INFECTIVE CAUSES (I.E. :
LIVING ORGANISMS)
Table of contents :
germ theory : the doctrine that infectious diseases are of microbic
origin.
Classification
-
monoinfection : infection with a single
kind of organism
-
infections (subcellular or unicellular
living organisms)
-
infestations
(multicellular Eukarya)
Epidemiology : approximately 1.5 billion people
carry a parasitic (helminthic and protozoan ) burden.
-
infections with
unknown aetiology

-
mixed infection / polyinfection
: infection of an organ or tissue by more than one microorganism, as in
wound infections, abscesses, pneumoniae
,
and rarely meningitis
and endocarditis
;
mixtures of every type occur, e.g., bacterial
and viral
,
bacterial
and fungal
,
and protozoan
and viral
-
secondary infection : infection
by a microorganism following an infection by another kind of microorganism.
An estimated 1,415 microbes are infectious for humans. Of these, 868
(61%), are considered to be zoonotic; overall, zoonotic pathogens are
twice as likely to be associated with emerging diseases (Taylor LH, Latham
SM, Woolhouse ME. Risk factors for human disease emergence. Philos Trans
R Soc Lond B Bio Sci. 2001;356:983–9).
Total cases of death caused by infectious diseases in 2000 : 17 million
(30% of all deaths)
infectious disease : a disease caused by a pathogenic microorganism;
the etiologic agent may be a bacterium, virus, fungus, or animal parasite,
and may be transmitted from another host or arise from the host's own indigenous
microflora
-
communicable disease : an infectious disease transmitted from one
individual to another, either by direct contact or indirectly by means
of a vector or fomites
-
contagious disease : communicable disease transmitted by contact
notifiable or reportable
disease : one required to be reported to federal, state, or local health
officials when diagnosed, because of infectiousness, severity, or frequency
of occurrence
Parasitism
Transmission
may be ...
-
horizontal transmission : the spread of an infectious agent from
one individual to another, usually through contact with bodily excretions
or fluids, such as sputum or blood, that contain the agent
-
vertical transmission : transmission
from one generation to another. The term is restricted by some to genetic
transmission and extended by others to include also transmission of infection
from one generation to the next, as by
milk or through the placenta
-
homogeneous (no invertebrate interposition)
-
homonymous (1 only affected host)
-
heteronymous (among vertebrates, including accidental hosts
in which the disease is usually more severe)
-
heterogeneous (invertebrate interposition)
-
homonimous (1 only affected host : e.g. in malaria, Plasmodium
doesn't infect Anopheles)
-
heteronimous (more than one affected host : e.g. in plague, rodents
=> rats ==Xenopsylla cheopis==> Homo sapiens)
-
cross infection : infection transmitted between individuals infected
with different pathogenic microorganisms.
vection : the carrying of disease germs from an infected person
to a well person. It is
-
direct, immediate, and radial when transferred directly from one person
to another.
-
circumferential, indirect, or mediate when pathogens are carried by an
intermediate host
The incidence of diarrheal disease among cruise ship passengers
declined from 29.2 cases per 100,000 passenger days in 1990 to 16.3 per
100,000 passenger days in 2000. In 2002, the Vessel Sanitation Program
of the Centers for Disease Control and Prevention reported 29 outbreaks
(3% or more passengers ill) of acute gastroenteritis on cruise ships, an
increase from 3 in 2001. During 2001-2004, the background and outbreak-associated
incidence rates of passengers with acute gastroenteritis per cruise were
25.6 and 85, respectively. Acute gastroenteritis outbreaks per 1000 cruises
increased overall from 0.65 in 2001 to 5.46 in 2004; outbreaks increased
from 2 in 2001 to a median of 15 per year in 2002–2004. Median ship inspection
scores remained relatively constant during the study period (median 95
on a 100-point scale), and were not significantly associated with either
gastroenteritis incidence rates. Despite good performance on environment
health sanitation inspections by cruise ships, the expectation of passenger
cases of gastroenteritis on an average 7-day cruise increased from two
cases during 1990–2000 to 3 cases during the study period. This increase,
likely attributable to noroviruses, highlights the inability of environmental
programs to fully predict and prevent risk factors common to person-to-person
and fomite spread of diseaseref.
Approximately 60 episodes of viral gastroenteritis aboard ships, involving
10 000 to 11 000 passengers, have been reported since 1986 (unless otherwise
indicated, outbreaks affected ships embarking from the USA) :
-
1986 : outbreaks (392 passengers and 30 crew -- in 2 outbreaks) were reported
during 2 one-week Caribbean ship cruises -- Norwalk virus presumed and
source not established.
-
1986 : an outbreak (119 cases) of SRSV (probably norovirus) infection was
reported aboard a British cruise ship.
-
1994 (publication year) : an outbreak (217 cases) of Norwalk virus infection
aboard a cruise ship in Hawaii was traced to contaminated ice.
-
1995 (publication year) : an outbreak (585 cases, approximate) was reported
aboard an aircraft carrier.
-
1997 : an outbreak (450 cases reported; true number estimated at 1806)
of probable [norovirus] infection occurred on an American aircraft carrier
off the coast of Japan in 1997 - source unknown.
-
1999 : outbreaks (587 cases total - 162 + 425 cases) were reported among
military ships following port visits in Southeast Asia.
-
2001 : a total of seven outbreaks were reported on U.S. cruise ships.
-
2002 : outbreaks (2098 cases in 24 outbreaks) affecting 18 ships were reported.
These figures included a Disney cruise ship in Florida (2 outbreaks encompassing
approximately 185 cases). Other sources reported 29 shipboard outbreaks
of diarrhea during 2002.
-
2002 : an outbreak (300 cases) was reported aboard an aircraft carrier.
-
2002 : an outbreak (250 or more cases) of norovirus infection affected
over 250 passengers on a cruise ship in Alaska -- source unknown.
A 2nd outbreak (218 cases) occurred on the same cruise ship two weeks later;
and a 3rd outbreak (183 cases) the following month.
-
2003 : an outbreak (247 cases) was reported on a cruise ship from Los Angeles
to Hawaii.
-
2003 : an outbreak (150 cases) was reported on a cruise ship in New Orleans.
-
2003 : an outbreak (500 or more cases) of norovirus infection was reported
aboard a British cruise ship to the Mediterranean.
-
2003 : an outbreak (340 cases) was reported on a north Atlantic cruise
ship.
-
2003 : an outbreak (300 cases) of norovirus infection was reported aboard
a Danish cruise ship.
-
2004 : an outbreak (39 cases) of suspected norovirus infection was reported
on a cruise ship in the Caribbean.
-
2004 : an outbreak (116 cases) of norovirus infection was reported on a
cruise ship to the Caribbean.
-
2004 : an outbreak (67 cases) was reported aboard a German cruise ship
docked in Scotland.
-
2004 : an outbreak (358 cases) of presumed norovirus gastroenteritis occurred
aboard a cruise ship sailing from Vancouver, British Colombia.
-
2005 : an outbreak (94 cases) of norovirus infection was reported on a
cruise ship from Florida to the Caribbean.
-
2005 : an outbreak (200 cases) of presumed norovirus infection was reported
on a Norwegian cruise ship in Valparaiso.
-
2006 : an outbreak (362 cases) of presumed norovirus infection was reported
on a cruise ship to the Caribbean.
-
2006 : an outbreak (115 cases) of presumed norovirus gastroenteritis was
reported among passengers on a cruise ship from Seattle, Washington to
Alaska.
-
2006 : an outbreak (700 or more cases) of norovirus gastroenteritis was
reported among passengers on a cruise ship from Italy to Florida.
-
2006 : an outbreak (100 or more cases) of presumed norovirus infection
-
2006 : an outbreak (200 cases) of presumed norovirus infection was reported
aboard an English cruise ship.
-
2006 : an outbreak (116 cases) of presumed norovirus gastroenteritis.
-
2006 : an outbreak (700 or more cases) of norovirus gastroenteritis was
reported among passengers on a cruise ship from Rome to the United States.
-
2006 : outbreaks (98 cases in 3 outbreaks) of norovirus infection were
reported aboard Dutch cruise ships.
-
2006 : an outbreak (380 or more cases) of norovirus gastroenteritis was
reported among passengers on a cruise ship in the Caribbean.
Contagion :
the communication of disease from one individual to another. It may be
...
direct contagion (parasites are transmitted
from one individual to another belonging to the same species)
-
anthroponoses
: a disease that is spread from humans to humans; said of infection
that causes disease in non-human hosts but that can be perpetuated solely
in Homo sapiens, with some varieties that spread from animals
to humans (zoonoses) and others that spread from humans to humans, particularly
in reference to parasitic disease such as dry cutaneous leishmaniasis or
malaria
in which the disease can be spread from one human to another by an appropriate
vector.
-
skin penetration
-
(injured) mucosal surfaces
-
digestive or enteral route
-
oro-faecal route : this route may
involve or not a hepatic stage.
-
colostral transmission (vertical
transmission)
-
breast milk and colostrum
Eliminating lymphocytes from breast milk may be prudent. Removing these
cells could be accomplished by placing leukocyte reduction filters (routinely
used to eliminate leukocytes from blood used for transfusion) into nipple
shields, which are used by many women who have cracked or otherwise painful
nipples. Such filters also could be placed into the nipples of bottles
containing milk collected by breast pumps
-
tears : SARS
coronavirus

Web resources :
-
Enter-net
: the international surveillance network for human gastrointestinal infections.
It involves all 15 countries of the European Union (EU), plus Australia,
Canada, Japan, South Africa, Switzerland and Norway. The newly associated
states of Eastern Europe will formally be able to join the network in 2003,
although
an informal working relationship already exists with the Czech Republic,
Hungary, Latvia and Poland
-
DIVINE-NET,
the European network for the prevention of emerging (food-borne) enteric
viral infections
-
parenteral routes
-
respiratory or inhalatory route : respiratory secretions (Pflüger
droplets, Ø < 100 mm). Only droplets
with 0.5 < Ø < 3 mm can reach alveoli
: those smaller remain in suspension and are breathed out, while those
greater are usually blocked by kinocilia.
-
genital or sexual route (sexually
transmitted diseases (STD)
)(vertical
transmission)
-
perinatal infection : infection
in the newborn acquired shortly before or during delivery, due to ...
-
ascending or transcervical infection : infection of the fetus by
microorganisms that gain access to the uterus from the vagina, usually
following rupture of membranes but sometimes acquired in utero while
the membranes are intact
-
contact with microorganisms in the birth canal during delivery
-
hematogenous infection
-
transplacental infection
: infection acquired by the fetus in utero by the hematogenous spread
of a maternal infection across the placenta via the chorionic villi(vertical
transmission)
-
transfusion
of infected blood or derivatives (transfusion-associated transmission (TAT))
(for parasites with a hematic stage)
-
transplantation
of infected organs
-
HBV

-
HCV

-
HDV

-
HIV-1

-
HTLV

-
also transplacental :
Contaminated products prepared in compounding pharmacies have been implicated
in clusters of infections, including Exophiala
dermatiditis
joint infections caused by injectable steroidsref;
Pseudomonas
spp.
and Serratia spp.
infections, resulting in meningitis from epidural injections (CDC, unpublished
data, 2002; Contra Costa Health Services, unpublished data, 2002); Burkholderia
cepacia
blood stream infections from intravenous flush (CDC, unpublished data,
2004), and Pseudomonas
fluorescens
blood stream infections from intravenous flush. Regulatory oversight of
compounding pharmacies varies among states. However, compounding pharmacies
are subject to inspection by pharmacy boards, FDA, and accreditation organizations.
The American Society of Health-System Pharmacists and the U.S. Pharmacopeia
have developed guidance and standards that address quality assurance and
sterile preparation of compounded products (American Society of Health-System
Pharmacists. ASHP technical assistance bulletin on quality assurance for
pharmacy-prepared sterile products. Am J Hosp Pharm 1993; 50:2286-98. U.S.
Pharmacopeial Convention, Inc. U.S. pharmacopeia 28 [Chapter 797]. Pharmaceutical
compounding: sterile preparations. Rockville, MD: U.S. Pharmacopeial Convention,
Inc.; 2004:2461-77). In addition, in May 2004, the Pharmacy Compounding
Accreditation Board (PCAB) established a task force to set standards for
a voluntary accreditation board for compounding pharmaciesref.
Companies that manufacture products intended for injection should follow
FDA regulations for ensuring the sterility of these productsref.
Treatment for potential patients should include targeted antimicrobial
therapy and consideration of removing their cathetersref.
-
germinal infection : transmission
of infection to the fetus or child by means of the oocyte (transovarial
transmission) or sperm of the parent (vertical
transmission)
indirect contagion : environmental
microorganisms are often more drug-resistant than parasitic ones due to
daily survival from antibiosis (e.g. : down-regulated and narrowed porins)..
-
fomites / vehicles : an inanimate object
on which pathogenic material exists
-
favouring vehicles
-
food-borne diseases or illnesses (e.g.
meat, milk and derivatives) (see also primary
prevention
)ref
-
PrPSc

-
Vibrio cholerae

-
Yersinia enterocolitica

-
Clostridium
botulinum serotype B
(from foods preserved in olive-oil) : incubation = 8-36 days; duration
= days to 1 year
-
food-borne infections : toxins
produced during invasion and/or toxins produced during proliferation at
expenses of nutrients in the food
Epidemiology : in the USA around 76 million
cases of foodborne diseases, resulting in 325,000 hospitalisations and
5,000 deaths, are estimated to occur each year. 61 deaths and 73,000 illnesses
– such as bloody diarrhoea and hemorrhagic colitis - are blamed on eating
foods contaminated with E. coli each year. Relative rates of laboratory-diagnosed
foodborne infection with Vibrio, Salmonella, Campylobacter,
Listeria, and Shiga toxin–producing E. coli O157, as compared
with 1996–1998 rates :
Aetiology :
-
short-incubation illnesses (< 18 hours) without fever are likely to
be related to preformed toxin
-
Staphylococcus aureus
(from pastries, salads, remnants, protein-rich foods) : 1-8 hours (usually
< 6-hour) incubation period; mostly nausea and vomiting, diarrhea, abdominal
cramping; lasting for 24-48 hours
-
Clostridium perfringens
(from meat (expecially chicken)) : incubation period 8-22 (12-18) hours
(average 12), more diarrhea; lasting for 24 hours
-
Bacillus cereus
(from starch-rich foods (e.g. rice, pasta), cereals, sauce, spices, Chinese
restaurants) : incubation period = 30'-5 hours; duration = 6-24 hours
Prevention : preserve above 60°C and
heat at 74°C
These illnesses tend to be < 24 hours in duration.
-
illnesses with longer incubation periods, fever
,
and more prolonged symptoms are more likely due to the in situ replication
of enteric pathogens
-
bacteria
-
Salmonella enterica
(up to 72 hours)
-
Shigella dysenteriae
(from unpasteurized milk and derivatives, salad) : incubation = 1-7 days;
duration = 1-3 days
-
Campylobacter spp.

-
Escherichia coli

-
Escherichia coli O157:H7
(from chicken, eggs, meat, fish, milk and derivatives) : incubation = 6-72
hours; duration = 2-3 days
-
Listeria monocytogenes
(from animal bowels, field, milk, meat, shellfish, cheese) : incubation
= 1 day-3 weeks
-
viruses
-
fungi
-
protozoa :
-
metazoa
Symptoms & signs are generally intestinal
(but neurological in botulinum intoxication) and usually epidemics.
Specific food-borne infections :
-
unpasteurized cow milk-borne
infections :
-
primary contamination from cow :
-
viruses :
-
foot-and-mouth
disease virus (FMDV)

-
rabies virus
: in 1996 and 1998, there were 2 episodes involving rabid cows that occurred
in Massachusettsref.
Milk from rabid cows can contain rabies virus, and transmission via unpasteurized
milk is theoretically possible. Temperatures reached during pasteurization
kill the virus. 80 persons consumed unpasteurized milk that was collected
from the 2 cows, and 9 more had contact with saliva from the cows. All
89 persons received postexposure rabies prophylaxis, and no human cases
of rabies eventuated. A similar report in Oklahoma of possible rabies exposure
associated with the consumption of raw milk or cream from a rabid cow was
circulated in 2006
-
tickborne encephalitis virus (TBEV)
,
a zoonotic arbovirus infection usually transmitted to humans by the bite
of an Ixodes persulcatus or Ixodes ricinus tick, is endemic
to Central Europe, Eastern Europe, and Russiaref.
However, the virus can be found in the milk of cows and goats with tickborne
encephalitis and was reported to be transmissible to humans by the consumption
of unpasteurized milkref.
A case-control study failed to confirm oral transmissionref.
-
bacteria :
-
secondary contamination from personnel or environment :
-
viruses :
-
bacteria :
-
Brainerd diarrhearef
: outbreaks of chronic watery diarrhea of unknown etiology characterized
by acute onset and prolonged duration, named after an outbreak which affected
122 residents of Brainerd, Minnesota, between December 1983 and July 1984.
The illness lasted at least one year for 75% of case-patients and was characterized
by acute onset, marked urgency, a lack of systemic symptoms, and a failure
of response to conventional antimicrobial agents, and a long median duration
of illness (median duration, 16.5 months). Clinical and laboratory data
indicate that the diarrhea was caused by a secretory mechanism. Consumption
of raw milk from a single dairy was associated with illness (OR =28.3;
95% CI = 9.0-89.0). A median incubation period of 15 days was determined
for seven case-patients. Possible secondary transmission was noted in one
family. Extensive laboratory examination did not identify an etiologic
agent. Outbreaks or sporadic cases of a similar illness have occurred in
at least seven states; the outbreaks were less extensively investigated
and findings were not published, but raw milk consumption was common in
the affected persons. This illness appears to represent a previously unrecognized
but important clinical entity and public health problem. The etiology and
effective therapy for this illness must be determined by further studies
of sporadic cases and outbreaksref1,
ref2,
ref3.
No etiologic agent was ever isolated. The outbreak of Brainerd diarrhea
stopped when all of the dairy's output was diverted and pasteurizedref
(MT Osterholm, personal communication). Subsequent outbreaks in Illinois
and Texas were not directly associated with milk, although cattle had been
in the vicinity of an Illinois well that had its water implicated as a
vehicle of transmissionref.
Another outbreak of Brainerd-like diarrhea, although not associated with
raw milk but rather water supply, affected 58 (15%) of 394 passengers aboard
a cruise ship visiting the Galapagos Islands in Ecuadorref.
Histologically there is colonic epithelial lymphocytosis similar to that
seen in collagenous and lymphocytic colitis, but without distortion of
mucosal architecture, surface degenerative changes, or thickened subepithelial
collagen platesref1,
ref2
Industrialization of the USA dairy industry began in the 1800s. The pooling
of milk and mass distribution resulted in outbreaks of disease. Milk pooled
from large numbers of cows permitted pathogen-containing milk that originated
in one cow to contaminate thousands of gallons. Therefore, Certified Milk
Commissions were established to improve milk sanitation in all phases of
milk production, packaging, and distributionref1,
ref2.
The commissions set standards, oversaw milk production, and certified the
products of compliant dairies as Grade A certified. With the advent of
high-volume pasteurization technology, most public health officials, physicians,
and veterinarians concluded that pasteurization would ensure a safe milk
supplyref.
Many members of the commissions believed that pasteurization engendered
sterilized filth and destroyed essential nutrients in the milkref.
Eventually, the model for the production of safe milk included the commissions'
sanitary standards, as well as pasteurizationref.
In 1995, a total of 28 states permitted the intrastate sale of raw milk
to consumersref.
Jurisdictions with legal raw milk sales experienced a disproportionate
share of the milkborne outbreaks of illness reported to the Centers for
Disease Control and Prevention from 1973 through 1992, with 40 (87%) of
46 raw milk-associated outbreaks of disease occurring in states with legal
raw milk salesref.
Raw milk accounted for < 1% of total milk sold in states permitting
such salesref.
Interstate transportation of raw milk that was not destined for pasteurization
was prohibited in 1987ref.
E.
coli O157:H7, an important cause of gastroenteritis that is sometimes
complicated by the hemolytic uremic syndrome, is carried by cattle and
can contaminate raw milk. In one studyref,
E.
coli O157:H7 was isolated from 153 (4.3%) of 3593 bovine rectal swab
samples. A recent illustrative example of raw milk being associated with
an outbreak of illness due to E. coli O157:H7 infection was reported
in Oregonref.
The organism that was causing disease was associated with raw milk from
a specific dairy that was being sold in grocery stores. E. coli
isolates from the 6 initial human cases were homologous with those from
the dairy herd. The health authorities instituted warnings and labeling
requirements and increased monitoring of the dairy. Nevertheless, retail
sales -- and associated cases of illness -- continued to occur for more
than a yearref.
Low-level outbreaks associated with raw milk can continue indefinitely
if distribution and sales continue. Washington allows the direct sale of
unpasteurized milk by only 6 farms, which are licensed for production and
bottling. In December 2005, E. coli O157 infected 16 people after
they drank unpasteurized milk from an unlicensed farm. Milk samples were
tested for the pathogen, with positive results.
Internet and lay publications are replete with claims that raw milk
will cure diverse ailments and prevent many moreref.
Persons who drink unpasteurized milk and milk products might believe that
these products taste better, provide greater nutrition than pasteurized
products, and/or decrease the risk for various medical conditionsref.
However, the benefits of consuming unpasteurized milk and milk products
have never been validated scientificallyref.
The professional position regarding this claim has not changed since The
Journal of the American Medical Association published a commentary
in 1984ref.
The National Council for Reliable Health Information discussed the controversy
regarding the regulation of the production and sale of Certified Raw Milk
in Californiaref.
They referred to a report in the Los Angeles Times that quotes a dairyman
in reference to raw milk: "`The Lord gives us everything in its wholeness,
and that's the way He meant us to keep it'" (Jones RA: Raw milk: a holy
war over health. Los Angeles Times 31 August 1984; sect 1:1, 3,
20, 21). Raw milk and raw milk products should be avoided, unless the consumer
believes that the improved taste of the product warrants the risk. Warning
labels should appear on all raw milk and raw milk products that clearly
spell out the possible dangers, so the consumer can make an informed choice:
caveat emptor. A vocal constituency considers raw milk and its derivatives
to be health foods and will continue to lobby for availability to ensure
the availability of those products
Skimmed milk is more likely to harbor bacteria such as Salmonella
and E.coli than full-fat milk : many smaller dairies used machines
built before skimmed milk became popular. These dairies skimmed off the
cream and failed to pasteurize the remaining milk properly. The flow-rate
is speeded up, so the milk is not held at high temperature for long enough
: after the pasteurization process a test looks for phosphatase, an enzyme
supposed to be destroyed during an effective pasteurization process. But
the phosphatase tends to bind to the fat in milk, most of which was removed
when the cream was skimmed off, so that low-fat milk could test negative
for the enzyme even if it was not pasteurized properly.
-
uneviscerated fish products that are salt-cured, dried, or smokedref
: uneviscerated, salt-cured, whole fish products have caused several outbreaks
of botulism and death. C. botulinum spores are ubiquitous in fishery
products and the marine environment. The spores represent a public health
hazard when conditions are suitable for vegetative cell growth and toxin
production. 3 outbreaks of botulism, causing 3 deaths and 11 illnesses,
resulted from kapchunka in the USA between 1981 and 1987. Kapchunka, an
ethnic food usually produced from whitefish, is also known as "rybetz,"
"ribeyza," or "rostov." Kapchunka is an uneviscerated, salt-cured, air-dried,
whole fish, which may or may not be smoked. It is consumed without further
preparation, such as cooking. The fish are salt-cured under minimum refrigeration
conditions for a minimum of 25 days and then air dried at ambient temperature
for 3 to 7 days. Kapchunka may be smoked before packing and are commonly
stored under refrigeration. In 1991, 2 botulism outbreaks occurred. In
one, "Faseikh" was
implicated in at least 91 illnesses and 18 deaths in Egypt. Faseikh
is a traditional product made by fermenting uneviscerated fresh mullet
for up to one day and then salt-curing it in barrels which may be tightly
sealed from one week to one year. In another, an ethnic fish product called
"moloha" caused a botulism outbreak involving 4 family members in New Jersey.
Moloha is an uneviscerated, salt-cured
fish product similar to "faseikh." The preparation steps in the New
Jersey incident were not identified since the source of the "moloha"
could not be found. Other salt-cured products, such as "bloaters,"
can also pose a public health hazard. Bloaters are prepared by salt-curing
uneviscerated, whole herring, which may or may not be smoked. Bloaters
may be transformed into other products, such as fillets or bloater paste.
In addition to the products noted above, whole fish that are dried, pickled,
or fermented can also pose a public health hazard. The referenced episodes
of botulism are representative of a well-documented history of life-threatening
health hazards associated with uneviscerated, salt-cured fish. The problems
with these products are compounded by the difficulty in attaining sufficient
levels of salt in all portions of an uneviscerated fish to inhibit the
growth of the C. botulinum. Consequently, any fish product that
is salt-cured and then dried, smoked, pickled, or fermented can pose a
public health hazard. Toxin may be present in these products even when
there are no outward signs of microbiological spoilage or other clear indications
to alert the consumer. Control of growth and toxin production from C.
botulinum in fishery products is based on spore destruction (e.g.,
retorting canned foods) or inhibition of vegetative cell growth (e.g.,
control of water activity, or pH, or use of approved chemical inhibitors).
The control measures must be applied rapidly and uniformly throughout the
product to protect consumers from this potentially life-threatening toxin.
Control of botulism can also be achieved in salted, dried, or smoked products
prepared from small species of uneviscerated fish (generally 3 to 5 inches
in length). Typically, these products are prepared from small anchovy and
herring sprats. As uneviscerated fish under 5 inches in length are processed,
their smaller size helps to ensure complete permeation of the flesh with
inhibitory levels of salt or drying to a uniformly low water activity,
resulting in the attainment of conditions that prevent the growth of C.
botulinum. FDA considers uneviscerated fish that are salt-cured, dried,
or smoked to represent a potentially life-threatening health hazard. In
addition, fillets, parts, or other products derived from uneviscerated
fish pose the same potential health hazard as the original product. Therefore,
with the exception of small, uneviscerated fish as described above, FDA
considers uneviscerated fish that have been salt-cured, dried, or smoked,
as well as products made from them, to be adulterated within the meaning
of section 402(a)(4) of the Federal Food, Drug, and Cosmetic Act, in that
the product has been prepared, packed, or held under unsanitary conditions
whereby it may have been rendered injurious to health. These products are
hazardous whether stored at ambient temperature, refrigerated, or frozen,
or whether packaged in air, vacuum, or modified atmosphere.
-
seafood-borne infections represent only 10%
of all foodborne illnesses in the USA, making seafood a relatively safe
food commodity. Concerns from undercooked or raw bivalve shellfish such
as oysters and clams include :
-
steak, per se, does not usually function as a vehicle, because even if
poorly cooked on the inside, the bacteria are likely on the surface and
exposed to the cooking process much more directly
-
berries : freezing allows viruses to survive in berries for a long time.
Transmission of viruses such as hepatitis A virus by contaminated berries
has been reported in the literatureref1,
ref2,
ref3.
Outbreaks of norovirus infections attributed to raspberries have been documented
in Canada in 1997, Finland in 2002 and 2003ref1,
ref2,
ref3,
and France in 2005ref.
It is likely that the raspberries were contaminated prior to freezing rather
than after importation, for several reasons: the distinctive virus genotype,
harvesting of fruit is usually carried out by casual itinerant labour;
and washing of soft fruit prior to preservation by freezing is difficult.
Prevention : alcohol with a meal can lower
the risk of food poisoning : in 2002, for example, health officials in
Spain studied an outbreak of salmonella among people who had been exposed
to contaminated potato salad and tuna at a large banquet : the rate of
sickness was lowest in those who had consumed large amounts of beer, wine
or spiritsref.
Consumers of larger amounts of alcohol also had the lowest levels of sickness
documented in earlier studies of large salmonella outbreaks in Spain. In
a 1992 study health officials in the United States looked at an oyster-borne
outbreak of HAV and found that only drinks with an alcohol concentration
> 10% prevented or reduced the severity of the sickness.
Web resources :
-
indifferent vehicles
-
hands (see also hand
hygiene
)
: theoretically any infectious organism can be transmitted
-
air-borne infection : an infection
that is contracted by inhalation of microorganisms or spores suspended
in air on
Microorganisms are often rendered airborne as a result of a sneeze or cough.
The risk for transmission
of respiratory infectious diseases during air
travel
might depend on several factorsref,
including :
-
immunity of passengers
-
infectiousness of the organism
-
degree of shedding of the pathogen by infected passengers
-
hygienic practices of infectious passengers
-
hygienic practices of the other passengers/crew
-
flight duration (with > 8 hours indicating an increased risk)
-
cabin environment of the aircraft
-
proximity of the index passenger (with seating within two rows indicating
an increased risk)ref1,
ref2,
ref3
Transmission of respiratory pathogens during air travel has been reported
:
Other food-borne pathogens can be transmitted on commercial air flights
:
eManifest is a new software application developed by the CDC Division
of Global Migration and Quarantine (DGMQ) to securely import, sort, and
assign passenger-locating information to jurisdictions to facilitate timely
identification of exposed persons. These data are securely transmitted
to state and territorial health departments via the Epidemic
Information Exchange (Epi-X) for notification of potentially exposed
passengers
Agents associated with outbreaks of respiratory infection among the
military :
-
influenzaviruses

-
Adenoviruses
were originally described during outbreaks among American military personnel
during the 1950s. These agents accounted for about 72% of all respiratory
disease and 10% of hospitalization among recruits in 1958. Military outbreaks
tend to involve adenovirus types 4 or 7. Adenoviruses were implicated in
53% of respiratory disease among military trainees during 1996 to 1998.
2 recruits died of adenovirus infection in Illinois in 2000, the 1st fatalities
among military personnel since 1972. A live oral vaccine was released in
1971 for routine use in the military : recent discontinuance of vaccination
has been followed by large outbreaks of acute respiratory diseaseref1,
ref2.
Notable outbreaks:
-
1986 : an outbreak (132 cases) of keratoconjunctivitis due to adenovirus
type 8 was reported at a military teaching hospital.
-
1988 to 1989 : an outbreak (2603 cases) of acute conjunctivitis at an American
air base in the Philippines was caused by adenovirus types 19 and 8, as
well as enteroviruses.
-
1997 : an outbreak (541 cases of adenovirus type 7 and 132 of adenovirus
type 3) was reported at the Great Lakes Naval Recruiting facility in Illinois.
-
1997 : an outbreak (146 cases) occurred among students at a job training
facility in South Dakota - this was the 1st non-military outbreak reported
in the USA
-
1997 : an outbreak (1000 or more hospitalized) of adenovirus type 4 infection
was reported from an army basic training center in South Carolina.
-
Mycoplasma
pneumoniae
was 1st isolated from American military personnel in 1944. At the time,
the organism was estimated to account for 68% of "atypical pneumonias"
among recruits. As many as 57% of recruits had evidence of acute infection,
and up to 56% of pneumonia among recruits during the 1960's to 1990's was
ascribed to this organism. Notable outbreaks:
-
1966 (publication year) - An outbreak was reported aboard a nuclear submarine.
-
water-borne
infection : infection caused by microorganisms which may be transmitted
through water and acquired through ingestion, bathing, or other means
-
viruses :
-
HAV

-
enterovirus

-
in a recent study, RNA with nucleotide sequeces specific for Norwalk
virus
was detected in 21 mineral waters of 11 different brands of European mineral
waters by RT-PCR. All isolated NLV gg I strains have a similarity of 70
to 87% with the common Desert Shield virus (UO4469), and all isolated NLV
gg II strains have a similarity of 89 to 93% with the Camberwell virus
(U46500). The presence of NLV sequences could not be correlated either
with bottle characteristics or with chemical properties like mineralization,
pH, or the presence of carbonic acidref.
In a following study NLV sequences belonging entirely to genogroup II were
detected in 33% of samples without gases analyzed in the range of 10 to
100 genomic equivalents per liter. After 6 months, all samples remained
positive; after 12 months, 90% samples were still positive for NLV sequences,
suggesting that an envelope of proteins surrounds the virus protecting
its RNA and possibly still allowing infectiveness (not tested anyway)ref.
Human faeces are sporadically contaminating the water either at the source
or some time during the bottling procedure. Unpublished evidence suggests
that low levels of the virus in mineral water may give some elderly people
gastroenteritis.
-
bacteria :
-
protozoa :
-
fungi

Water-borne diseases remain a serious threat in many poor regions of the
world, with around 2 million children dying each year from diarrhoea. Efforts
to provide safe drinking water have had difficulty reaching remote areas.
Even in places with basic water-purification systems, people often opt
for riskier wells under trees because the water is cooler. In India people
believe that traditional brass water containers offer some protection against
sickness : Escherichia coli are indeed less likely to thrive in
brass water pots than in earthenware or plastic ones, and after 48 hours
they fell to undetectable levels. The key to the result is copper, which
can disrupt biological systems by interfering with the membranes and enzymes
of cells; for bacteria, this can mean death. Pots made of brass, an alloy
of copper and zinc, shed copper particles into the water they contain.
The amounts that circulate into the brass water vessels would not harm
humans : even a person drinking 10 litres of such water in a single day
would take in less than the daily recommended dose of copper or zinc. Brass
water pots also easily outperformed plastic ones, which did not inactivate
the bacteria. But many people in developing nations use plastic drinking
vessels, because they view them as more modern and cheaper. They work at
the individual household level, so you don't need a great deal of infrastructure
unlike other safe-water systems
Web resources :
-
cutting instruments : in 2003
the prevalence of HCV
among among injecting drug users (IDUs) in the UK who had 1st injected
in the last 3 years was 18%, double the prevalence among this group in
2000 (9%) and earlier years. Between Apr and Dec 2003, 18 cases of methicillin-resistant
Staphylococcus
aureus
(MRSA) blood infection were identified among IDUs. Laboratory tests of
the MRSA isolates show they are different from those associated with healthcare.
Severe group A Streptococcus
spp. (GAS)
reports among IDUs have increased, from less than 10 per annum in the early
to mid-1990s to 160 in 2003. An outbreak of tetanus
,
which started with 11 cases reported in 2003, has continued into 2004.
While during 2003 there were also 14 reports of suspected cases of wound
botulism
among
IDUs, 7 of which were confirmed by laboratory tests. Although an effective
needle exchange program to minimize blood-borne infection transfer may
minimize HBV
and HCV
,
bacterial infections due to streptococci and staphylococci as well as toxemias
from clostridrial infection (tetanus, botulism) will likely persist, as
they are related to the contaminated drug itself or are already present
on the skin of the userref
-
syringes : there has been a lot of research
on the development of "auto-destructible" syringes that can only be used
once, to prevent a recycling of needles and syringes already used in vaccination
programs into those for use (multiple use) in the curative sector where
medications are administeredref1,
ref2.
In a review of the literature on injection practices, Hutin et alref
found that: "The analysis excluded 4 regions (predominantly affluent, developed
nations) where reuse of injection equipment in the absence of sterilisation
was assumed to be negligible. In the 10 other regions, the annual ratio
of injections per person ranged from 1.7 to 11.3. Of these, the proportion
administered with equipment reused in the absence of sterilisation ranged
from 1.2 percent to 75.0 percent. Reuse was highest in the South East Asia
region "D" (7 countries, mostly located in South Asia), the eastern Mediterranean
region "D" (9 countries, mostly located in the Middle East crescent), and
the western Pacific region "B" (22 countries). No information regarding
injection safety was available for Latin America." They concluded
that: "Overuse of injections and unsafe practices are still common in developing
and transitional countries. An urgent need exists to use injections safely
and appropriately, to prevent healthcare associated infections with HIV
and other bloodborne pathogens." A study prepared byvan Staa and Hardon
for the WHO Action programme on essential drugsref
demonstrated a high proportion of individuals having received injections
in the 2 weeks preceding the study. In Indonesia 40% of households
had received one or more injections, in Uganda 30% of households had received
one or more injections in the 2 weeks preceding the survey. In both countries,
6-7 out of 10 visits to the health care facilities were associated with
the patient receiving an injection. With respect to injection equipement,
in Indonesia disposable syringes were reused by health care providers,
and in Uganda, households brought their own infection equipment to health
facilities, but sterility procedures were not supervised guaranteed in
this latter case. Simonson et alref
did a literature review addressing the transmission of bloodborne pathogens
related to unsafe injection practices in the developing world. From this
study they estimated that each person in the developing world receives
an average of 1.5 injections per year. In addition, institutionalized children,
and children and adults who are ill or hospitalized, including those infected
with HIV, are often exposed to 10-100 times as many injections. They noted
"an average of 95% of injections were therapeutic, the majority of which
were judged to be unnecessary." They found that "at least 50% of
injections were unsafe in 14 of 19 countries for which data were available.
18 studies reported a convincing link between unsafe injections and the
transmission of hepatitis B and C, HIV, Ebola and Lassa virus infections
and malaria. 5 studies attributed 20-80% of all new hepatitis B infections
to unsafe injections while 3 implicated unsafe injections as a major mode
of transmission of hepatitis C". They concluded that "unsafe injections
occur routinely in most developing world regions, implying a significant
potential for the transmission of any bloodborne pathogen. Unsafe injections
currently account for a significant proportion of all new hepatitis B and
C infections. This situation needs to be addressed immediately, as a political
and policy issue, with responsibilities clearly defined at the global,
country and community levels" Given the long history of civil unrest with
disruption of the health sector in Angola, it would not be surprising to
learn that supplies to the periphery (and Uige Province is in the northern
sector of Angola, a significant distance from the capital city Luanda)
have been somewhat deficient, and that needles and syringes were reused
in health facilities due to a lack of supplies, in keeping with studies
conducted in other developing countries. Presumable the epidemiologic studies
conducted in Angola will be addressing these issues in the attempt to define
risk factors for development of Marburg disease in this unprecedented outbreak.
-
obstacling vehicles (e.g. alcohol or CO2-containing
drinks)
-
vectors (vector-borne infection) are
Bilateria intermediate hosts
that may act as :
-
accidental host : one that harbors
an organism that is not ordinarily parasitic in the particular species.
-
intermediate or secondary
host : a host in which a parasite passes one or more of its asexual
(larval) stages; usually designated first and second, if there is more
than one.
-
paratenic, transfer or transport host
: a potential or substitute intermediate host that serves until the appropriate
definitive host is reached, and in which no development of the parasite
occurs; it may or may not be necessary to the completion of the parasite's
life cycle. In paratenic transmission frequently the method of infection
is carnivorism of the paratenic host. The parasite simply waits for an
opportunity to infect the ...
-
definitive, final or primary host
: a host in which a parasite attains sexual maturity
-
host of predilection : the host
preferred by a parasite
-
mechanical vector : an animal vector
not essential to the life cycle of the parasite (mechanical indirect
transmission)
-
biological vector : an animal
vector in whose body the pathogenic organism develops and multiplies before
being transmitted to the next host (cyclic indirect transmission)
-
zoonoses
: a disease of animals that may be transmitted to humans under natural
conditions; an infection that perpetuates among Metazoa and that
is transmissible to Homo sapiens or vice-versa. The definition of
zooanthroponosis and anthropozoonosis is often confused because the opposites
are used in the Russian literature.
-
anthropozoonoses : a disease
of Homo sapiens transmissible to Metazoa. Anthropozoonses
are those diseases where the direction of transmission is from animals
to man (such as rabies).
-
zooanthroponoses
: infection Homo sapiens can acquire from Metazoa.
Zooanthroponoses are those diseases where the direction of transmission
is from man to animals (such as tuberculosis) (CW Schwabe 1984. Veterinary
Medicine and Human Health. (Williams & Wilkins, Baltimore, 1984)
pp 196-7.)
-
reservoir host / reservoir of infection
: an alternate or passive host or carrier that harbors pathogenic organisms,
without injury to itself, and serves as a source from which other individuals
(humans) can be infected
Caution must be exercised when determining the role of arthropod vectors
and vertebrate animals in the transmission and maintenance of a virus in
any given region. Mere isolation of the virus from a field-collected arthropod
does not establish its capacity to serve as a vector. That is done
by determining its relative susceptibility following ingestion of
a blood meal containing a known amount of virus, replication of the virus
in the body of the arthropod, the subsequent presence of the virus in salivary
glands followed by transmission by bite to a susceptible vertebrate animal.
The arthropod must be associated with host vertebrates in nature at the
time and in the place that these hosts are viremic. Similarly, serological
data have to be interpreted with caution. Presence of antibodies to a given
virus simply indicates that they were exposed to it, and does not prove
that the animal developed a viremia of high enough titer and sufficient
duration to infect
arthropod vectors. Establishing vector and host capacity requires laboratory
experiments under conditions of adequate biological safety. These experiments
are expensive to conduct.
Web resources : Compendium
of Measures To Prevent Disease Associated with Animals in Public Settings,
2005 National Association of State Public Health Veterinarians, Inc. (NASPHV)
An estimated 50 million people acquired zoonotic diseases between 2000
and 2005 and up to 78,000 have died. Zoonotic killers between 2000 and
2005 included:
-
rabies virus
,
which killed an estimated 30,000 people
-
dengue virus
,
which affected 50 million people and killed approximately 25,000
-
Japanese encephalitis
virus
,
with up to 50,000 estimated cases and up to 15,000 estimated deaths
-
Lassa fever
,
which affected up to 300,000 people and killed about 5,000
-
SARS coronavirus
,
which killed 774 of the 8102 people infected
Even a zoonotic virus like yellow
fever virus (YFV)
- for which an effective vaccine exists - is estimated to affect 200,000
peopleref
Nematoda
Arthropoda:
bites of hematophagous (i.e. used to blood meal) and/or coprophagous
arthropods.
-
Chelicerata
-
Arachnida
-
Acari
-
Acariformes (mites)
-
Trombidiformes, Prostigmata, Anystina, Parasitengona, Trombiculoidea,
Trombiculidae
-
Eutrombicula : vector of Orientia
tsutsugamushi

-
Trombicula akamushi / Microtrombidium akamushi (kedani mite)
in Japan
-
Trombicula deliensis outside of Japan
-
Trombicula fletcheri
-
Trombicula intermedia
-
Trombicula pallida
-
Trombicula scutellaris

-
Parasitiformes
-
Holothyrida
-
Ixodida (ticks).
Web
resources : The
tick collection at University of Edinburgh
-
Argasidae (softbacked ticks)
-
Argas
-
Ornithodoros (relapsing fever ticks : night feeders, feeding quite
quickly (5-20') and painlessly)
-
Ixodidae (hardbacked ticks)
-
Amblyomma
-
Amblyomma
americanum (lone star tick) : vector of Rickettsia
rickettsii
,
Ehrlichia
chaffeensis
,
Ehrlichia
ewingii
,
Francisella
tularensis
;
found on the atlantic coast of USA from New York southwards to Virginia,
Georgia, New England and Florida and extending westwards into Texas
and Oklahoma (also causing tick
paralysis
)
-
Amblyomma
cajennense (Cayenne tick) : vector of Rickettsia
rickettsii

-
Amblyomma cooperi : vector
of Rickettsia rickettsii

-
Amblyomma
hebraeum (African cattle bont ticks) : vector
of Rickettsia africae
.
An “engorgement factor" termed voraxin (a cocktail of 2 peptides
that are upregulated in the testis and vas deferens of fed, but not unfed,
males : they have no effect on female feeding if given alone) transferred
from male ticks to females during copulation not only stimulates the females
to gorge on food, but also stimulates the development of the ovary and
the degeneration of salivary glands, preparing females for the reproductive
tasks ahead. The feeding cycle of adult female ticks is divided into preparatory,
slow and rapid feeding phases. At the transition from slow to rapid feeding,
females reach a 'critical weight' (CW; approx. 10x the unfed weight) that
is characterized by several behavioural and physiological changes. 5 of
these changes were used as criteria to establish a more precise estimate
of CW than we have to date. The CW as defined by re-attachment to the host
was 9x the unfed weight, while for haemolymph ecdysteroid titre, salivary
gland degeneration, ovary weight, oocyte length and oocyte vitellin content
the CW was 10x, 10x, 12x, 12x and 13x, respectively. CW thus varies depending
on the parameter measured. Although previous studies have established the
influence of ecdysteroids on salivary gland degeneration and vitellogenesis,
they also have a role in inhibiting re-attachment to the hostref.
Virgin female will not feed beyond a CW of around 10 times their unfed
body mass, but mated ticks will. There was already evidence that components
of seminal fluid can have important behavioral and physiologic consequences
for females, e.g. in D. melanogaster seminal fluid protein genes
expressed only in males affect female receptivity, ovulation, oogenesis,
sperm storage, sperm competition and mating plug formationref.
It is interesting that sex proteins also occur in noninsect species like
ticks because this suggests that these male factors could be quite ubiquitous.
In the case of the tick, it appears that these sex peptides are acting
in the reproductive interests of both sexes. It's a kind of switch effect
to tell females that they've been properly mated : iIt's only worth starting
to produce eggs and develop your ovaries once you have been mated. If an
effective vaccine can be derived from voraxin, the anticipated results
from reduced feeding would include less salivation, hence reduced pathogen
transmission to the host and a reduction in oocyte development. When normal
mated females were put on a rabbit immunized against voraxin, 74% showed
little interest in feeding, but all mated ticks put on a control, nonimmunized
rabbit engorged normally. So, a vaccine that blocks the action of voraxin
should reduce feeding, argued Kaufman, and hence transmission of tick-borne
pathogens such as the bacterium Ehrlichia ruminantium, which causes
a Rickettsia-like infection in African cattle : it is argued whether voraxin-based
vaccine would achieve better control of ticks than existing vaccines based
on antigens from the southern cattle tick Boophilus microplus
-
Amblyomma
maculatum : Borrelia
parkeri

-
Amblyomma
variegatum
-
Aponomma
-
Boophilus
-
Dermacentor
-
Dermacentor albopictus
: vector of Colorado
tick fever virus

-
Dermacentor
andersoni (a.k.a. Dermatocentor venustus, wood tick)
: a reddish brown tick that is responsible for transmitting Rickettsia
rickettsii
,
Colorado
tick fever virus
,
and Francisella tularensis
to humans and for causing tick
paralysis
in Rocky Mountain and western areas of the USA and Canada. Its hosts include
Cervidae,
elk, antelope, grizzly bear, porcupine,
Cynomys
parvidens , and various
Oryctolagus
spp..
-
Dermacentor arumapertus
: vector of Colorado
tick fever virus

-
Dermacentor
marginatus : vector of Rickettsia
sibirica

-
Dermacentor nuctallii :
vector of Rickettsia
sibirica

-
Dermacentor
occidentalis : vector of Colorado
tick fever virus

-
Dermacentor sylvarum :
vector of Rickettsia
sibirica

-
Dermacentor taiwanensis :
vector of Rickettsia
japonica

-
Dermacentor
variabilis (a.k.a. American dog tick) : a dark brown tick found
along the California coast and widely distributed east of the Rocky Mountains
in USA central and south eastern states including Virginia and Georgia,
Canis
familiaris being the principal host of the adults, which are found
also on Bos taurus, Equus
caballus, Oryctolagus cuniculus,
and man; it is the principal vector of Rickettsia
rickettsii
,
Francisella
tularensis
,
Ehrlichia
chaffeensis
and Anaplasma
phagocytophilum
(also causing tick paralysis
)
-
Haemaphysalis
-
Hyalomma