Concurrent Outbreaks Research Articles

Outbreak in African lions of Yersinia pseudotuberculosis infection, with aberrant bacterial morphology.

A concurrent outbreak of infection with Yersinia pseudotuberculosis occurred in adult captive African lions (Panthera leo). Two 17-y-old male lions and one 14-y-old female lion developed respiratory distress, lethargy, ataxia, and hyporexia. Within 3-5 d of the onset of clinical signs, one male and the female lion died and were submitted for postmortem examination. Macroscopically, the liver and spleen had multifocal-to-coalescing, semi-firm, pale-tan nodules throughout the parenchyma. The lungs were non-collapsed and marked by petechiae. Histologic examination identified lytic, necrosuppurative foci in the liver, spleen, lungs, and kidney, with abundant intralesional gram-negative coccobacilli in the male lion. Similar findings were seen in the female lion in the liver, spleen, kidney, and mesenteric lymph node; however, the intralesional bacterial colonies were more pleomorphic, comprising rod and filamentous morphologies. Aerobic bacterial culture of the liver, spleen, and lung revealed Y. pseudotuberculosis growth. The source of infection is unknown, and an epidemiologic study was performed. Sources to be considered are from the predation of rodent and/or bird reservoirs, or contaminated soil or water. Mortality associated with Y. pseudotuberculosis has been described in an African lion cub, however, to our knowledge, Y. pseudotuberculosis has not been reported in adult African lions, and this is only the second report of Y. pseudotuberculosis with aberrant bacterial morphology observed histologically.

Co-circulation of Orthobunyaviruses and Rift Valley Fever Virus in Mauritania, 2015.

Ngari virus (NRIV) has been mostly detected during concurrent outbreaks of Rift Valley fever virus (RVFV). NRIV is grouped in the genus Orthobunyavirus within the Bunyaviridae family and RVFV in the genus Phlebovirus in the family Phenuiviridae. Both are zoonotic arboviruses and can induce hemorrhagic fever displaying the same clinical picture in humans and small ruminants. To investigate if NRIV and its parental viruses, Bunyamwera virus (BUNV) and Batai virus (BATV), played a role during the Mauritanian RVF outbreak in 2015/16, we analyzed serum samples of sheep and goats from central and southern regions in Mauritania by quantitative real-time RT-PCR, serum neutralization test (SNT) and ELISA. 41 of 458 samples exhibited neutralizing reactivity against NRIV, nine against BATV and three against BUNV. Moreover, complete virus genomes from BUNV could be recovered from two sheep as well as two NRIV isolates from a goat and a sheep. No RVFV-derived viral RNA was detected, but 81 seropositive animals including 22 IgM-positive individuals were found. Of these specimens, 61 samples revealed antibodies against RVFV and at least against one of the three orthobunyaviruses. An indirect ELISA based on NRIV/BATV and BUNV derived Gc protein was established as complement to SNT, which showed high performance regarding NRIV, but decreased sensitivity and specificity regarding BATV and BUNV. Moreover, we observed high cross-reactivity among NRIV and BATV serological assays. Taken together, the data indicate the co-circulation of at least BUNV and NRIV in the Mauritanian sheep and goat populations.

Changes in tree drought sensitivity provided early warning signals to the California drought and forest mortality event.

Climate warming in recent decades has negatively impacted forest health in the western United States. Here, we report on potential early warning signals (EWS) for drought-related mortality derived from measurements of tree-ring growth (ring width index; RWI) and carbon isotope discrimination (∆13 C), primarily focused on ponderosa pine (Pinus ponderosa). Sampling was conducted in the southern Sierra Nevada Mountains, near the epicenter of drought severity and mortality associated with the 2012-2015 California drought and concurrent outbreak of western pine beetle (Dendroctonus brevicomis). At this site, we found that widespread mortality was presaged by five decades of increasing sensitivity (i.e., increased explained variation) of both tree growth and ∆13 C to Palmer Drought Severity Index (PDSI). We hypothesized that increasing sensitivity of tree growth and ∆13 C to hydroclimate constitute EWS that indicate an increased likelihood of widespread forest mortality caused by direct and indirect effects of drought. We then tested these EWS in additional ponderosa pine-dominated forests that experienced varying mortality rates associated with the same California drought event. In general, drier sites showed increasing sensitivity of RWI to PDSI over the last century, as well as higher mortality following the California drought event compared to wetter sites. Two sites displayed evidence that thinning or fire events that reduced stand basal area effectively reversed the trend of increasing hydroclimate sensitivity. These comparisons indicate that reducing competition for soil water and/or decreasing bark beetle host tree density via forest management-particularly in drier regions-may buffer these forests against drought stress and associated mortality risk. EWS such as these could provide land managers more time to mitigate the extent or severity of forest mortality in advance of droughts. Substantial efforts at deploying additional dendrochronological research in concert with remote sensing and forest modeling will aid in forecasting of forest responses to continued climate warming.

Rapid transmission of respiratory infections within but not between mountain gorilla groups

Minimizing disease transmission between humans and wild apes and controlling outbreaks in ape populations is vital to both ape conservation and human health, but information on the transmission of real infections in wild populations is rare. We analyzed respiratory outbreaks in a subpopulation of wild mountain gorillas (Gorilla beringei beringei) between 2004 and 2020. We investigated transmission within groups during 7 outbreaks using social networks based on contact and proximity, and transmission between groups during 15 outbreaks using inter-group encounters, transfers and home range overlap. Patterns of contact and proximity within groups were highly predictable based on gorillas’ age and sex. Disease transmission within groups was rapid with a median estimated basic reproductive number (R0) of 4.18 (min = 1.74, max = 9.42), and transmission was not predicted by the social network. Between groups, encounters and transfers did not appear to have enabled disease transmission and the overlap of groups’ ranges did not predict concurrent outbreaks. Our findings suggest that gorilla social structure, with many strong connections within groups and weak ties between groups, may enable rapid transmission within a group once an infection is present, but limit the transmission of infections between groups.

Dengue and COVID-19 infections in the ASEAN region: a concurrent outbreak of viral diseases.

Member countries of the Association of Southeast Asian Nations (ASEAN) have faced dengue outbreaks for decades, and the region has one of the highest rates of dengue globally. Outbreaks continue to occur concurrently with the coronavirus disease 2019 (COVID-19) pandemic in the 10 ASEAN countries. Both infectious diseases pose a tremendous burden in these countries related to both infection control and the economy. Increases in the number of dengue cases occurred in part due to disruptions in the pathogen-host-vector relationship caused by changes in human behaviour in response to the COVID-19 pandemic. The spread of dengue was further aggravated by the implementation of lockdowns and social distancing policies. These measures limited the coverage of dengue preventive programs and delayed the medical management of both diseases due to co-infection and misdiagnosis. It is of the utmost importance for the population to remain aware of both diseases, and dengue vector control strategies must be devised to properly address outbreaks using digitalization and remote surveillance. Similarly, critical triage algorithms and further research are also needed to combat co-infection and misdiagnosis. Controlling the spread of COVID-19 though vaccination should also be undertaken to reduce the impact of the pandemic.

Real-Time Genomics for Tracking Severe Acute Respiratory Syndrome Coronavirus 2 Border Incursions after Virus Elimination, New Zealand.

Since severe acute respiratory syndrome coronavirus 2 was first eliminated in New Zealand in May 2020, a total of 13 known coronavirus disease (COVID-19) community outbreaks have occurred, 2 of which led health officials to issue stay-at-home orders. These outbreaks originated at the border via isolating returnees, airline workers, and cargo vessels. Because a public health system was informed by real-time viral genomic sequencing and complete genomes typically were available within 12 hours of community-based positive COVID-19 test results, every outbreak was well-contained. A total of 225 community cases resulted in 3 deaths. Real-time genomics were essential for establishing links between cases when epidemiologic data could not do so and for identifying when concurrent outbreaks had different origins.

Investigation of Lethal Concurrent Outbreak of Chlamydiosis and Pigeon Circovirus in a Zoo.

Simple SummaryThe present study aimed to investigate a lethal outbreak of chlamydiosis and pigeon circovirus (PiCV) infection in a zoo. A retrospective follow-up indicates that the lethal outbreak might be an independent episode. The high prevalence of PiCV positivity in the aviaries suggests that PiCV infection might play a key role in augmenting the lethality of chlamydiosis in birds. Persistently monitoring both pathogens and identifying potential PiCV carriers or transmitters might also help prevent lethal disease outbreaks.During the spring, an outbreak of sudden death involving 58 birds occurred in a zoo. Histopathological examinations revealed variable numbers of intracytoplasmic basophilic microorganisms in the macrophages, hepatocytes, and renal epithelium of most birds, along with occasional botryoid intracytoplasmic inclusion bodies within histiocytes in the bursa of Fabricius. Based on the results of histopathological examinations, immunohistochemical staining, transmission electron microscopy, and polymerase chain reactions, genotype B Chlamydia psittaci infection concurrent with pigeon circovirus (PiCV) was diagnosed. A retrospective survey, including two years before the outbreak and the outbreak year, of C. psittaci and PiCV infections of dead birds in the aviaries, revealed that the outbreak was an independent episode. The findings of this study indicate that concurrent infection with C. psittaci and PiCV might lead to lethal outbreaks of chlamydiosis, particularly Streptopelia orientalis. In addition, persistently monitoring both pathogens and identifying potential PiCV carriers or transmitters might also help prevent lethal disease outbreaks.

Wall painting following terminal cleaning with a chlorine solution as part of an intervention to control an outbreak of carbapenem-resistant Acinetobacter baumannii in a neurosurgical intensive care unit in Israel

BackgroundTo describe the use of wall painting as part of an intervention to control an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB). MethodsAn interrupted time-series analysis was performed analyzing an intervention in a neurosurgical intensive care unit (NSICU) and an inpatient hematology department in a tertiary level medical center in Israel. The intervention involved wall painting using a water based acrylic paint following patient discharge and terminal cleaning with sodium troclosene as part of an infection control bundle for an outbreak of CRAB in a NSICU and concurrent outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) colonization/infection in the same NSICU and the hematology department. ResultsBetween January 2013 and December 2018, 122 patients hospitalized in the NSICU were identified with new CRAB colonization/infection. The median incidence in the periods prior to/post intervention were 2.24/1000 HD (interquartile range [IQR] 0.84–2.90/1000) vs. 0/1000 HD (IQR 0–0.49/1000), respectively. Poisson regression indicated a decrease of 92% in the CRAB incidence following the intervention onset (relative risk [RR] 0.080, 95% confidence interval [CI] 0.037–0.174, p < 0.001). Forty-seven patients in the NSICU and 110 in the hematology department were colonized/infected with CRE in the same time period; a significant change was not observed following the start of the intervention in either department (for NSICU RR 1.236, 95% CI 0.370–4.125, p = 0.731; for hematology RR 0.658, 95% CI 0.314–1.378, p = 0.267). ConclusionsA. baumannii is able to survive on environmental surfaces despite decontamination efforts; wall-painting as part of a bundle may be a successful infection control measure.

Consumer-Based Activity Trackers as a Tool for Physical Activity Monitoring in Epidemiological Studies During the COVID-19 Pandemic: Development and Usability Study.

BackgroundConsumer-based physical activity trackers have increased in popularity. The widespread use of these devices and the long-term nature of the recorded data provides a valuable source of physical activity data for epidemiological research. The challenges include the large heterogeneity between activity tracker models in terms of available data types, the accuracy of recorded data, and how this data can be shared between different providers and third-party systems.ObjectiveThe aim of this study is to develop a system to record data on physical activity from different providers of consumer-based activity trackers and to examine its usability as a tool for physical activity monitoring in epidemiological research. The longitudinal nature of the data and the concurrent pandemic outbreak allowed us to show how the system can be used for surveillance of physical activity levels before, during, and after a COVID-19 lockdown.MethodsWe developed a system (mSpider) for automatic recording of data on physical activity from participants wearing activity trackers from Apple, Fitbit, Garmin, Oura, Polar, Samsung, and Withings, as well as trackers storing data in Google Fit and Apple Health. To test the system throughout development, we recruited 35 volunteers to wear a provided activity tracker from early 2019 and onward. In addition, we recruited 113 participants with privately owned activity trackers worn before, during, and after the COVID-19 lockdown in Norway. We examined monthly changes in the number of steps, minutes of moderate-to-vigorous physical activity, and activity energy expenditure between 2019 and 2020 using bar plots and two-sided paired sample t tests and Wilcoxon signed-rank tests.ResultsCompared to March 2019, there was a significant reduction in mean step count and mean activity energy expenditure during the March 2020 lockdown period. The reduction in steps and activity energy expenditure was temporary, and the following monthly comparisons showed no significant change between 2019 and 2020. A small significant increase in moderate-to-vigorous physical activity was observed for several monthly comparisons after the lockdown period and when comparing March-December 2019 with March-December 2020.ConclusionsmSpider is a working prototype currently able to record physical activity data from providers of consumer-based activity trackers. The system was successfully used to examine changes in physical activity levels during the COVID-19 period.

An outbreak of African swine fever in small-scale pigs, Gauteng, South Africa, July 2020

ObjectivesSince 2012, outbreaks of African swine fever (ASF) in domestic pigs have increased outside of South Africa’s ASF control zone. This study describes the epidemiological investigation and findings of an ASF outbreak in a small-scale pig unit in Gauteng Province and makes recommendations to prevent future outbreaks. MethodsPCR testing and molecular analysis were performed on pig tissue samples. Veterinary services conducted epidemiological investigations, forward and backward tracing, and surveillance. Farm management and biosecurity practices were assessed. Quarantine, culling, carcass disposal, and disinfection were implemented. ResultsASF virus genotype I was detected. A concurrent ASF outbreak in neighbouring Mpumalanga Province was identified as a possible source. Inadequate biosecurity measures probably facilitated viral transmission. Potential mechanisms for the introduction of the ASF virus include swill feeding practices, free roaming of pigs, scavenging, illegal slaughter, and trade of pig products within the community. ConclusionsMolecular typing of the ASF virus linked the outbreak to an ongoing ASF outbreak in Mpumalanga Province. Pig enterprises with poor biosecurity practices may face greater risk of ASF introduction. Small-scale pig keepers should be targeted for ASF awareness and education campaigns. Innovative and cost-effective biosecurity solutions are needed in this resource-poor setting.

Infectious Diseases Seeker (IDS): An Innovative Tool for Prompt Identification of Infectious Diseases during Outbreaks

Background: Several technologies for rapid molecular identification of pathogens are currently available; jointly with monitoring tools (i.e., web-based surveillance tools, infectious diseases modelers, and epidemic intelligence methods), they represent important components for timely outbreak detection and identification of the involved pathogen. The application of these approaches is usually feasible and effective when performed by healthcare professionals with specific expertise and skills and when data and resources are easily accessible. Contrariwise, in the field situation where healthcare workers or first responders from heterogeneous competences can be asked to investigate an outbreak of unknown origin, a simple and suitable tool for rapid agent identification and appropriate outbreak management is highly needed. Most especially when time is limited, available data are incomplete, and accessible infrastructure and resources are inadequate. The use of a prompt, user-friendly, and accessible tool able to rapidly recognize an infectious disease outbreak and with high sensitivity and precision may be a game-changer to support emergency response and public health investigations. Methods: This paper presents the work performed to implement and test an innovative tool for prompt identification of infectious diseases during outbreaks, called Infectious Diseases Seeker (IDS). IDS is a standalone software that runs on the most common operative systems. It has been built by integrating a database containing an interim set of 60 different disease causative agents and COVID-19 data and is able to work in an off-line mode without requiring a network connection. Results: IDS has been applied in a real and complex scenario in terms of concomitant infectious diseases (yellow fever, COVID-19, and Lassa fever), as can be in the second part of 2020 in Nigeria. The outcomes have allowed inferring that yellow fever (YF), and not Lassa fever, was affecting the area under investigation. Conclusions: Our result suggests that a tool like IDS could be valuable for the quick and easy identification and discrimination of infectious disease outbreaks even when concurrent outbreaks occur, like for the case study of YF and COVID-19 pandemic in Nigeria.

The Political Determinants of China'S New Health Constitution.

The Basic Healthcare and Health Promotion Law 2019 became the new constitution of China’s health system in June 2020, giving legal effect to ambitious health reform programmes like Healthy China 2030. The concurrent outbreak of coronavirus disease 2019 must not distract us from appreciating the fact that this Law will comprehensively overhaul the health regulatory framework of the world’s most populous country during the coming decade, if not beyond. This article offers an original evaluation of the Law in its political context. The Law commendably promises to safeguard the right to health, assist citizens to live a ‘complete cycle of life’, and promote health using the resources of the public health system. However, it is also deeply politicised, guaranteeing extensive and penetrative political control in health campaigns, digitalised health data, the governance of health institutions, and the resolution of medical disputes. This can be explained by the consequential roles played by epidemics in China’s historical dynastic cycles, but even more so by powerful tendencies of centralisation on the part of the Leninist Party-state. The Law’s potential is thus subject to the overriding caveat that the Party-state’s existence and influence over law and public health must be secured.

Emergent chikungunya fever and vertical transmission in Yunnan Province, China, 2019.

During the dengue epidemic in Yunnan Province, China, during 2019, a concurrent outbreak of chikungunya occurred in the city of Ruili, which is located in the southwest of the province, adjacent to Myanmar. As part of this outbreak, three neonatal cases of infection with indigenous chikungunya virus from mother-to-child (vertical) transmission were observed. Isolates of chikungunya virus were obtained from 37 serum samples of patients with chikungunya during this outbreak, and a phylogenetic analysis of these isolates revealed that they belong to the Indian Ocean subclade of the East/Central/South African genotype. The E1 genes of these viruses did not harbor the A226V mutation.

Emerging carbapenem-resistant Klebsiella pneumoniae sequence type 16 causing multiple outbreaks in a tertiary hospital in southern Vietnam.

The emergence of carbapenem resistance in Klebsiella pneumoniae represents a major global public health concern. Nosocomial outbreaks caused by multidrug-resistant K. pneumoniae are commonly reported to result in high morbidity and mortality due to limited treatment options. Between October 2019 and January 2020, two concurrent high-mortality nosocomial outbreaks occurred in a referral hospital in Ho Chi Minh City, Vietnam. We performed genome sequencing and phylogenetic analysis of eight K. pneumoniae isolates from infected patients and two environmental isolates for outbreak investigation. We identified two outbreaks caused by two distinct lineages of the international sequence type (ST) 16 clone, which displayed extensive drug resistance, including resistance to carbapenem and colistin. Carbapenem-resistant ST16 outbreak strains clustered tightly with previously described ST16 K. pneumoniae from other hospitals in Vietnam, suggesting local persistence and transmission of this particular clone in this setting. We found environmental isolates from a hospital bed and blood pressure cuff that were genetically linked to an outbreak case cluster, confirming the potential of high-touch surfaces as sources for nosocomial spread of K. pneumoniae . Further, we found colistin resistance caused by disruption of the mgrB gene by an ISL3-like element, and carbapenem resistance mediated by a transferable IncF/bla OXA-181 plasmid carrying the ISL3-like element. Our study highlights the importance of coordinated efforts between clinical and molecular microbiologists and infection control teams to rapidly identify, investigate and contain nosocomial outbreaks. Routine surveillance with advanced sequencing technology should be implemented to strengthen hospital infection control and prevention measures.

Viral intra-host evolution in immunocompetent children contributes to human norovirus diversification at the global scale

ABSTRACT Norovirus is a major cause of acute gastroenteritis. Human noroviruses present >30 different genotypes, with a single genotype (GII.4) predominating worldwide. Concurrent outbreaks of norovirus are often associated with the emergence of new viruses. While different hypotheses have been presented, the source of new mutations in noroviruses is still unknown. In this study, we applied high-resolution sequencing to determine the intra-host viral diversity presented by noroviruses during the acute and shedding phase of infection in children. Profiling viral intra-host diversification at nearly full genome level indicated that GII.4 viruses presented dynamic intra-host variation, while non-GII.4 viruses presented minimal variation throughout the infection. Notably, the intra-host genetic variation during the shedding phase recapitulates the genetic diversity observed at the global level, particularly those mapping at the VP1 antigenic sites. Thus the intra-host evolution in healthy children explains the source of norovirus mutations that results in diversification at the global scale.

Concurrent outbreak of Cholera and Shigella in Ronihal village, Bijapur, Karnataka, India, 2016

Concurrent outbreak of Cholera and Shigella in Ronihal village, Bijapur, Karnataka, India, 2016

It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19.

It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19.

Whole-genome sequencing to investigate two concurrent outbreaks of Salmonella Enteritidis in South Africa, 2018.

Salmonella enterica serotype Enteritidis (Salmonella Enteritidis) is a major cause of foodborne disease outbreaks worldwide. In 2018, two concurrent outbreaks of Salmonella Enteritidis gastroenteritis in one district of South Africa were investigated. We describe the use of whole-genome sequencing (WGS) analysis of bacterial isolates to assist with the investigation of these outbreaks. Outbreak A affected children (n=27) attending a day-care centre, while outbreak B affected adults (n=16) who ate breakfast at the same restaurant. Salmonella Enteritidis was isolated from stool samples in both outbreaks (four children in outbreak A; 12 restaurant customers and three restaurant food-handlers in outbreak B). In outbreak B, Salmonella Enteritidis was isolated from three food retention samples (raw chicken egg, hollandaise sauce and rocket-herb). Available isolates from both outbreaks (n=13) were investigated using WGS analysis. Sequencing data for isolates were analysed at the EnteroBase web-based platform and included core-genome multi-locus sequence typing (cgMLST). Isolates with epidemiological links to the restaurant (n=10) and day-care centre (n=3), were shown by cgMLST to be highly genetically related, with no more than five allele differences when comparing one isolate against another. On food history, eggs and hollandaise sauce were the common food items consumed by ill restaurant customers. Unfortunately, Salmonella Enteritidis isolated from the egg and hollandaise sauce were not available for WGS analysis. Our investigation concluded that the two concurrent outbreaks were caused by a highly related strain of Salmonella Enteritidis, suggesting the possibility of a common contaminated food source, of which contaminated eggs are strongly implicated.

The Importance of Environmental Screening in a Methicillin-Resistant Staphylococcus aureus (MRSA) Outbreak Investigation in a Transplant Unit

Background: Methicillin-resistant Staphylococcus aureus (MRSA) colonization conveys a higher risk of invasive infection. The transplant cohort is a group of immunocompromised patients who are at higher risk of infection. We conducted an outbreak investigation of hospital-acquired MRSA colonization within the transplant unit, which led to the discovery of positive isolates within our environment and to changes in our hospital disinfection policies. Methods: Our transplant unit consists of 8 single, positive-pressure rooms housed separately at the side of a larger ward. Staffing from this unit differs from the rest of the shared ward that houses up to 60 patients. As part of hospital screening, we found that a patient admitted for a stem-cell transplant had acquired nosocomial MRSA colonization. Given the unusual occurrence of such an event, a root-cause analysis was conducted. Results: A meeting was convened together with nursing, medical staff, and ancillary staff. Identified areas of potential transmission were deemed equipment, staff, and patients, and screening was performed. Shared equipment included the portable electrocardiogram (ECG) machines and portable x-ray machines and boards. In particular, ECG machines were shared with the adjoining nontransplant oncology ward. The usual practice was to clean the machine after use but not prior to the next use. This was deemed a possible exposure risk in view of a recent MRSA outbreak in a separate section of the ward. Positive isolates were found on both the x-ray and ECG machines. All healthcare workers were screened and were negative for MRSA. Furthermore, 7 patients admitted during the same time period were also screened for MRSA and were negative. Given the concurrent outbreak within the ward, pulsed-field gel electrophoresis was performed for all MRSA isolates obtained and the outbreak strain. These were found to be nonclonal (Table 1). Work processes for both the cleaning of ECG and x-ray machines were enhanced and modified. Hand hygiene measures to ward and radiology staff were reinforced. Thus far, no further cases have been detected. Conclusions: The environment is an important part of outbreak investigation. Shared equipment is often overlooked during day to day processes but should not be neglected. This can result in changes to hospital disinfection policy.Funding: NoneDisclosures: Indumathi Venkatachalam reports receiving honoraria for speaking engagements for bioMérieux and Pfizer and serving on an expert panel for MSD Pharma.

Concerns about COVID-19 and arboviral (chikungunya, dengue, zika) concurrent outbreaks

Concerns about COVID-19 and arboviral (chikungunya, dengue, zika) concurrent outbreaks