Emerging Infectious Diseases (EMERG INFECT DIS)

To the Editor: Rates and severity of Clostridium difficile infection (CDI) have recently increased worldwide and correlate with dissemination of hypervirulent epidemic strains designated PCR-ribotype 027. CDI caused by this PCR-ribotype is characterized by strong toxin A and B production, presence of binary toxin genes, and, usually, a high level of resistance to fluoroquinolones (1).

We conducted a population-based study in Manitoba, Canada, to investigate whether use of inactivated trivalent influenza vaccine (TIV) during the 2008-09 influenza season was associated with subsequent infection with influenza A(H1N1)pdm09 virus during the first wave of the 2009 pandemic. Data were obtained from a provincewide population-based immunization registry and laboratory-based influenza surveillance system. The test-negative case-control study included 831 case-patients with confirmed influenza A(H1N1)pdm09 virus infection and 2,479 controls, participants with test results negative for influenza A and B viruses. For the association of TIV receipt with influenza A(H1N1)pdm09 virus infection, the fully adjusted odds ratio was 1.0 (95% CI 0.7-1.4). Among case-patients, receipt of 2008-09 TIV was associated with a statistically nonsignificant 49% reduction in risk for hospitalization. In agreement with study findings outside Canada, our study in Manitoba indicates that the 2008-09 TIV neither increased nor decreased the risk for infection with influenza A(H1N1)pdm09 virus.

In recent years, population and evolutionary biologists have questioned the traditional view that parasite-mediated morbidity and mortality¿virulence¿is a primitive character and an artifact of recent associations between parasites and their hosts. A number of hypotheses have been proposed that favor virulence and suggest that it will be maintained by natural selection. According to some of these hypotheses, the pathogenicity of HIV, Vibrio cholerae, Mycobacterium tuberculosis,theShigella,as well as Plasmodium falciparum,and many other microparasites, are not only maintained by natural selection, but their virulence increases or decreases as an evolutionary response to changes in environmental conditions or the density and/or behavior of the human population. Other hypotheses propose that the virulence of microparasites is not directly favored by natural selection; rather, microparasite-mediated morbidity and mortality are either coincidental to parasite-expressed characters (virulence determinants that evolved for other functions) or the product of short-sighted evolution in infected hosts. These hypotheses for the evolution and maintenance of microparasite virulence are critically reviewed, and suggestions are made for testing them experimentally.

TO THE EDITOR: Legionella pneumophila serogroups (SGs) 1-16 cause pneumonia in humans. Although SG 1 is the serogroup most commonly associated with disease (1), we report a case of community-acquired legionellosis caused by SG 11.

AmpC β-lactamase, altered porins, or both are usually responsible for cefoxitin resistance in Escherichia coli. We examined the relative importance of each. We studied 18 strains of clinical isolates with reduced cefoxitin susceptibility and 10 initially-susceptible strains passaged through cefoxitin-gradient plates. Of 18 wild-resistant strains, 9 had identical promoter mutations (including creation of a consensus 17-bp spacer) and related pulsed-field gel electrophoresis patterns; the other 9 strains were unrelated. Nine strains had attenuator mutations; two strains did not express OmpC or OmpF. After serial passage, 8 of 10 strains developed cefoxitin resistance, none developed promoter or attenuator mutations, 6 lost both the OmpC and OmpF porin proteins, and 1 showed decreased production of both. One strain had neither porin alteration or increased AmpC production. Porin mutants may occur more commonly and be less fit and less inclined to spread or cause disease than strains with increased β-lactamase expression.

New guidance recommends annual influenza vaccination for all children 5-18 years of age in the United States. During 2007-2008, Hawaii offered inactivated and live attenuated influenza vaccine at school-located clinics for grades kindergarten through 8. Most (90%) public and private schools participated, and 622 clinics were conducted at 340 schools. Of 132,775 children 5-13 years of age, 60,760 (46%) were vaccinated. The proportion vaccinated peaked at 54% for those 6 years of age and declined for older cohorts. More than 90% of schoolchildren transited the clinic in <10 minutes. A total of 16,920 staff-hours were expended; estimated cost per dose administered was $27 and included vaccine purchase and administration, health staffing resources, printing costs, data management, and promotion. This program demonstrates the feasibility of conducting mass school-located influenza vaccination programs in public and private schools statewide, as might be indicated to respond to pandemic influenza.

On the basis of a 14th-century account by the Genoese Gabriele de' Mussi, the Black Death is widely believed to have reached Europe from the Crimea as the result of a biological warfare attack. This is not only of great historical interest but also relevant to current efforts to evaluate the threat of military or terrorist use of biological weapons. Based on published translations of the de' Mussi manuscript, other 14th-century accounts of the Black Death, and secondary scholarly literature, I conclude that the claim that biological warfare was used at Caffa is plausible and provides the best explanation of the entry of plague into the city. This theory is consistent with the technology of the times and with contemporary notions of disease causation; however, the entry of plague into Europe from the Crimea likely occurred independent of this event.

We document the absence of carriage of Neisseria meningitidis W-135 of the sequence type 11 in returning pilgrims after the Hajj 2002. This finding contrasts with the 15% carriage rate we previously reported in pilgrims returning from the Hajj 2001. The epidemiology of carriage may be changing or may have been controlled by vaccination and a policy of administering antibiotics to pilgrims from countries with a high incidence of meningococcal disease.

An outbreak of serogroup W-135 meningococcal disease occurred during the 2000 Hajj in Saudi Arabia. Disease was reported worldwide in Hajj pilgrims and their close contacts; however, most cases were identified in Saudi Arabia. Trends in Saudi meningococcal disease were evaluated and the epidemiology of Saudi cases from this outbreak described. Saudi national meningococcal disease incidence data for 1990 to 2000 were reviewed; cases from January 24 to June 5, 2000, were retrospectively reviewed. The 2000 Hajj outbreak consisted of distinct serogroup A and serogroup W-135 outbreaks. Of 253 identified cases in Saudi Arabia, 161 (64%) had serogroup identification; serogroups W-135 and A caused 93 (37%) and 60 (24%) cases with attack rates of 9 and 6 cases per 100,000 population, respectively. The 2000 Hajj outbreak was the first large serogroup W-135 meningococcal disease outbreak identified worldwide. Enhanced surveillance for serogroup W-135, especially in Africa, is essential to control this emerging epidemic disease.

We describe 3 culture-proven cases of adenovirus serotype 14 infection in New Brunswick, Canada, during the summer of 2011. Strains isolated from severely ill patients were closely related to strains of a genomic variant, adenovirus 14p1, circulating in the United States and Ireland. Physicians in Canada should be aware of this emerging adenovirus.

Despite a regional decline in influenza A(H1N1)pdm09 virus infections during 2013-14, cases at a Florida hospital were more severe than those during 2009-10. Examined strains had a hemagglutinin polymorphism associated with enhanced binding to lower respiratory tract receptors. Genetic changes in this virus must be monitored to predict the effect of future pandemic viruses.

The purpose of this communication is to update the veterinary public health community as to what poultry-related interventions were presented at the recent biennial International Workshop on Campylobacter, Helicobacter and Related Organisms (CHRO), which was held in Niigata, Japan, September 2-5, 2009. More than 30 years have passed since the publication of Martin Skirrow's seminal paper in the British Medical Journal in which he described Campylobacter enteritis as a new disease (1). This publication precipitated a global interest in thermophilic campylobacters. Three decades later, these organisms still pose a grave threat to public health. Furthermore, 10 years have passed since Parkhill et al. published the genome sequence of Campylobacter jejuni NCTC11168 (2).

Venezuela had the highest number of human malaria cases in Latin American before 1936. During 1891–1920,malaria was endemic to >600,000 km2 of this country; malaria death rates led to major population decreases during 1891–1920. No pathogen, including the influenza virus that caused the 1918 pandemic, caused more deaths than malaria during 1905–1945. Early reports of malaria eradication in Venezuela helped spark the world's interest in global eradication. We describe early approaches to malaria epidemiology in Venezuela and how this country developed an efficient control program and an approach to eradication.Arnoldo Gabaldón was a key policy maker during this development process. He directed malaria control in Venezuela from the late 1930s to the end of the 1970s and contributed to malaria program planning of the World Health Organization.We discuss how his efforts helped reduce the incidence of malaria in Venezuela and how his approach diverged from World Health Organization guidelines.

The purpose of this communication is to update the veterinary public health community as to what poultry-related interventions were presented at the recent biennial International Workshop on Campylobacter, Helicobacter and Related Organisms (CHRO), which was held in Niigata, Japan, September 2-5, 2009. More than 30 years have passed since the publication of Martin Skirrow's seminal paper in the British Medical Journal in which he described Campylobacter enteritis as a new disease (1). This publication precipitated a global interest in thermophilic campylobacters. Three decades later, these organisms still pose a grave threat to public health. Furthermore, 10 years have passed since Parkhill et al. published the genome sequence of Campylobacter jejuni NCTC11168 (2).

Venezuela had the highest number of human malaria cases in Latin American before 1936. During 1891–1920,malaria was endemic to >600,000 km2 of this country; malaria death rates led to major population decreases during 1891–1920. No pathogen, including the influenza virus that caused the 1918 pandemic, caused more deaths than malaria during 1905–1945. Early reports of malaria eradication in Venezuela helped spark the world's interest in global eradication. We describe early approaches to malaria epidemiology in Venezuela and how this country developed an efficient control program and an approach to eradication.Arnoldo Gabaldón was a key policy maker during this development process. He directed malaria control in Venezuela from the late 1930s to the end of the 1970s and contributed to malaria program planning of the World Health Organization.We discuss how his efforts helped reduce the incidence of malaria in Venezuela and how his approach diverged from World Health Organization guidelines.

To the Editor: In Bioterrorism-Related Inhalational Anthrax: The First 10 Cases Reported in the United States, Jernigan et al. noted that in the mid-1800s inhalational anthrax related to the textile industry became known as woolsorters’ disease (in England) and ragpickers’ disease (in Germany and Austria) because of the frequency of infection in mill workers exposed to imported animal fibers contaminated with Bacillus anthracis spores (1). During the 1800s, as in Europe, industry-related human cases of anthrax also occurred in the United States.

Frank John Fenner (Figure), one of the world's most distinguished virologists and a dear friend of many colleagues around the world, died in Canberra, Australia, on November 22, 2010, at the age of 95. This In Memoriam must be different from those usually published here. After all, quite detailed pieces are anticipated from the Australian Academy of Sciences, the Royal Society, et al., and Frank had published a comprehensive autobiography (1). Thus, there is opportunity to present personal memories, hoping to provide more of a sense of the man, the colleague, and the friend of so many members of the global virology community. This tribute seems to fit in with the closing paragraphs of Frank's autobiography, in which he reflects on friendship and special friends.

To the Editor: Brundage and Shanks (1) have studied time to death from the onset of influenza symptoms during the 1918 pandemic in military and civilian populations and found a median time to death of 7–11 days. They argue that these data support the idea that the deaths may be predominantly due to bacterial superinfection after the acute phase of influenza. We observed a similar 10-day median time to death among soldiers dying of influenza in 1918 (2), a finding consistent with the time to death for a bacterial superinfection, specifically pneumococcal bacteremic pneumonia (3). The major bacterial pathogen associated with influenza-related pneumonia in 1918 was Streptococcus pneumoniae (1,3). Neither antimicrobial drugs nor serum therapy was available for treatment in 1918. To further analyze the time course of death from influenza in relation to that of pneumococcal pneumonia in 1918, we examined data collected by Tilghman and Finland (4) from the pre–antimicrobial drug era of the 1920s and 1930s. The Figure shows the distribution of time from onset of illness to death due to influenza-related pneumonia in 1918 compared with time to death due to untreated pneumococcal pneumonia in the 1920s and 1930s. The Figure indicates a close concordance of the times to death. Similar times to death do not prove the specific bacterial etiology of the 1918 deaths. However, pneumococcal bacteremia was associated with most of the pneumonia deaths reported by Tilghman and Finland (4), and most 1918 influenza-related deaths were due to bacterial pneumonia (5). Also, up to 50% of patients dying from pneumonia in 1918 had pneumococcal bacteremia (3). These similar times to death provide additional evidence that the influenza-related pneumonia deaths during the 1918 influenza pandemic were largely due to the pneumococcus. Figure Distribution of days of illness before death from influenza-related pneumonia, 1918, and from untreated pneumococcal pneumonia, 1920s and 1930s.

We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918-1920 influenza pandemic in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.

With the recent outbreaks of avian influenza A (H5N1), the risk for the next influenza pandemic has increased. For effective countermeasures against the next pandemic, investigation of past pandemics is necessary. We selected cases diagnosed as influenza from medical records and hospitalization registries of Japanese army hospitals during 1918-1920, the Spanish influenza era, and investigated clinical features and circumstances of outbreaks. Admission lists showed a sudden increase in the number of inpatients with influenza in November 1918 and showed the effect of the first wave of this pandemic in Tokyo. The death rate was high (6%-8%) even though patients were otherwise healthy male adults.

Suggested citation for this article: Morens DM. In memoriam: Michael B. Gregg (1930–2008). Emerg Infect Dis [serial on the Internet]. 2008 Sep [date cited]. Available from http://www.cdc.gov/EID/content/14/9/1476.htm

A cluster of tuberculosis cases in a rural community in Arkansas persisted from 1991 to 1999. The cluster had 13 members, 11 linked epidemiologically. Old records identified 24 additional patients for 40 linked cases during a 54-year period. Residents of this neighborhood represent a population at high risk who should be considered for tuberculin testing and treatment for latent tuberculosis infection.

Marcos Cueto, Editor; Woodrow Wilson Center Press, Johns Hopkins University Press, Baltimore, Maryland, USA, 2007 ISBN: 978-0-8018 8645-4 Pages: 288; Price: US $45.00Marcos Cueto is a medical historian who describes the details of malaria eradication efforts in Mexico in the context of the Cold War era authoritarianism. His approach works overall, but occasionally he overreaches.Mr. Cueto asserts that the politics of the time allowed the medical community to be similarly authoritarian in forcing malaria eradication to be the accepted strategy. He states that the political climate relied on fear-based tactics of spreading anxiety about the communist threat and that similar strategies were used to gain public support for the malaria eradication effort, incorporating military jargon such as "enemy" mosquitoes and "campaigns" against disease into the public health lexicon. These campaigns included a propaganda arm in which pop stars became champions for the cause, to make the public sympathetic to their efforts. At one point, the author likens the strategy of screening persons for asymptomatic malaria parasitemia to the 1950s McCarthy-style witch hunts for hidden communists-stretching the analogy beyond tolerable limits.

We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918-1920 influenza pandemic in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.

With the recent outbreaks of avian influenza A (H5N1), the risk for the next influenza pandemic has increased. For effective countermeasures against the next pandemic, investigation of past pandemics is necessary. We selected cases diagnosed as influenza from medical records and hospitalization registries of Japanese army hospitals during 1918-1920, the Spanish influenza era, and investigated clinical features and circumstances of outbreaks. Admission lists showed a sudden increase in the number of inpatients with influenza in November 1918 and showed the effect of the first wave of this pandemic in Tokyo. The death rate was high (6%-8%) even though patients were otherwise healthy male adults.

Suggested citation for this article: Morens DM. In memoriam: Michael B. Gregg (1930–2008). Emerg Infect Dis [serial on the Internet]. 2008 Sep [date cited]. Available from http://www.cdc.gov/EID/content/14/9/1476.htm

A cluster of tuberculosis cases in a rural community in Arkansas persisted from 1991 to 1999. The cluster had 13 members, 11 linked epidemiologically. Old records identified 24 additional patients for 40 linked cases during a 54-year period. Residents of this neighborhood represent a population at high risk who should be considered for tuberculin testing and treatment for latent tuberculosis infection.