National Microbiology Laboratory Research Articles

In Vitro Activity of 22 Antimicrobial Agents against Corynebacterium and Microbacterium Species Referred to the Canadian National Microbiology Laboratory

As better methods to more accurately identify organisms belonging to the genera Corynebacterium and Microbacterium have been recently introduced into the clinical microbiology laboratory routine, the clinical significance of various members of these genera is emerging, and antimicrobial susceptibilities, in turn, are becoming more important. Therefore, the results of antimicrobial susceptibility testing (AST) on Gram-positive bacilli identified using DNA sequencing methods as Corynebacterium or Microbacterium species are provided in this review to serve as a reference for clinical microbiologists. Susceptibility testing was performed using Clinical Laboratory Standards Insitute broth microdilution methods against 16 antibiotics with breakpoints and 6 antibiotics without breakpoints. Multidrug resistance (MDR), defined here as resistance to 1 or more antibiotics within 3 or more drug classes, was frequently observed; in some instances, susceptible strains could be detected for species which otherwise usually demonstrated MDR. Of note, all Corynebacterium isolates tested were susceptible to vancomycin and linezolid, with most (99.5%) being susceptible to daptomycin and >85% being susceptible to quinupristin/dalfopristin, rifampin, tetracycline, gentamicin, and meropenem. In contrast, 26%, 90%, and 71% of Microbacterium isolates were resistant to vancomycin, daptomycin, and meropenem, respectively; all were susceptible to linezolid. Based on the data summarized here, the use of definitive identification methods and performing AST are recommended for clinically relevant strains of Corynebacterium and Microbacterium species.

Nature’s laboratory should be included in the fight against Ebola

In 2014 I sent an emailed Christmas greeting of myself to an academic who specializes on African topics. His response was to ask me to send a copy of my doctoral thesis on medicinal plants of Trinidad and Tobago to an African scientist working on the Ebola crisis. The current outbreak of Ebola started in 2012 with the deaths of 5000 great apes in the Democratic Republic of the Congo (and deforestation in Guinea), and the fight against Ebola should include veterinarians who know about indigenous knowledge. The colonial attitude towards indigenous medical beliefs was to denigrate them as superstition and primitive. Nicholas King, Associate Professor in McGill’s Department of the Social Studies of Medicine, wrote that the replacement of indigenous knowledge with Western science was part of the justification of colonialism as a humanitarian endeavour. Indigenous knowledge can be used immediately in emergencies, while help from abroad takes longer and a vaccine will take at least a year. The Toronto Star reported on January 9, 2015 that the commercial rights to the Canadian Ebola vaccine developed at the National Microbiology Laboratory in Winnipeg were sold by the Public Health Agency of Canada in 2010 to anAmerican middleman for $205,000, who in turn reaps the $50 million in commercial rights offered by Merck. Testing the experimental vaccine on humans was paid for by the Canadian Department of National Defence. The middleman NewLink Genetics in Iowa did little to develop the vaccine. The CanadianGovernment donated 800 vials of the experimental vaccine to the World Health Organization (WHO) in August, 2014, and it took two more months for the vials to arrive at theWHOheadquarters in Geneva. According to the Centres for Disease Control and Prevention (CDC) there were 13 042 Ebola infections and 8259 deaths in Guinea, Liberia and Sierra Leone while all this was taking place. From week 13 to week 40 of the 2014 epidemic infections increased by 7000. The 2014 outbreak wasmore deadly than the 1976 Ebola outbreak. Merck’s $50 million offer should be seen in context. The total funding for health care in Sierra Leone in 2007 was US $31 million of which US $22 million came from aid agencies. A BMJ editorial published on September 27, 2014 reports that Liberia has 0.1 physicians, 1.7 nurses and midwives, and eight hospital beds for every 10,000 people. There are also the transportation costs of sending Western doctors to treat Ebola and isolation costs when they return. And there are unforeseen costs like the closure of the thirtyyear-old Ohio Bridal Shop visited by the Ebolainfected Texas nurse Amber Vinson. Vaccinations are not always effective. In British Columbia the 2014/15 flu shot did not give complete C. Lans (&) Instituut voor Etnobotanie en Zoofarmacognosie, Rijksstraatweg 158, 6573 DG Beek-Ubbergen, The Netherlands e-mail: trini0846@gmail.com

The polio eradication endgame: Why immunization and continued surveillance is critical.

The poliovirus is very close to being eradicated from the world. To this end, the four main objectives of the World Health Organization's Polio Eradication & Endgame Strategic Plan 2013-2018 are to: detect and interrupt all poliovirus transmission; strengthen immunization systems and withdraw oral polio vaccine; contain poliovirus and certify interruption of transmission; and plan polio's legacy. There is a need to maintain vigilance for circulating vaccine-derived polioviruses as well as maintaining both epidemiological and laboratory surveillance for polio at this critical point in history. Despite the elimination of indigenous wild poliovirus transmission in Canada, the risk of wild poliovirus importation from endemic countries, and the risk of importation of circulating vaccine strains remains. Due to this ongoing risk, active surveillance of acute flaccid paralysis (AFP) in children less than 15 years of age remains important. At least one stool specimen from all suspect AFP cases should be sent to the National Microbiology Laboratory at the Public Health Agency of Canada for polio isolation and testing to support and verify Canada's polio-free status. An added benefit of this is that it may also help identify other non-polio enteroviruses, such as enterovirus D68.

Evolving patterns of antiretroviral drug resistance from HIV genotyping in Northern Alberta, Canada: 2007–2013, a retrospective 15 year analysis

No: 1421 Presentation at ESCV 2015: Poster 2 A comparison of 4 anti-hepatitis C virus antibody assays in a low prevalence general Canadian population C. Osiowy1,∗, H. Gunning2, E. Giles1, C. Charlton2, A. Andonov1, J.W. Tang2 1 National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada 2 Alberta Provincial Laboratory for Public Health,

A new diagnostic test for Creutzfeldt-Jakob disease: Real-time quaking-induced conversion (RT-QulC).

Currently, definitive diagnoses of Creutzfeldt-Jakob disease (CJD) require an examination of the brains of deceased patients. In cooperation with an international consortium, Canada's National Microbiology Laboratory is performing a validation of a new test that can diagnose CJD in living patients. This test, the real-time quaking-induced conversion (RT-QuIC) assay, directly detects the disease associated form of the prion protein in cerebrospinal fluid. If validated, RT-QuIC will represent a major advance in the diagnoses of patients suspected to have CJD.

Acute flaccid paralysis surveillance: The need for ruling out polio infection

Afive-year-old, previously well male was admitted to hospital with severe headache after a three-day history of fever, cough and breathing difficulty. The child had not travelled outside of Canada and had received all recommended immunizations. The following day, he developed leg weakness, right-sided calf pain, limited lower extremity movement and decreased lower extremity reflexes bilaterally. Although given a presumptive diagnosis of Guillain-Barre syndrome (GBS) and started on intravenous immunoglobulin, his leg weakness continued to progress. To determine the etiology of his acute flaccid paralysis (AFP), brain and spine magnetic resonance imaging and lumbar puncture were conducted. Because viral culture from stool is the most sensitive test for identifying poliovirus, a stool sample was sent to the National Microbiology Laboratory (NML, Winnipeg, Manitoba) to rule out poliomyelitis. Samples from other sources (eg, nasopharyngeal swab) may be useful for detecting other viruses but stool culture is still recommended for detecting polio. The stool sample was obtained early within the recommended 14 days to ensure the highest probability of poliovirus detection. Results returned after 10 days were negative for poliovirus and further investigations were undertaken. The present case was reported to the local public health unit and the Canadian Paediatric Surveillance Program (CPSP). A 60-day follow-up with the attending physician was scheduled through neurology.

Emerging mosquito-borne bunyaviruses in Canada.

California serogroup and Cache Valley viruses are arboviruses (tick- and mosquito-borne pathogens) belonging to the genus Orthobunyavirus (Family Bunyaviridae). Although the majority of exposures to these viruses result in asymptomatic or mild infections, both California serogroup and Cache Valley viruses can cause febrile and neurological diseases similar in nature to those associated with infections by West Nile virus. California serogroup and Cache Valley viruses are widely distributed across North America and circulate in a number of vertebrate hosts and mosquito vectors, including several species of Aedes and other non-Culex mosquitoes. The Jamestown Canyon and snowshoe hare viruses are the most common kind of California serogroup viruses found in Canada and have been identified throughout the country. These potential pathogens may be contributing to a higher burden of illness than previously recognized and should be considered as part of the differential diagnosis for febrile and neuroinvasive disease during the mosquito season. Diagnosis can be made by requesting a diagnostic panel at the Viral Zoonoses program at the National Microbiology Laboratory. To decrease the risk of infection, education about these viruses and the importance of personal preventive measures is warranted.

National surveillance for non-polio enteroviruses in Canada: Why is it important?

A widespread outbreak of enterovirus D68 (EV-D68) was detected in association with respiratory illness in children across Canada and the United States during the autumn of 2014. The majority of cases were mild, but some were associated with more severe illness requiring hospitalization; some of the cases also had neurological symptoms including paralysis, and three deaths were reported in British Columbia. EV-D68 is one of many enteroviruses that include Coxsackieviruses, echovirusesand polio virus. Other than polio virus, there are no vaccines available for the prevention of enterovirus infections, nor are there any antiviral medications that have been approved for their treatment. More than 46 different serotypes have been identified to be circulating in Canada over the last 25 years. Until 2014, EV-D68 was rare. Routine genotyping surveillance done by Canada's National Microbiology Laboratory (NML) identified only 85 isolates of EV-D68 between 1991 and 2013, while 282 were detected between July and October 2014. The complexity of the epidemiology of these enteroviruses demonstrates the need for genotype surveillance, to detect outbreaks spatially and temporally, to determine their relative incidence and impact on the population, and to investigate evolutionary trends, such as recombination events, that are thought to play an important part in strain variation and emergence of epidemic strains. In particular, it is important to carry out virological testing on unusual cases of paralysis in children, and to genotype and sequence any viruses identified. Submission of specimens (virus cultures, stool, cerebrospinal fluid or respiratory specimens) from any such cases to the National Centre for Enteroviruses at NML is encouraged.

FluWatch summary: February 8-14, 2015 (Week 6).

To provide a summary of the weekly FluWatch report on influenza activity in Canada for the week of February 8-14, 2015. The FluWatch programs consists of a network of sentinel laboratories, sentinel primary care practices, provincial and territorial ministries of health, and sentinel hospitals that report on the seven main influenza indictors on a weekly basis across Canada. Information is aggregated by the FluWatch program and disseminated through weekly reports during the activity influenza season and bi-weekly reports during the low season. In week 6, influenza activity levels declined for six surveillance indicators. Seven regions reported widespread activity: Ontario (2), Quebec (2), Manitoba (1), Prince Edward Island (1) and Newfoundland (1). Twenty-one regions reported localized activity: New Brunswick (7), Nova Scotia (5), Ontario (5), Alberta (1) and Manitoba (1), and 22 regions reported sporadic activity. The national influenza-like-illness (ILI) consultation rate decreased from the previous week to 44.5 consultations per 1,000, which is higher than expected levels for week 6. A total of 74 outbreaks have been reported this week and the majority of outbreaks this season have been reported in long-term care facilities (LTCF). Laboratory detections of influenza decreased from the previous week from 1,884 in week 5 to 1,625 in week 6. The number of positive respiratory syncytial virus (RSV) tests decreased to 914 RSV detections down from 1,110 RSV detections in week 5 and remains the second most frequently detected virus after influenza. To date, 4,817 influenza hospitalizations and 342 deaths have been reported through the national severe outcome surveillance system; with the majority reported in adults aged 65 and over. In the 2014-15 season, the National Microbiology Laboratory (NML) has characterized 194 influenza viruses and found that the majority of influenza A (H3N2) specimens tested to date was not optimally matched to the vaccine strain; but all those tested for resistance were all found to be sensitive to oseltamivir and zanamivir. Two Canadian studies, one by the Sentinel Physician Surveillance Network (SPSN) and the other by the Canadian Immunization Research Network (CIRN), examined mid-season data on the current influenza vaccine's effectiveness and both studies observed little to no vaccine protection against the A(H3N2) virus. (See ID News). Influenza A (H3N2) continues to be the most common type of influenza affecting Canadians. In laboratory detections, hospitalizations and deaths, the majority of cases have been among seniors greater than 65 years of age. The patterns of many indicators such as laboratory detections and outbreaks have been similar to the 2012-13 season when influenza A (H3N2) also predominated. The NML and the SPSN study have found that the majority of the circulating influenza A (H3N2) specimens are not optimally matched to the vaccine strain. Several indicators have been continuously declining since week 1, indicating that the peak of the 2014-15 influenza season has passed. The FluWatch surveillance system will continue to monitor influenza activity throughout the remainder of the 2014-15 season and publish findings in the FluWatch report.

Chlamydia and lymphogranuloma venereum in Canada: 2003-2012 Summary Report.

Chlamydia continues to be the most commonly reported sexually transmitted infection in Canada. Lymphogranuloma venereum (LGV), caused by certain serovars of Chlamydia trachomatis, is becoming established in some populations in a number of Western countries. To identify trends in reported cases of chlamydia and LGV in Canada from January 1, 2003 to December 31, 2012. Notifiable disease data on chlamydia were submitted to the Public Health Agency of Canada by provincial and territorial epidemiological units and summarized at the national level by age and sex. Confirmatory testing for suspected LGV cases and serovar subtyping were performed by the National Microbiology Laboratory (NML). Where possible, provincial/territorial health authorities use a standardized national case report form to collect enhanced epidemiological data on each case and to submit the data to the Agency. Rates of reported cases of chlamydia increased by 57.6%, from 189.6 to 298.7 per 100,000 between 2003 and 2012. The rate of reported cases of chlamydia among females (383.5 per 100,000) was almost twice as high as that among males (212.0 per 100,000), although the highest relative rate increase occurred among males. In both males and females, the rates of chlamydia were highest in those aged 20 to 24 years. From 2004 to 2012, 170 cases of LGV were reported to the Agency by provincial health authorities (including 104 confirmed and 66 probable cases). In 2012, case reports were received on 12 confirmed and probable cases, compared to 38 laboratory-positive cases confirmed by the NML. In Canada, as in many countries, chlamydia rates have markedly increased over the last 10 years, in part due to improved diagnosis through nucleic acid amplification (NAAT) testing. Consistent with trends in Europe and other countries, LGV is emerging in Canada among men who have sex with men (MSM).

Antimicrobial resistance to Neisseria gonorrhoeae in Canada: 2009-2013.

Gonorrhea is on the rise in Canada. Treatment has been complicated by the fact that Neisseria gonorrhoeae has acquired resistance to many antibiotics, including penicillin, tetracycline, erythromycin and ciprofloxacin. The emergence of isolates with decreased susceptibilities to the third generation cephalosporins and reports of treatment failures in Canada and around the world are cause for concern. To assess the resistance levels of common antibiotics to N. gonorrhoeae and to observe trends in resistance and/or decreased susceptibility to ciprofloxacin, third generation cephalosporins and azithromycin. Laboratory surveillance data for N. gonorrhoeae isolates submitted by provincial microbiology laboratories to the National Microbiology Laboratory (NML) from 2009-2013 were compared. Since 2009, there has been an overall rise in antibiotic-resistant N. gonorrhoeae. In 2013, 24.3% of the isolates were resistant to erythromycin, 18.9% were resistant to penicillin, 33.0% were resistant to tetracycline, and 29.3% were resistant to ciprofloxacin. The percentage of isolates with decreased susceptibility to ceftriaxone (≥0.125 mg/L) and/or cefixime (≥0.25 mg/L) was 3.9% in 2013. This number represents a decrease from 5.9% in 2012 and 7.6% in 2011. The proportion of azithromycin resistant (MIC ≥2 mg/L) N. gonorrhoeae isolates increased from 0.4% in 2009 to 1.2% in 2013. Resistance to erythromycin, penicillin, tetracycline and ciprofloxacin is common. Decreased susceptibility to ceftriaxone and/or cefixime is now almost 4% and azithromycin resistance is emerging but remains low at 1.2%. These results have informed the gonococcal infection treatment recommendations in the Canadian Guidelines on Sexually Transmitted Infections.

Travel-related chikungunya cases in Canada, 2014.

Since the spring of 2014, there has been a large increase in travel-related chikungunya cases diagnosed in Canada. As of December 9, 2014, 320 confirmed and 159 probable cases have been diagnosed in Canada, with the majority of provinces identifying at least one imported case. This surge in Canadian infections has been associated with the incursion of chikungunya virus into the Caribbean and the expansion of the virus in the Americas. Ongoing outbreaks in the Asia-Pacific region have also contributed to imported cases among Canadian travellers. Heightened awareness of chikungunya among clinicians is key to diagnosis. This highlights the need to ask for a travel history from anyone who presents with fever or recent onset of polyarthralgia, and to consider testing by provincial laboratories and the National Microbiology Laboratory for chikungunya virus and other diseases as indicated. Also essential is continued communication with travellers regarding the use of preventative measures to decrease the risk of exposure to mosquitoes when travelling to endemic areas.

Dominance of two genotypes of Bordetella pertussis during a period of increased pertussis activity in Alberta, Canada: January to August 2012

The purpose of this study was to undertake an epidemiological analysis of an increase in Bordetella pertussis activity during the period January 1 to August 31, 2012 in Alberta, Canada. B. pertussis testing was done using an IS481 real-time PCR assay with PCR-positive and indeterminate specimens cultured and stored for further analysis. Laboratory data were linked to Alberta Health (AH) cases that were reported in the Communicable Disease Reporting System (CDRS) to identify case isolates; exclusion criteria were used to avoid biases. Case isolates were analyzed at the National Microbiology Laboratory (NML) by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Pertussis immunization data were extracted from the Alberta Provincial Immunization Repository (Imm/ARI) and linked to the pertussis cases. Using PFGE and MLST, 52 case isolates could be divided into two main sequence type groups: 41 cases belonged to the ST-1 group (ST-1 and the novel ST-19) and 11 cases belonged to the ST-2 group (ST-2 and the novel ST-20). Of the total cases genotyped (N=52), 18 (34.6%) had a history of immunization, 28 (53.8%) were not immunized, and six (11.6%) had an unknown immunization history. Of the total non-immunized cases, 25/28 (89.2%) belonged to the ST-1 group. Furthermore, of the 41 ST-1 group cases, 25 were not immunized compared to only three of the ST-2 group cases (p=0.0004, Fisher's exact test). This study shows the dominance of two genotypes of B. pertussis in our jurisdiction and indicates less pertussis immunization in individuals infected with the ST-1 group.

Antimicrobial resistance surveillance in Canadian hospitals, 2007-2012.

The Canadian Nosocomial Infection Surveillance Program (CNISP) is a collaborative effort of the Public Health Agency of Canada's Centre for Communicable Diseases and Infection Control, the National Microbiology Laboratory, and 54 largely university-affiliated tertiary care sentinel hospitals in 10 provinces across Canada. To provide a summary of antibiotic resistance rates of four key antibiotic resistant organisms in major hospitals across Canada from January 1, 2007, to December 31, 2012. Patients' clinical and demographic data and associated results of laboratory analyses were submitted to the Agency by participating hospitals. The infection rates were summarized per 1,000 patient admissions at national and regional levels. In Canada, the overall health care-associated Clostridium difficile infection (HA-CDI), HA-CDI rates peaked in 2008 at 5.8 HA-CDI infections per 1,000 patient admissions then remained stable between 2009 and 2012 at approximately 5 HA-CDI infections per 1,000 admissions; the West and Central regions had higher rates than the Eastern region. The rates of methicillin-resistant Staphylococcus aureus (MRSA) peaked in 2009 at 9.5 MRSA infections per 1,000 patient admissions then decreased to 8.8 MRSA infections per 1,000 admissions in 2012, with the Central region having higher rates than the Western and Eastern regions. The rates of vancomycin-resistant Enterococci (VRE), have been low but rising with 0.08 VRE infections per 1,000 patient admissions in 2007, gradually rising to 0.5 VRE infections per 1,000 admissions in 2012, with consistently higher rates in the Western region, slightly lower rates in the Central region and the lowest rates in the Eastern region. The rates of carbapenem-resistant Enterobacteriaceae (CRE) have been measured since 2010 and have been low and stable, with 0.11 CRE infections per 1,000 patient admissions in 2010 and 0.14 CRE infections per 1,000 admissions in 2012, with higher rates in the Western and Central regions and lower rates in the Eastern region. In Canada, of the four antibiotic resistant organisms under surveillance, HA-CDI and MRSA have been gradually decreasing, VRE is low but rising, and CRE remains low with Western and Central rates consistently higher than Eastern rates.

MERS-CoV- Low risk to Canadians.

Middle East respiratory syndrome - Coronavirus (MERS-CoV) -- is a novel coronavirus that has caused a number of community-acquired cases and health care associated outbreaks in Saudi Arabia and the United Arab Emirates (UAE) as well as sporadic cases in other countries, especially in the Middle East. The evidence to date links MERS-CoV cases with exposure to camels, including camel products or to probable or confirmed human cases of MERS-CoV. It typically presents as an acute respiratory illness and is associated with a 35% mortality rate. Based on available information at this time, the current risk to Canadians for acquiring MERS-CoV infections is considered low. However, the International Health Regulations Committee concerning MERS-CoV has cautioned that the upsurge of cases seen this past spring (2014) may be predictive of an increase in cases related to the Hajj - an annual pilgrimage to Mecca in Saudi Arabia that took place in early October 2014. Although the overall risk is low, the Public Health Agency of Canada and its National Microbiology Laboratory (NML) in close collaboration with provincial and territorial partners, the Canadian Public Health Laboratory Network (CPHLN) and infection prevention and control experts have developed a number of preparedness guidance documents and protocols to address the risk of an imported case of MERS-CoV in Canada.

Correction for Rehman et al., High-Quality Draft Whole-Genome Sequences of 162 Salmonella enterica subsp. enterica Serovar Enteritidis Strains Isolated from Diverse Sources in Canada.

Volume 2, no. 2, [e00348-14][1], 2014. Page 3: The first paragraph of the Acknowledgments should read as follows. “We sincerely thank the NCBI PGAP team for genome annotation services and Shaun Tyler at the PHAC National Microbiology Laboratory and staff at McGill University, Genome Quebec, and

Why has the Ebola outbreak in West Africa been so challenging to control?

West Africa is in the midst of the largest Ebola outbreak ever; there have been over 1000 deaths and many new cases are reported each day. The World Health Organization (WHO) declared it an outbreak in March 2014 and on August 6, 2014 the WHO declared the outbreak a public health emergency of international concern. Based on the number of deaths and total number of cases reported to the WHO as of August 11, 2014, the current outbreak has an overall mortality rate of 55%. Outbreak control measures against Ebola virus disease are effective. Why then, has this outbreak been so challenging to control? Ebola is transmitted through bodily fluids and immediately attacks the immune system, then progressively attacks the major organs and the lining of blood vessels. Sierra Leone, Guinea and Liberia are small countries that have limited resources to respond to prolonged outbreaks, especially in rural areas. This has been made more challenging by the fact that health care workers are at risk of contracting Ebola virus disease. Treatment to date has been supportive, not curative and outbreak control strategies have been met with distrust due to fear and misinformation. However, important progress is being made. The international response to Ebola is gaining momentum, communication strategies have been developed to address the fear and mistrust, and promising treatments are under development, including a combination of three monoclonal antibodies that has been administered to two American Ebola infected health care workers. The National Microbiology Laboratory of the Public Health Agency of Canada (PHAC) has been supporting laboratory diagnostic efforts in West Africa and PHAC has been working with the provinces and territories and key stakeholders to ensure Canada is prepared for a potential Ebola importation.

Measles molecular epidemiology: What does it tell us and why is it important?

Measles molecular epidemiology was a key component of the verification of elimination of indigenous measles in Canada and is an invaluable tool during public health investigations, both to establish whether connections exist between concurrent measles cases and to indicate possible sources of importations. There are 24 distinct genotypes however the genotype is usually not sufficient to describe the complex molecular epidemiology of measles cases. The exact genetic sequence of the last 450 nucleotides of the nucleoprotein (N) gene (N-450) is used. The measles genome mutates very slowly and so cases within the same chain of transmission usually have identical N-450 sequences. In Canada, the National Microbiology Laboratory (NML) sequences the N-450 and deposits it into the WHO measles sequence database, MeaNS. This database can be used to identify other geographic regions where the measles sequence was detected, supporting or excluding connections. For commonly detected N-450 sequences, MeaNS designates a "sequence variant." Sequence variants are used as the defining characteristic of measles cases with identical sequences and this designation is fundamental to the description of measles molecular epidemiology both locally and globally. As progress is made towards global measles eradication, its genetic diversity decreases and distinct importations of measles from a single reservoir can be difficult to distinguish using current methods. Extending sequencing methods beyond the N-450 is required. While sequencing the entire hemagglutinin (H) gene, which is currently done routinely at the NML, can be helpful, whole genome sequencing will be required for effective molecular surveillance to monitor the sustained elimination of measles in Canada.insert text here.

A community outbreak of travel-acquired measles, Ontario 2009.

Canada has held elimination status for measles since 1998; however, imported cases continue to occur. To describe the public health response to an imported measles case in the Waterloo Region of Ontario in May 2009. Contacts and exposures were traced, and cases were quickly investigated to identify the source. Through routine reporting mechanisms it was found that the index case had likely been exposed while on holiday in Disney World to a laboratory-confirmed measles case in a nine year old unimmunized boy from the United Kingdom (UK). Canada's National Microbiology Laboratory confirmed that the index case had the same D4 measles strain as the UK case and the strain that had been circulating in the UK. In total, one probable case and six confirmed cases were reported. The median age of confirmed cases was 14.5 years (mean age 17 years, range 6 to 39 years). Five confirmed cases (83%) were female. One confirmed case (17%) was hospitalized; no deaths were associated with the outbreak. This outbreak highlights the importance of collaboration with clinical care, the laboratory and public health at all levels of government to investigate and control a measles outbreak. Global travel and sustained local transmission may continue to pose a challenge with respect to the eradication of measles in developed countries.

Severe clinical outcome is uncommon in Clostridium difficile infection in children: a retrospective cohort study

BackgroundClostridium difficile infection (CDI) is the most common cause of health care–associated diarrhea in children and adults. Although serious complications of CDI have been reported to be increasing in adults, this trend has not yet been demonstrated in children. The purpose of this study was to examine the features of CDI in a pediatric population, with special attention to the occurrence of CDI-related severe outcomes.MethodsA chart review was conducted for patients with C. difficile infection detected by cytotoxin assay between August, 2008 and July, 2012. Basic demographics, mode of acquisition (nosocomial versus community), laboratory and clinical features, treatment, and outcome data were collected. Pulsed-field gel electrophoresis and polymerase chain reaction detection of toxin A (tcdA), toxin B (tcdB), binary toxin (cdtB) and tcdC genes were performed on isolates from nosocomial cases by the National Microbiology Laboratory, Winnipeg, Manitoba.ResultsNinety percent of children with CDI experienced resolution of symptoms by 30 days after disease onset and 2% experienced a severe outcome. There were no cases where colectomy was performed for CDI, and only one case where CDI contributed to death. Various combinations of clinical and laboratory features were not predictive of a severe outcome. Seventy-four percent of cases were nosocomial-associated. Among all cultured strains, the NAP4 strain occurred most frequently (24%), followed by NAP1 (11%). There was no association between strain type and clinical outcome; however, relapses were significantly more frequent in NAP4-infected children.ConclusionsSevere outcomes due to CDI are uncommon in children compared to adults. Further prospective pediatric studies on CDI in community and hospital settings are required to better understand risk factors, optimal treatment and the significance of NAP4 in pediatric CDI.