aerosol-borne particles.

Detecting laboratory DNA contamination using polyester-rayon wipes: a method validation study

Due to the high sensitivity of many PCR assays, extraneous target DNA in a laboratory setting can lead to false positive results. To assess the presence of extraneous DNA, many laboratories use gauze wipes to sample laboratory surfaces. The accuracy, precision, limits of detection, linearity, and robustness of a wipe test method and each associated wipe processing step were evaluated using E. coli genomic DNA. The method demonstrated a limit of detection of 108 copies of DNA, which equates to detectable surface concentration of 4.5×10(5) copies of DNA per area sampled. Recovery efficiency or accuracy is 22±10% resulting from a >58% loss of DNA occurring at the wipe wash step. The method is robust, performing consistently despite deliberate modifications of the protocol.

Storage Effects on Sample Integrity of Environmental Surface Sampling Specimens with Bacillus anthracis Spores

The effect of packaging, shipping temperatures and storage times on recovery of Bacillus anthracis. Sterne spores from swabs was investigated. Macrofoam swabs were pre-moistened, inoculated with Bacillus anthracis spores, and packaged in primary containment or secondary containment before storage at -15°C, 5°C, 21°C, or 35°C for 0-7 days. Swabs were processed according to validated Centers for Disease Control/Laboratory Response Network culture protocols, and the percent recovery relative to a reference sample (T₀) was determined for each variable. No differences were observed in recovery between swabs held at -15° and 5°C, (p ≥ 0.23). These two temperatures provided significantly better recovery than swabs held at 21°C or 35°C (all 7 days pooled, p ≤ 0.04). The percent recovery at 5°C was not significantly different if processed on days 1, 2 or 4, but was significantly lower on day 7 (day 2 vs. 7, 5°C, 10², p=0.03). Secondary containment provided significantly better percent recovery than primary containment, regardless of storage time (5°C data, p ≤ 0.008). The integrity of environmental swab samples containing Bacillus anthracis spores shipped in secondary containment was maintained when stored at -15°C or 5°C and processed within 4 days to yield the optimum percent recovery of spores.

Comparison of swab and sponge methodologies for identification of Acinetobacter baumannii from the hospital environment

The ideal sampling method for identification of Acinetobacter baumannii from the health care environment is unknown. In this study, we sampled 145 surfaces in the rooms of patients with known A. baumannii colonization/infection, comparing two methods: swab and sponge. The sensitivity of the swab method was 87%, while the sensitivity of the sponge method was 75%. Given the comparable results, use of the cheaper and less laborious swab technique is acceptable and may be preferable.

Comparison of quantitative PCR and culture-based methods for evaluating dispersal of Bacillus thuringiensis endospores at a bioterrorism hoax crime scene

Since the anthrax mail attacks of 2001, law enforcement agencies have processed thousands of suspicious mail incidents globally, many of which are hoax bioterrorism threats. Bio-insecticide preparations containing Bacillus thuringiensis (Bt) spores have been involved in several such threats in Australia, leading to the requirement for rapid and sensitive detection techniques for this organism, a close relative of Bacillus anthracis. Here we describe the development of a quantitative PCR (qPCR) method for the detection of Bt crystal toxin gene cry1, and evaluation of the method's effectiveness during a hoax bioterrorism event in 2009. When combined with moist wipe sampling, the cry1 qPCR was a rapid, reliable, and sensitive diagnostic tool for detecting and quantifying Bt contamination, and mapping endospore dispersal within a mail sorting facility. Results from the cry1 qPCR were validated by viable counts of the same samples on Bacillus-selective agar (PEMBA), which revealed a similar pattern of contamination. Extensive and persistent contamination of the facility was detected, both within the affected mailroom, and extending into office areas up to 30m distant from the source event, emphasising the need for improved containment procedures for suspicious mail items, both during and post-event. The cry1 qPCR enables detection of both viable and non-viable Bt spores and cells, which is important for historical crime scenes or scenes subjected to decontamination. This work provides a new rapid method to add to the forensics toolbox for crime scenes suspected to be contaminated with biological agents.

National validation study of a cellulose sponge wipe-processing method for use after sampling Bacillus anthracis spores from surfaces

This work was initiated to address the gaps identified by Congress regarding validated biothreat environmental sampling and processing methods. Nine Laboratory Response Network-affiliated laboratories participated in a validation study of a cellulose sponge wipe-processing protocol for the recovery, detection, and quantification of viable Bacillus anthracis Sterne spores from steel surfaces. Steel coupons (645.16 cm(2)) were inoculated with 1 to 4 log(10) spores and then sampled with cellulose sponges (Sponge-Stick; 3M, St. Paul, MN). Surrogate dust and background organisms were added to the sponges to mimic environmental conditions. Labs processed the sponges according to the provided protocol. Sensitivity, specificity, and mean percent recovery (%R), between-lab variability, within-lab variability, and total percent coefficient of variation were calculated. The mean %R (standard error) of spores from the surface was 32.4 (4.4), 24.4 (2.8), and 30.1 (2.3) for the 1-, 2-, and 4-log(10) inoculum levels, respectively. Sensitivities for colony counts were 84.1%, 100%, and 100% for the 1-, 2-, and 4-log(10) inocula, respectively. These data help to characterize the variability of the processing method and thereby enhance confidence in the interpretation of the results of environmental sampling conducted during a B. anthracis contamination investigation.

The NYC native air sampling pilot project: using HVAC filter data for urban biological incident characterization

Native air sampling (NAS) is distinguished from dedicated air sampling (DAS) devices (eg, BioWatch) that are deployed to detect aerosol disseminations of biological threat agents. NAS uses filter samples from heating, ventilation, and air conditioning (HVAC) systems in commercial properties for environmental sampling after DAS detection of biological threat agent incidents. It represents an untapped, scientifically sound, efficient, widely distributed, and comparably inexpensive resource for postevent environmental sampling. Calculations predict that postevent NAS would be more efficient than environmental surface sampling by orders of magnitude. HVAC filter samples could be collected from pre-identified surrounding NAS facilities to corroborate the DAS alarm and delineate the path taken by the bioaerosol plume. The New York City (NYC) Native Air Sampling Pilot Project explored whether native air sampling would be acceptable to private sector stakeholders and could be implemented successfully in NYC. Building trade associations facilitated outreach to and discussions with property owners and managers, who expedited contact with building managers of candidate NAS properties that they managed or owned. Nominal NAS building requirements were determined; procedures to identify and evaluate candidate NAS facilities were developed; data collection tools and other resources were designed and used to expedite candidate NAS building selection and evaluation in Manhattan; and exemplar environmental sampling playbooks for emergency responders were completed. In this sample, modern buildings with single or few corporate tenants were the best NAS candidate facilities. The Pilot Project successfully demonstrated that in one urban setting a native air sampling strategy could be implemented with effective public-private collaboration.

Evaluation of procedures for the collection, processing, and analysis of biomolecules from low-biomass surfaces

To comprehensively assess microbial diversity and abundance via molecular-analysis-based methods, procedures for sample collection, processing, and analysis were evaluated in depth. A model microbial community (MMC) of known composition, representative of a typical low-biomass surface sample, was used to examine the effects of variables in sampling matrices, target cell density/molecule concentration, and cryogenic storage on the overall efficacy of the sampling regimen. The MMC used in this study comprised 11 distinct species of bacterial, archaeal, and fungal lineages associated with either spacecraft or clean-room surfaces. A known cellular density of MMC was deposited onto stainless steel coupons, and after drying, a variety of sampling devices were used to recover cells and biomolecules. The biomolecules and cells/spores recovered from each collection device were assessed by cultivable and microscopic enumeration, and quantitative and species-specific PCR assays. rRNA gene-based quantitative PCR analysis showed that cotton swabs were superior to nylon-flocked swabs for sampling of small surface areas, and for larger surfaces, biological sampling kits significantly outperformed polyester wipes. Species-specific PCR revealed differential recovery of certain species dependent upon the sampling device employed. The results of this study empower current and future molecular-analysis-based microbial sampling and processing methodologies.

Recovery of bacillus spore contaminants from rough surfaces: a challenge to space mission cleanliness control

Microbial contaminants on spacecraft can threaten the scientific integrity of space missions due to probable interference with life detection experiments. Therefore, space agencies measure the cultivable spore load ("bioburden") of a spacecraft. A recent study has reported an insufficient recovery of Bacillus atrophaeus spores from Vectran fabric, a typical spacecraft airbag material (A. Probst, R. Facius, R. Wirth, and C. Moissl-Eichinger, Appl. Environ. Microbiol. 76:5148-5158, 2010). Here, 10 different sampling methods were compared for B. atrophaeus spore recovery from this rough textile, revealing significantly different efficiencies (0.5 to 15.4%). The most efficient method, based on the wipe-rinse technique (foam-spatula protocol; 13.2% efficiency), was then compared to the current European Space Agency (ESA) standard wipe assay in sampling four different kinds of spacecraft-related surfaces. Results indicate that the novel protocol out-performed the standard method with an average efficiency of 41.1% compared to 13.9% for the standard method. Additional experiments were performed by sampling Vectran fabric seeded with seven different spore concentrations and five different Bacillus species (B. atrophaeus, B. anthracis Sterne, B. megaterium, B. thuringiensis, and B. safensis). Among these, B. atrophaeus spores were recovered with the highest (13.2%) efficiency and B. anthracis Sterne spores were recovered with the lowest (0.3%) efficiency. Different inoculation methods of seeding spores on test surfaces (spotting and aerosolization) resulted in different spore recovery efficiencies. The results of this study provide a step forward in understanding the spore distribution on and recovery from rough surfaces. The results presented will contribute relevant knowledge to the fields of astrobiology and B. anthracis research.

Remediating office environments of spore-forming bacteria

This study examines decontamination processes that were developed on an emergency basis to eliminate Bacillus anthracis spores from deliberately contaminated buildings. The recommended steps include a survey with sampling, the removal of sensitive items, and HEPA vacuuming of all readily available surfaces, followed by biocide treatment and subsequent analyses for viable cells. There are several analytical challenges posed by this approach. These include the ability to discriminate the added strain from naturally occurring resident microbes, determining detection limits for anthrax spores in settled dusts, and detecting viable but nonculturable spores. There are also logistical issues relating to the various skill sets required from investigation to reconstruction. In the present study, a model office was constructed, and a strain of Bacillus pumilus was isolated from the carpet and reintroduced to the office in excess. The abundance of the B. pumilus strain was monitored in settled dust using a strain-specific, quantitative polymerase chain reaction (QPCR)-based detection method following repeated HEPA vacuum cleanings. The QPCR method had a limit of detection corresponding to < or = 10(2) colony forming units per gram of settled dust. QPCR results were compared with measures of dust recoveries and fungal glucan and endotoxin levels in the dust samples. The largest fraction (ca. 81%) of added spores was recovered during the first HEPA cleaning. Subsequent cleanings resulted in incrementally lower recoveries, with removal of 93% of the initial inoculum by the third HEPA vacuuming. HEPA vacuuming prior to removal of items such as office contents and furnishings would result in much less resuspension of dust and limiting the extent of contamination. This approach also ensures that residual contaminants are as low as can be reasonably achieved.

Setting risk-informed environmental standards for Bacillus anthracis spores

In many cases, human health risk from biological agents is associated with aerosol exposures. Because air concentrations decline rapidly after a release, it may be necessary to use concentrations found in other environmental media to infer future or past aerosol exposures. This article presents an approach for linking environmental concentrations of Bacillus. anthracis (B. anthracis) spores on walls, floors, ventilation system filters, and in human nasal passages with human health risk from exposure to B. anthracis spores. This approach is then used to calculate example values of risk-informed concentration standards for both retrospective risk mitigation (e.g., prophylactic antibiotics) and prospective risk mitigation (e.g., environmental clean up and reoccupancy). A large number of assumptions are required to calculate these values, and the resulting values have large uncertainties associated with them. The values calculated here suggest that documenting compliance with risks in the range of 10(-4) to 10(-6) would be challenging for small diameter (respirable) spore particles. For less stringent risk targets and for releases of larger diameter particles (which are less respirable and hence less hazardous), environmental sampling would be more promising.

Multigeneration cross contamination of mail with Bacillus species spores by tumbling

In 2001, envelopes loaded with Bacillus anthracis spores were mailed to Senators Daschle and Leahy as well as to the New York Post and NBC News buildings. Additional letters may have been mailed to other news agencies because there was confirmed anthrax infection of employees at these locations. These events heightened the awareness of the lack of understanding of the mechanism(s) by which objects contaminated with a biological agent might spread disease. This understanding is crucial for the estimation of the potential for exposure to ensure the appropriate response in the event of future attacks. In this study, equipment to simulate interactions between envelopes and procedures to analyze the spread of spores from a "payload" envelope (i.e., loaded internally with a powdered spore preparation) onto neighboring envelopes were developed. Another process to determine whether an aerosol could be generated by opening contaminated envelopes was developed. Subsequent generations of contaminated envelopes originating from a single payload envelope showed a consistent two-log decrease in the number of spores transferred from one generation to the next. Opening a tertiary contaminated envelope resulted in an aerosol containing 10(3) B. anthracis spores. We developed a procedure for sampling contaminated letters by a nondestructive method aimed at providing information useful for consequence management while preserving the integrity of objects contaminated during the incident and preserving evidence for law enforcement agencies.

National validation study of a swab protocol for the recovery of Bacillus anthracis spores from surfaces

Twelve Laboratory Response Network (LRN) affiliated laboratories participated in a validation study of a macrofoam swab protocol for the recovery, detection, and quantification of viable B. anthracis (BA) Sterne spores from steel surfaces. CDC personnel inoculated steel coupons (26cm(2)) with 1-4 log(10) BA spores and recovered them by sampling with pre-moistened macrofoam swabs. Phase 1 (P1) of the study evaluated swabs containing BA only, while dust and background organisms were added to swabs in Phase 2 (P2) to mimic environmental conditions. Laboratories processed swabs and enumerated spores by culturing eluted swab suspensions and counting colonies with morphology consistent with BA. Processed swabs were placed in enrichment broth, incubated 24h, and cultured by streaking for isolation. Real-time PCR was performed on selected colonies from P2 samples to confirm the identity of BA. Mean percent recovery (%R) of spores from the surface ranged from 15.8 to 31.0% (P1) and from 27.9 to 55.0% (P2). The highest mean percent recovery was 31.0% (sd 10.9%) for P1 (4 log(10) inoculum) and 55.0% (sd 27.6%) for P2 (1 log(10) inoculum). The overall %R was higher for P2 (44.6%) than P1 (24.1%), but the overall reproducibility (between-lab variability) was lower in P2 than in P1 (25.0 vs 16.5%CV, respectively). The overall precision (within-lab variability) was close to identical for P1 and P2 (44.0 and 44.1, respectively), but varied greatly between inoculum levels. The protocol demonstrated linearity in %R over the three inoculum levels and is able to detect between 26 and 5x10(6)spores/26cm(2). Sensitivity as determined by culture was >98.3% for both phases and all inocula, suggesting that the culture method maintains sensitivity in the presence of contaminants. The enrichment broth method alone was less sensitive for sampled swabs (66.4%) during P2, suggesting that the presence of background organisms inhibited growth or isolation of BA from the broth. The addition of real-time PCR testing to the assay increased specificity from >85.4% to >95.0% in P2. Although the precision was low at the 1 log(10) inoculum level in both phases (59.0 and 50.2%), this swab processing protocol, was sensitive, specific, precise, and reproducible at 2-4 log(10)/26cm(2) spore concentrations.

Use of a foam spatula for sampling surfaces after bioaerosol deposition

The present study had three goals: (i) to evaluate the relative quantities of aerosolized Bacillus atrophaeus spores deposited on the vertical, horizontal top, and horizontal bottom surfaces in a chamber; (ii) to assess the relative recoveries of the aerosolized spores from glass and stainless steel surfaces with a polyester swab and a macrofoam sponge wipe; and (iii) to estimate the relative recovery efficiencies of aerosolized B. atrophaeus spores and Pantoea agglomerans using a foam spatula at several different bacterial loads by aerosol distribution on glass surfaces. The majority of spores were collected from the bottom horizontal surface regardless of which swab type and extraction protocol were used. Swabbing with a macrofoam sponge wipe was more efficient in recovering spores from surfaces contaminated with high bioaerosol concentrations than swabbing with a polyester swab. B. atrophaeus spores and P. agglomerans culturable cells were detected on glass surfaces using foam spatulas when the theoretical surface bacterial loads were 2.88 x 10(4) CFU and 8.09 x 10(6) CFU per 100-cm(2) area, respectively. The median recovery efficiency from the surfaces using foam spatulas was equal to 9.9% for B. atrophaeus spores when the recovery was calculated relative to the theoretical surface spore load. Using a foam spatula permits reliable sampling of spores on the bioaerosol-exposed surfaces in a wide measuring range. The culturable P. agglomerans cells were recovered with a median efficiency of 0.001%, but staining the swab extracts with fluorescent dyes allowed us to observe that the viable cell numbers were higher by 1.83 log units than culturable organisms. However, additional work is needed to improve the analysis of the foam extracts in order to decrease the limit of detection of Bacillus spores and Gram-negative bacteria on contaminated surfaces.

The infrared spectra of Bacillus bacteria part II: sporulated Bacillus--the effect of vegetative cells and contributions of calcium dipicolinate trihydrate, CaDP.3H2O

Our previous paper showed that certain infrared (IR) peaks, e.g., the peak at 1739 cm(-1), are due to varying (trace) amounts of vegetative cells amongst the Bacillus spores and that these and other vegetative bands are associated with lipid-soluble compounds, likely an ester or phospholipid. This work investigates the infrared spectra of eight different sporulated Bacillus bacteria. For the endospores it is observed that peaks at 1441, 1277, and 1015 cm(-1) along with a distinct quartet of peaks at 766, 725, 701, and 659 cm(-1) are clearly associated with calcium dipicolinate trihydrate, CaDP.3H2O. It is emphasized that the spore peaks, especially the quartet, arise from the calcium dipicolinate trihydrate and not from dipicolinic acid or other dipicolinate hydrate salts. The CaDP.3H2O infrared peaks and the effects of hydration are studied using quantum chemistry in the PQS software package. The quartet is associated with many modes including contributions from the Ca2+ counterion and hydration waters including Ca-O-H bends, H2O-Ca-O torsions, and O-C-O bends. The 1441 and 1015 cm(-1) modes are planar pyridine modes with the 1441 cm(-1) mode primarily a ring C-N stretch and the 1015 cm(-1) mode primarily a ring C-C stretch.

Implications of limits of detection of various methods for Bacillus anthracis in computing risks to human health

Used for decades for biological warfare, Bacillus anthracis (category A agent) has proven to be highly stable and lethal. Quantitative risk assessment modeling requires descriptive statistics of the limit of detection to assist in defining the exposure. Furthermore, the sensitivities of various detection methods in environmental matrices are vital information for first responders. A literature review of peer-reviewed journal articles related to methods for detection of B. anthracis was undertaken. Articles focused on the development or evaluation of various detection approaches, such as PCR, real-time PCR, immunoassay, etc. Real-time PCR and PCR were the most sensitive methods for the detection of B. anthracis, with median instrument limits of detection of 430 and 440 cells/ml, respectively. There were very few peer-reviewed articles on the detection methods for B. anthracis in the environment. The most sensitive limits of detection for the environmental samples were 0.1 CFU/g for soil using PCR-enzyme-linked immunosorbent assay (ELISA), 17 CFU/liter for air using an ELISA-biochip system, 1 CFU/liter for water using cultivation, and 1 CFU/cm(2) for stainless steel fomites using cultivation. An exponential dose-response model for the inhalation of B. anthracis estimates of risk at concentrations equal to the environmental limit of detection determined the probability of death if untreated to be as high as 0.520. Though more data on the environmental limit of detection would improve the assumptions made for the risk assessment, this study's quantification of the risk posed by current limitations in the knowledge of detection methods should be considered when employing those methods in environmental monitoring and cleanup strategies.

Surface sampling of spores in dry-deposition aerosols

The ability to reliably and reproducibly sample surfaces contaminated with a biological agent is a critical step in measuring the extent of contamination and determining if decontamination steps have been successful. The recovery operations following the 2001 attacks with Bacillus anthracis spores were complicated by the fact that no standard sample collection format or decontamination procedures were established. Recovery efficiencies traditionally have been calculated based upon biological agents which were applied to test surfaces in a liquid format and then allowed to dry prior to sampling tests, which may not be best suited for a real-world event with aerosolized biological agents. In order to ascertain if differences existed between air-dried liquid deposition and biological spores which were allowed to settle on a surface in a dried format, a study was undertaken to determine if differences existed in surface sampling recovery efficiencies for four representative surfaces. Studies were then undertaken to compare sampling efficiencies between liquid spore deposition and aerosolized spores which were allowed to gradually settle under gravity on four different test coupon types. Tests with both types of deposition compared efficiencies of four unique swabbing materials applied to four surfaces with various surface properties. Our studies demonstrate that recovery of liquid-deposited spores differs significantly from recovery of dry aerosol-deposited spores in most instances. Whether the recovery of liquid-deposited spores is overexaggerated or underrepresented with respect to that of aerosol-deposited spores depends upon the surface material being tested.

How clean is clean? Proposed methods for hospital cleaning assessment

SUMMARY

Reducing infection rates in hospitals depends on a variety of factors, including environmental measures. Although microbiological standards have been proposed for surface hygiene in hospitals, standard methods for environmental sampling have not been discussed. The aim of this study was to assess the effectiveness of cleaning/disinfection in critical care units using the wipe-rinse method to detect an indicator organism and dipslides to quantitatively determine the microbial load. Frequent-hand-touch surfaces from clinical and non-clinical areas were microbiologically surveyed, targeting both meticillin-susceptible (MSSA) and meticillin-resistant (MRSA) Staphylococcus aureus. A subset of the surfaces targeted was sampled quantitatively to determine the total aerobic count. MRSA was isolated from 9 (6.9%) and MSSA was isolated from 15 (11.5%) of the 130 samples collected. Seven of 81 (8.6%) samples collected from non-clinical areas grew MRSA, compared with two (4.1%) from 49 samples collected from clinical areas. Of 116 sites screened for the total aerobic count, 9 (7.7%) showed >5 cfu/cm(2) microbial growth. Bed frames, telephones and computer keyboards were among the surfaces that yielded a high total viable count. There was no direct correlation between the findings of total aerobic count and MRSA isolation. We suggest, however, that combining both standards will give a more effective method of assessing the efficacy of cleaning/disinfection strategy. Further work is required to evaluate and refine these standards in order to assess the frequency of cleaning required for a particular area, or for changing the protocol or materials used.

Adaptive management: a paradigm for remediation of public facilities following a terrorist attack

Terrorist actions are aimed at maximizing harm (health, psychological, economical, and political) through the combined physical impacts of the act and fear. Immediate and effective response to a terrorist act is critical to limit human and environmental harm, effectively restore facility function, and maintain public confidence. Though there have been terrorist attacks in public facilities that we have learned from, overall our experiences in restoration of public facilities following a terrorist attack are limited. Restoration of public facilities following a release of a hazardous material is inherently far more complex than in industrial settings and has many unique technical, economic, social, and political challenges. For example, there may be a great need to quickly restore the facility to full operation and allow public access even though it was not designed for easy or rapid restoration, and critical information is needed for quantitative risk assessment and effective restoration must be anticipated to be incomplete and uncertain. Whereas present planning documents have substantial linearity in their organization, the "adaptive management" paradigm provides a constructive parallel paradigm for restoration of public facilities that anticipates and plans for uncertainty, inefficiencies, and stakeholder participation. Adaptive management grew out of the need to manage and restore natural resources in highly complex and changing environments with limited knowledge about causal relationships and responses to restoration actions. Similarities between natural resource management and restoration of a public facility after a terrorist attack suggest that integration of adaptive management principles explicitly into restoration processes will result in substantially enhanced and flexible responses necessary to meet the uncertainties of potential terrorist attacks.

Inhibiting the transport of hazardous spores using polymer-based solutions

A series of polymer solutions were developed for the purpose of immobilizing aerosolized 1-10 mu m sized hazardous biological particles. The polymer solutions were designed as tools for emergency response and remediation personnel. The inhibition of secondary aerosolization and migration of biothreat particles has important implications for public health protection and contamination cleanup. Limiting further dispersion of particles such as Bacillus anthracis spores may reduce inhalation hazards and enhance remediation efficiencies. This study evaluated film-forming polymers that have multiple functional groups capable of attracting and binding particles; these included acrylates, cellulosics, vinyl polymers, and polyurethanes. The selected polymers were combined with appropriate solvents to design solutions that met specific performance objectives. The polymer solutions were then evaluated for key characteristics, such as high adhesion, high elasticity, low density, short drying time, low viscosity, and low surface tension. These solutions were also evaluated for their adhesion to biothreat agent in a series of wind tunnel experiments using highly refined aerosolized Bacillus atrophaeus spores (a simulant for anthrax, 1-3 mu m). Results demonstrated that a polymer solution, an amphoteric acrylate identified as NS-2, was the best candidate for attaching to spores and inhibiting reaerosolization. This polymer solution was anionic, thus providing the electrostatic (coulombic) attraction to cationic spores, had low surface tension, and performed well in wind tunnel tests.

An integrated culture and real-time PCR method to assess viability of disinfectant treated Bacillus spores using robotics and the MPN quantification method

Using robotics and the MPN technique, a 96-microwell method was developed to compare two procedures for enumeration of viable chlorine-treated B. atrophaeus spores: broth-culture enrichment followed by real-time polymerase chain reaction analysis; and filter plating on agar. Recoveries of chlorine-treated spores were improved by broth enrichment over filter plating, whereas recoveries of non-treated spores were not different in the two procedures.

Evaluation of rayon swab surface sample collection method forBacillusspores from nonporous surfaces

AIM

To evaluate US Centers for Disease Control and Prevention recommended swab surface sample collection method for recovery efficiency and limit of detection for powdered Bacillus spores from nonporous surfaces.

METHODS AND RESULTS

Stainless steel and painted wallboard surface coupons were seeded with dry aerosolized Bacillus atrophaeus spores and surface concentrations determined. The observed mean rayon swab recovery efficiency from stainless steel was 0.41 with a standard deviation (SD) of +/-0.17 and for painted wallboard was 0.41 with an SD of +/-0.23. Evaluation of a sonication extraction method for the rayon swabs produced a mean extraction efficiency of 0.76 with an SD of +/-0.12. Swab recovery quantitative limits of detection were estimated at 25 colony forming units (CFU) per sample area for both stainless steel and painted wallboard.

CONCLUSIONS

The swab sample collection method may be appropriate for small area sampling (10 -25 cm2) with a high agent concentration, but has limited value for large surface areas with a low agent concentration. The results of this study provide information necessary for the interpretation of swab environmental sample collection data, that is, positive swab samples are indicative of high surface concentrations and may imply a potential for exposure, whereas negative swab samples do not assure that organisms are absent from the surfaces sampled and may not assure the absence of the potential for exposure.

SIGNIFICANCE AND IMPACT OF THE STUDY

It is critical from a public health perspective that the information obtained is accurate and reproducible. The consequence of an inappropriate public health response founded on information gathered using an ineffective or unreliable sample collection method has the potential for undesired social and economic impact.

Evaluation of vacuum filter sock surface sample collection method for Bacillus spores from porous and non-porous surfaces

Vacuum filter socks were evaluated for recovery efficiency of powdered Bacillus atrophaeus spores from two non-porous surfaces, stainless steel and painted wallboard and two porous surfaces, carpet and bare concrete. Two surface coupons were positioned side-by-side and seeded with aerosolized Bacillus atrophaeus spores. One of the surfaces, a stainless steel reference coupon, was sized to fit into a sample vial for direct spore removal, while the other surface, a sample surface coupon, was sized for a vacuum collection application. Deposited spore material was directly removed from the reference coupon surface and cultured for enumeration of colony forming units (CFU), while deposited spore material was collected from the sample coupon using the vacuum filter sock method, extracted by sonication and cultured for enumeration. Recovery efficiency, which is a measure of overall transfer effectiveness from the surface to culture, was calculated as the number of CFU enumerated from the filter sock sample per unit area relative to the number of CFU enumerated from the co-located reference coupon per unit area. The observed mean filter sock recovery efficiency from stainless steel was 0.29 (SD = 0.14, n = 36), from painted wallboard was 0.25 (SD = 0.15, n = 36), from carpet was 0.28 (SD = 0.13, n = 40) and from bare concrete was 0.19 (SD = 0.14, n = 44). Vacuum filter sock recovery quantitative limits of detection were estimated at 105 CFU m(-2) from stainless steel and carpet, 120 CFU m(-2) from painted wallboard and 160 CFU m(-2) from bare concrete. The method recovery efficiency and limits of detection established in this work provide useful guidance for the planning of incident response environmental sampling for biological agents such as Bacillus anthracis.

Evaluation of two surface sampling methods for detection of Erwinia herbicola on a variety of materials by culture and quantitative PCR

This research was designed to evaluate surface sampling protocols for use with culture and quantitative PCR (QPCR) amplification assay for detection of the gram-negative bacterial biothreat simulant Erwinia herbicola on a variety of surface materials. Surfaces selected for evaluation were wood laminate, glass and computer monitor screens, metal file cabinets, plastic arena seats, nylon seat cushions, finished concrete flooring, and vinyl tile flooring. Laboratory and test chamber studies were performed to evaluate two sampling methods, a sponge and a macrofoam swab, for detection of E. herbicola on surface materials. In laboratory trials, seven materials were inoculated with a known concentration of E. herbicola cells and samples were collected from the surfaces of the materials to determine sampling efficiencies. Culture analysis was ineffective for assessing E. herbicola collection efficiency because very few culturable cells were obtained from surface samples. QPCR demonstrated that E. herbicola DNA was present in high concentrations on all of the surface samples, and sampling efficiencies ranged from 0.7 to 52.2%, depending on the sampling method and the surface material. The swab was generally more efficient than the sponge for collection of E. herbicola from surfaces. Test chamber trials were also performed in which E. herbicola was aerosolized into the chamber and allowed to settle onto test materials. Surface sampling results supported those obtained in laboratory trials. The results of this study demonstrate the capabilities of QPCR to enhance the detection and enumeration of biocontaminants on surface materials and provide information on the comparability of sampling methods.

Evaluation of a wipe surface sample method for collection of Bacillus spores from nonporous surfaces

Polyester-rayon blend wipes were evaluated for efficiency of extraction and recovery of powdered Bacillus atrophaeus spores from stainless steel and painted wallboard surfaces. Method limits of detection were also estimated for both surfaces. The observed mean efficiency of polyester-rayon blend wipe recovery from stainless steel was 0.35 with a standard deviation of +/-0.12, and for painted wallboard it was 0.29 with a standard deviation of +/-0.15. Evaluation of a sonication extraction method for the polyester-rayon blend wipes produced a mean extraction efficiency of 0.93 with a standard deviation of +/-0.09. Wipe recovery quantitative limits of detection were estimated at 90 CFU per unit of stainless steel sample area and 105 CFU per unit of painted wallboard sample area. The method recovery efficiency and limits of detection established in this work provide useful guidance for the planning of incident response environmental sampling following the release of a biological agent such as Bacillus anthracis.

Evaluation of a macrofoam swab protocol for the recovery of Bacillus anthracis spores from a steel surface

A protocol to recover Bacillus anthracis spores from a steel surface using macrofoam swabs was evaluated for its accuracy, precision, reproducibility, and limit of detection. Macrofoam swabs recovered 31.7 to 49.1% of spores from 10-cm2 steel surfaces with a < or =32.7% coefficient of variation in sampling precision and reproducibility for inocula of > or =38 spores.

Forensic application of microbiological culture analysis to identify mail intentionally contaminated with Bacillus anthracis spores

The discovery of a letter intentionally filled with dried Bacillus anthracis spores in the office of a United States senator prompted the collection and quarantine of all mail in congressional buildings. This mail was subsequently searched for additional intentionally contaminated letters. A microbiological sampling strategy was used to locate heavy contamination within the 642 separate plastic bags containing the mail. Swab sampling identified 20 bags for manual and visual examination. Air sampling within the 20 bags indicated that one bag was orders of magnitude more contaminated than all the others. This bag contained a letter addressed to Senator Patrick Leahy that had been loaded with dried B. anthracis spores. Microbiological sampling of compartmentalized batches of mail proved to be efficient and relatively safe. Efficiency was increased by inoculating culture media in the hot zone rather than transferring swab samples to a laboratory for inoculation. All mail sampling was complete within 4 days with minimal contamination of the sampling environment or personnel. However, physically handling the intentionally contaminated letter proved to be exceptionally hazardous, as did sorting of cross-contaminated mail, which resulted in generation of hazardous aerosol and extensive contamination of protective clothing. Nearly 8 x 10(6) CFU was removed from the most highly cross-contaminated piece of mail found. Tracking data indicated that this and other heavily contaminated envelopes had been processed through the same mail sorting equipment as, and within 1 s of, two intentionally contaminated letters.

Quantitative analysis of residual protein contamination on reprocessed surgical instruments

'Ready-for-use' instruments from surgical instrument trays were examined after routine cleaning and sterilization in a blinded study. These reprocessed instruments originated from five National Health Service hospital trust sterile service departments in England and Wales. Determination of residual protein and peptide contamination was carried out by acid stripping of the instrument surfaces, hydrolysis of the constituent amino acids and quantitative total amino acid analysis. One hundred and twenty instruments were analysed, and the median levels of residual protein contamination per instrument for the individual trays were 267, 260, 163, 456 and 756 microg. Scanning electron microscopy and energy dispersive X-ray spectroscopic analyses of the instruments showed that tissue deposits were localized on surfaces, but there was no significant correlation between overall protein soiling and instrument complexity. The highest levels of residual contamination were found on instruments used for tonsillectomy and adenoid surgery.

Community-associated methicillin-resistant Staphylococcus aureus skin infections in a religious community

In September 2004, an outbreak of community-associated methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTI) was reported among members of a religious community. We conducted a retrospective cohort study on all 175 community members; performed a nasal carriage survey, and environmental swab testing. We identified 24 MRSA cases (attack rate 14%). In multivariate analysis, sauna use [odds ratio (OR) 19.1, 95% confidence interval (CI) 2.7-206.1] and antimicrobial use within 12 months before infection (OR 11.7, 95% CI 2.9-47.6) were risk factors for infection. MRSA nasal carriage rate was 0.6% (1/174). Nine of 10 clinical isolates and an isolate from an administrative office within the community had the pulsed-field gel electrophoresis type USA300. Targeted hygiene improvement, wound care, and environmental cleaning were implemented. We describe the first reported outbreak of MRSA SSTI in a religious community. Adherence to appropriate personal and environmental hygiene might be critical factors in controlling transmission.