Body lice as tools for diagnosis and surveillance of reemerging diseases

Body lice are vectors of three bacteria which cause human disease: Rickettsia prowazekii, the agent of epidemic typhus; Bartonella quintana, the agent of trench fever; and Borrelia recurrentis, the agent of relapsing fever. A recrudescence of body lice is being observed as the numbers of individuals living under social conditions which predispose individuals to infestation have increased. Because this phenomenon may lead to the reemergence of infections transmitted by body lice, we aimed to assess the occurrence and prevalence of the three agents described above in more than 600 body lice collected from infested individuals in the African countries of Congo, Zimbabwe, and Burundi, in France, in Russia, and in Peru. The presence of the three bacteria in each louse was determined by specific PCR amplification, and the identities of the organisms detected were confirmed by determination of the nucleotide base sequences of the amplification products. Using this approach, we were able to confirm the presence of R. prowazekii in lice collected from refugees in Burundi, among whom typhus was epidemic, and the presence of B. quintana in lice collected from all locations except the Congo. B. recurrentis was never found. Molecular approaches are convenient tools for the detection and identification of bacterial DNA in body lice and for the epidemiological study of louse-borne bacteria from countries where no medical and biological laboratory facilities are available.     

Vectors vs. humans in Australia--who is on top down under? An update on vector-borne disease and research on vectors in Australia

Australia has a diversity of vectors and vector-borne human diseases. Mosquito-borne arboviruses are of greatest concern, but there are issues with other vector and pathogen systems. Mosquitoes were responsible for more than 35,000 cases of Ross River virus during 1991-1997. Barmah Forest virus is increasing nationwide, and unidentified bunyaviruses suspected of causing illness have been isolated. Cases of Murray Valley encephalitis have occurred in 14 of the past 20 years in northern Australia. Dengue is a continuing problem for northern Queensland, with various serotypes being active. Japanese encephalitis has appeared in the Torres Strait Islands and threatens mainland Australia. Although malaria is eradicated, almost 1,000 cases are imported annually and occasional cases of local transmission occur. With ticks, paralysis in children occurs annually in eastern Australia. Tick typhus (Queensland Tick Typhus--Rickettsia australis) occurs down the east coast, and (Flinders Island Spotted Fever--Rickettsia honei) in Bass Strait and probably Tasmania. Lyme disease is reported but its presence is controversial. Fleas were responsible for a recent outbreak of murine typhus (Rickettsia typhi) in Western Australia. Mites cause scrub typhus (Orientia tsutsugamushi), and there was a recent fatality in the Northern Territory. Overall, resources for investigation and control of vector-borne disease have generally been meager. However, various avenues of basic and applied research have been pursued, and have included investigations into mosquito ecology, vector competence, disease epidemiology, and vector control. Disease surveillance programs vary between states, and mosquito control programs are organized and effective in only a few regions. There are concerns for import of vectors such as Aedes albopictus and export of pathogens such as Ross River virus; the former has occurred but the species has not become established, and the latter has occurred and has resulted in a major outbreak in the South Pacific. The predicted scenarios of increased temperature and rainfall with global warming are also causing concern for increases in vector-borne diseases, particularly the endemic arboviruses. Interest by health authorities is gravitating more towards epidemiological reporting and less towards public health action. In many respects, humans have much to do to get 'on top' of vectors and their pathogens 'down under' in Australia.     

Prevalence of adult diabetes in Ibadan, Nigeria

The authors relate their experience controlling an epidemic of meningitis which broke out in the refugee camps of the Goma region, in northern Zaire, after the dramatic events which had happened in Rwanda in April and June 1994. Out of the 348 cases of purulent meningitis diagnosed by the Bioforce team, meningococcal etiology was confirmed 327 times. The isolated meningococci were all of the serogroup A, serotype A; 4; P 1,9. They were resistant to streptomycin and to sulphamides. The epidemic lasted one month, touched people of all ages and spread progressively to all the camps. The epidemic surveillance set up meant that vaccination was carried out very quickly and the epidemic brought rapidly under control, even if other factors did intervene. All those called upon to intervene in such a context should be made aware of the interest of the basic triad to fight these epidemics: rapid vaccination, treatment of cases with oily chloramphenicol and bio-epidemiological surveillance.     

Immunohistochemical diagnosis of typhus rickettsioses using an anti-lipopolysaccharide monoclonal antibody

A monoclonal antibody directed against an epitope on the lipopolysaccharide of typhus-group rickettsiae was developed for the purpose of detecting this heat-stable, proteinase-resistant antigen in formalin-fixed, paraffin-embedded tissues. Rickettsia prowazekii organisms were identified in endothelium and macrophages in sections of the brains of three Egyptian men who died of epidemic louse-borne typhus in Cairo during World War II and in the brain from a recent case of typhus fever acquired in Burundi. R. typhi organisms were identified in endothelial cells from a fatal case of murine typhus and in experimentally infected mice. This approach is applicable not only to the study of archival tissues and experimental animal models but also could be used to establish a timely diagnosis of typhus-group rickettsiosis by immunohistochemical examination of cutaneous biopsies of rash lesions during the acute stage of illness.     

Chronic Bartonella quintana bacteremia in homeless patients

BACKGROUND: Infection with Bartonella quintana can cause trench fever, endocarditis, bacillary angiomatosis, and peliosis. An outbreak of bacteremia due to B. quintana has been reported among homeless people in Seattle, and the seroprevalence is high among homeless people in both the United States and Europe. Body lice are known to be the vectors of B. quintana. METHODS: We studied all the homeless people who presented in 1997 to the emergency departments of the University Hospital, Marseilles, France. Blood was collected for microimmunofluorescence testing for antibodies against B. quintana and for culture of the bacterium. Body lice were collected and analyzed by the polymerase chain reaction and sequencing of a portion of the citrate synthase gene of B. quintana. RESULTS: In 10 of 71 homeless patients (14 percent), blood cultures were positive for B. quintana, and 21 of the patients (30 percent) had high titers of antibody against the organism. A total of 17 patients (24 percent) had evidence of recent infection (bacteremia or seroconversion). Tests of lice from 3 of the 15 patients from whom they were collected were positive for B. quintana. The homeless people with B. quintana bacteremia were more likely to have been exposed to lice (P=0.002), were more likely to have headaches (P=0.03) and severe leg pain (P<0.001), and had lower platelet counts (P=0.006) than the homeless people who were seronegative for B. quintana and did not have bacteremia; 8 of the 10 patients with bacteremia were afebrile. Five patients had chronic bacteremia, as indicated by positive blood cultures over a period of several weeks. CONCLUSIONS: In an outbreak of urban trench fever among homeless people in Marseilles, B. quintana infections were associated with body lice in patients with nonspecific symptoms or no symptoms.     

The refugee crisis in Africa and implications for health and disease: a political ecology approach

Political violence in civil war and ethnic conflicts has generated millions of refugees across the African continent with unbelievable pictures of suffering and unnecessary death. Using a political ecology framework, this paper examines the geographies of exile and refugee movements and the associated implications for re-emerging and newly emerging infectious diseases in great detail. It examines how the political ecologic circumstances underlying the refugee crisis influences health services delivery and the problems of disease and health in refugee camps. It has four main themes, namely, an examination of the geography of the refugee crisis: the disruption of health services due to political ecologic forces that produce refugees; the breeding of disease in refugee camps due to the prevailing desperation and destitution; and the creation of an optimal environment for emergence and spread of disease due to the chaotic nature of war and violence that produces refugees. We argue in this paper that there is great potential of something more virulent than cholera and Ebola emerging and taking a big toll before being identified and controlled. We conclude by noting that once such a disease is out in the public rapid diffusion despite political boundaries is likely, a fact that has a direct bearing on global health. The extensive evidence presented in this paper of the overriding role of political factors in the refugee health problem calls for political reform and peace accords, engagement and empowerment of Pan-African organizations, foreign policy changes by Western governments and greater vigilance of non-governmental organizations (NGOs) in the allocation and distribution of relief aid.     

Imported measles. A potential control problem

From Dec 23, 1978, through Jan 31, 1979, an outbreak of five laboratory-confirmed cases and four clinical cases of measles occurred in a Vietnamese refugee population living in a single housing complex in Albuquerque, NM. The index cases were in two refugee siblings in whom measles was incubating on arrival in the United States. Despite spread through three subsequent generations of disease transmission within the Vietnamese population, there was no additional spread into the general Albuquerque population. Responsible factors included the age distribution of susceptible persons, the social isolation of the refugee population, and the physical structure of the housing complex. There is a need to identify the problem of imported measles in "ethnic islands" in need of vaccination.     

Murine typhus presenting as subacute meningoencephalitis

Murine typhus is a febrile systemic illness, presenting with headache and undulating fever. Neurological involvement is considered a rare complication. During 1994 and 1995, 34 patients admitted to our hospital were diagnosed as having murine typhus. Five of these patients presented with a syndrome of subacute "aseptic" meningitis or meningoencephalitis. Three had bilateral papilloedema and 2 had focal neurological signs. None had a rash or other systemic findings suggestive of rickettsial disease. The diagnosis was based on serum and cerebrospinal fluid serology and on prompt response to doxycycline therapy. These cases suggest that neurological involvement in murine typhus is more common than previously suspected and that murine typhus should be included in the differential diagnosis of subacute meningitis in endemic areas.     

Impact of epidemic influenza A-like acute respiratory illness in a remote jungle highland population in Irian Jaya, Indonesia

A suspected epidemic of unknown etiology was investigated in April/May 1996 in the remote jungle highlands of easternmost Indonesia. Trend analysis demonstrates the area-wide occurrence of a major respiratory infection outbreak in November 1995 through February 1996. The monthly mean rate of respiratory infection episodes for the peak outbreak months (2,477 episodes/100,000 persons) was significantly higher (P < .0001) than for the 34 months leading up to the outbreak (109 episodes/100,000 persons). Notable were the high attack rates, particularly among adults: 202 episodes/1,000 persons aged 20-50 years in one community. Excess morbidity attributed to the outbreak was an estimated 4,338 episodes. The overall case-fatality rate was 15.1% of outbreak cases. Laboratory evidence confirmed the circulation of influenza A/Taiwan/1/86-like viruses in the study population, and high hemagglutination inhibition titer responses were indicative of recent infections. Historical documents from neighboring Papua New Guinea highlight the role of influenza A virus in repeated area outbreaks.     

A criterion for omitting superfluous variables in regression models

Since 1996, south-eastern Australia has been experiencing a pertussis epidemic which has resulted in the deaths of several infants, including four from NSW in the 12 months to July 1997. All were less than six weeks of age and died from overwhelming cardiovascular compromise despite intensive care support. This excessive infant mortality from a preventable disease demonstrates the need for better pertussis immunity in the community and for erythromycin treatment of all suspected cases and family contacts, especially infants.     

Pulse of a nation: Depressive mood reactions of Israelis to the Israel–Lebanon War.

Eleven national Israeli samples (N?=?11,944) were interviewed regarding their depressive mood on 11 occasions between August 1979 and June 1984, including interviews prior to, during, and following the 1982 Israel–Lebanon War. We analyzed major newspaper headlines at the time of each national sampling in order to assess the relation between major national events and depressive mood. The outbreak of war coincided with an increase in depression. There was a decrease in depression subsequent to the most intensive period of the war, suggesting that adaptation occurs amidst continued stressful circumstances. Peak depressive mood occurred at the time of the massacre of Palestinians at the Sabra and Shatilla refugee camps. Reactions to the massacre were more pronounced among women, older adults, Jews of European or American origin, and the more educated; but group differences had only modest effect sizes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Current problems in the laboratory control of louse-borne typhus infection in Ukraine

Surveys designed to study spread of typhus infection (persistent form and Brill's disease), and state of laboratory diagnosis in Ukraine showed an important role the laboratory diagnosis plays in the system of epidemiological surveillance aimed at preventing epidemic typhus. Main trends of activities on perfection of the system of laboratory control of the infection under present-day conditions are outlined.     

Documentation of violence against civilians in a civil war. Examples from Kashmir

Physicians for Human Rights/Denmark visited Kashmir three times in 1993 and 1994. In Indian-held Kashmir we examined victims of torture and gunshots and we assessed similar evidence collected by local lawyers and doctors. In refugee camps for Indian Kashmiries we examined ten children, who were reported to have been tortured at the age of 5-14 years, and ten other children who allegedly had been ill-treated. Furthermore, 17 adults, who reported that they had been tortured, were examined. In nearly all cases there were physical findings in accordance with the histories of torture. In many cases, including those of the children, the findings were highly remarkable by their shape and localization. We interpret them as evidence of intentionally inflicted injuries. In the refugee camps we carried out a prevalence study of exposure to organized violence. Approximately 95% of all families had been exposed to violence; 35% reported that their children had been ill-treated. The physical findings indicate that intentional traumatization of civilians including children in Indian-held Kashmir takes place; the results of the prevalence study suggest that exposure to violence is widespread.     

Scrub typhus in the Western Pacific region

Scrub typhus is widely endemic in Asia. Man's behaviour and climatic changes greatly influenced the occurrence of the disease. Increasing prevalences of scrub typhus have been reported from some Asian countries and may coincide with the widespread use of beta-lactam antibiotics or to improve diagnostic facilities and/or more urbanisation into rural areas. Many cases acquired in Asia surfaced in Europe and America. The disease probably is overlooked among paediatric patients. Most patients with scrub typhus present with acute fever of unknown origin (acute FUO). Eschars are rare among Southeast Asian patients. Complications usually develop after the first week of illness. The complications include pneumonitis, meningoencephalitis, renal failure and jaundice. Improved serologic and molecular diagnostic tests are now available. Although drug-resistant strain of Orientia tsutsugamushi has been reported, the infection usually responds to simple but unpopular drugs such as doxycycline or chloramphenicol.     

Re-emergence of epidemic Venezuelan equine encephalomyelitis in South America. VEE Study Group

BACKGROUND: Venezuelan equine encephalomyelitis (VEE) virus has caused periodic epidemics among human beings and equines in Latin America from the 1920s to the early 1970s. The first major outbreak since 1973 occurred in Venezuela and Colombia during 1995, and involved an estimated 75,000 to 100,000 people. We report an epidemiological and virological investigation of this epidemic. METHODS: Virus isolates were made in cell culture from human serum, human throat swabs, and brain tissue from aborted and stillborn human fetuses, as well as from horse brain tissue and pooled mosquito collections. Human sera were also tested for VEE-specific antibodies. The serotypes of VEE isolates were identified by antigen assays, and viruses were characterised genetically by sequencing PCR products generated from the E3 and E2 genes. Phylogenetic analyses were done to determine evolutionary relations with respect to previous epidemic/epizootic and enzootic VEE virus isolates. Mosquito collections were made to identify possible vectors, and clinical findings were determined by direct observation of patients visiting hospitals and clinics in affected regions, and by inspecting patient records. Equine vaccination and vector control were used in an attempt to halt the spread of the outbreak. FINDINGS: Most affected people had an acute, self-limited febrile illness of 3 to 4 days duration. However, convulsions were often seen in children, and abortions and fetal deaths occurred in pregnant women infected with VEE virus. Antigenic characterisation of 12 virus isolates spanning the temporal and spatial range of the outbreak indicated that all are VEE serotype IC. Phylogenetic analysis revealed that all of the 1995 viruses were closely related to serotype IC viruses isolated during a large VEE outbreak that occurred in the same regions of Colombia and Venezuela from 1962-1964. A 1983 mosquito isolate from north central Venezuela was also closely related to the 1995 isolates. INTERPRETATION: This outbreak was remarkably similar to one that occurred in same regions of Venezuela and Colombia during 1962-1964. Symptoms of infected patients, estimated mortality rates, meteorological conditions preceding the epidemic, and seasonal patterns of transmission were all very similar to those reported in the previous outbreak. In addition, viruses isolated during 1995 were antigenically and genetically nearly identifical to those obtained during 1962-1964. These findings suggest that the epidemic resulted from the re-emergence of an epizootic serotype IC VEE virus. Identification of a similar virus isolate in mosquitoes in Venezuela in 1983, 10 years after epidemic/epizootic VEE activity ceased, raises the possibility of a serotype IC enzootic transmission cycle in northern Venezuela.     

Assessment of asbestos burden in the placenta and tissue digests of stillborn infants in South Texas

Between June 1986 and May 1997, chronic wasting disease (CWD) was the only natural cause of adult mortality among captive Rocky Mountain elk (Cervus elaphus nelsoni) held at a wildlife research facility near Fort Collins, Colorado (USA). Of 23 elk that remained in this herd > 15 mo, four (17%) developed CWD. All affected elk were unrelated females from the founding cohort, captured as neonates and raised in 1986. The index case was diagnosed in 1989; time intervals between subsequent cases ranged from 13 to 32 mo. Initial age at onset of clinical signs ranged from about 2.9 to 8.1 yr; duration of clinical disease ranged from 5 to 12 mo (mean = 7.5 mo) prior to death. Intraspecific lateral transmission of CWD seemed the most plausible explanation for the epidemic pattern observed; neither periparturient nor maternal transmission appeared necessary to sustain this outbreak. Early detection and elimination of incubating or clinical individuals may have aided in reducing exposure or infection rates as compared to a previous outbreak in the same facility. Transmission routes and rates, pathogenesis, antemortem diagnostic tools, and the potential role of reservoirs or environmental contamination in perpetuating CWD epidemics warrant further investigation.     

The arthroscopic treatment of avascular necrosis of the proximal pole following scaphoid nonunion

To investigate the clinical character of an outbreak of aseptic meningitis in Iwamizawa 1997 caused by echovirus 30, and to investigate the spreading of the outbreak, we analyzed clinical character of 75 hospitalized patients in our hospital, and mapped the patients' distribution in Iwamizawa City each week. We detected in our hospital an epidemic outbreak of acute enteroviral meningitis caused by echovirus type 30 in Iwamizawa, from September to December, 1997. Regarding the patients, there was little prevalence in males, with an average age of 6 years and a range of 0 to 13 years of age. The most constant symptoms were three major one such as headache (90%), fever up (89%), vomiting/nausea (87%), sometimes sorethroat (30%) and abdominal pain (15%). One case had a febrile convulsion temporally, and two cases had acute meningoencephalopathy and- encephalitis. In the cereblospinal fluid (CSF), we found no predominance of mononuclear cell (MNC) (58%) in the differential cell count. The mean of the peak of CSF cell counts was 654/3. White blood cell (WBC) was 8940/microliters, and CRP 1.4 mg/dl. None of them was detected in the bacterial culture of the CSF. Viral cultures were performed on CSF in 26 cases. Echovirus type 30 was isolated in 4 cases of hospitalized patients, and in one case with meningismus without pleocytosis. The beginning of the outbreak was observed in two kindergarten and one elementary school side by side. The peak of the whole outbreak was detected in the 3rd to 6th week, however the school spreading peak was detected in the 3rd and 4th week, and spreading was going in the whole city.     

Sporadic Creutzfeldt-Jakob disease in the United Kingdom: analysis of epidemiological surveillance data for 1970-96

OBJECTIVE: To identify changes in the occurrence of Creutzfeldt-Jakob disease that might be related to the epidemic of bovine spongiform encephalopathy. DESIGN: Epidemiological surveillance of the United Kingdom population for Creutzfeldt-Jakob disease based on (a) referral of suspected cases by neurologists, neuropathologists, and neurophysiologists and (b) death certificates. SETTING: England and Wales during 1970-84, and whole of the United Kingdom during 1985-96. SUBJECTS: All 662 patients identified as sporadic cases of Creutzfeldt-Jakob disease. MAIN OUTCOME MEASURES: Age distribution of patients, age specific time trends of disease, occupational exposure to cattle, potential exposure to causative agent of bovine spongiform encephalopathy. RESULTS: During 1970-96 there was an increase in the number of sporadic cases of Creutzfeldt-Jakob disease recorded yearly in England and Wales. The greatest increase was among people aged over 70. There was a statistically significant excess of cases among dairy farm workers and their spouses and among people at increased risk of contact with live cattle infected with bovine spongiform encephalopathy. During 1994-6 there were six deaths from sporadic Creutzfeldt-Jakob disease in the United Kingdom in patients aged under 30. CONCLUSIONS: The increase in the incidence of sporadic Creutzfeldt-Jakob disease and the high incidence in dairy farmers in the United Kingdom may be unrelated to bovine spongiform encephalopathy. The most striking change in the pattern of Creutzfeldt-Jakob disease in the United Kingdom after the epidemic of bovine spongiform encephalopathy is provided by the incidence in a group of exceptionally young patients with a consistent and unusual neuropathological profile. The outcome of mouse transmission studies and the future incidence of the disease in the United Kingdom and elsewhere, will be important in judging whether the agent causing bovine spongiform encephalopathy has infected humans.     

Outbreak of serogroup C meningococcal disease associated with campus bar patronage

Between February 1991 and April 1992, eight undergraduates at a US residential university and one at a nearby 2-year college contracted serogroup C meningococcal disease. A case-control investigation with 20 controls per case, oropharyngeal carriage surveys, and multilocus enzyme electrophoresis (MEE) of serogroup C isolates were used to identify factors contributing to the outbreak. All eight sterile-site isolates from cases were closely related by MEE and were similar (though not identical) to the strain associated with the 1991-1992 epidemic of meningococcal disease in eastern Canada. Disease was associated with cigarette smoking (p = 0.012), recent patronage of campus-area bars (p = 0.034), estimated amount of time spent in campus-area bars (p = 0.0003), and, especially, recent patronage of one specific bar, bar A (p = 0.0006; odds ratio = 23.1, 95% confidence interval 3.0-571.5). In carriage surveys, 1,528 throat cultures taken from (primarily student) noncases yielded only five (0.3%) strains that were identical by MEE to those from cases. Two of these were found among 22 cultures obtained from bar A employees in spring 1992. Some cases in this outbreak may have followed transmission of the epidemic strain in bar A. Campus bar environments may facilitate the spread of meningococcal disease among teenagers and young adults.     

Epidemic of pediatric deaths from acute renal failure caused by diethylene glycol poisoning. Acute Renal Failure Investigation Team

CONTEXT: Contaminated pharmaceutical products can result in substantial morbidity and mortality and should be included in the differential diagnosis of deaths of unknown origin. OBJECTIVE: To investigate an outbreak of deaths among children from acute renal failure in Haiti to determine the etiology and institute control measures. DESIGN: Case-control study, cohort study, and laboratory toxicologic evaluation. SETTING: Pediatric population of Haiti. PARTICIPANTS: Cases were defined as Haitian residents younger than 18 years with idiopathic anuria or severe oliguria for 24 hours or longer. Febrile hospitalized children without renal failure were enrolled as control subjects. MAIN OUTCOME MEASURE: The odds of exposure to suspected etiologic agents among cases and controls. RESULTS: We identified 109 cases of acute renal failure among children. The clinical syndrome included renal failure, hepatitis, pancreatitis, central nervous system impairment, coma, and death. Of 87 patients with follow-up information who remained in Haiti for treatment, 85 (98%) died; 3 (27%) of 11 patients transported to the United States for intensive care unit management died before hospital discharge. A locally manufactured acetaminophen syrup was highly associated with disease (odds ratio, 52.7; 95% confidence interval, 15.2-197.2). Diethylene glycol (DEG) was found in patients' bottles in a median concentration of 14.4%. The median estimated toxic dose of DEG was 1.34 mL/kg (range, 0.22-4.42 mL/kg). Glycerin, a raw material imported to Haiti and used in the acetaminophen formulation, was contaminated with 24% DEG. CONCLUSIONS: An epidemic of severe systemic toxicity and deaths from DEG-contaminated acetaminophen syrup occurred in Haiti. Good manufacturing practice regulations should be used by all pharmaceutical manufacturers to prevent such tragedies.