Don’t Count Your Chicken Livers: an Outbreak of Campylobacter sp. Not Associated with Chicken Liver Parfait, England, November 2013


In England, several recent campylobacter outbreaks have been associated with poultry liver consumption. Following a lunch event in a hotel in Surrey in November 2013 where chicken liver parfait was served, guests reported having gastrointestinal symptoms. A retrospective cohort study showed 46 of 138 guests became unwell, with a median incubation period of two days and for 11 cases campylobacter infection was laboratory confirmed. Food item analysis identified an association between illness and consumption of roast turkey (aOR=3.02 p=0.041) or jus (aOR=3.55 p=0.045), but not with chicken liver parfait (OR=0.39 p=0.405). The environmental risk assessment did not identify non-compliance with standard food practice guidelines. This study presents a point-source outbreak of campylobacter with a high attack rate and epidemiological analysis results show that the jus or roast turkey was the likely source of infection although this could not be confirmed by the environmental assessment. Consuming the chicken liver dish was not a risk factor for developing symptoms as was initially hypothesised. Prior knowledge on the association between poultry liver food items and campylobacter outbreaks should not overly influence an outbreak investigation to ensure the true aetiology is identified and on-going public health risk is minimised.

The Ratio of Emergency Department Visits for ILI to Seroprevalence of 2009 Pandemic Influenza A (H1N1) Virus Infection, Florida, 2009


Background. A seroprevalence survey carried out in four counties in the Tampa Bay area of Florida provided an estimate of cumulative incidence of infection due to the 2009 influenza A (H1N1) as of the end of that year’s pandemic in the four counties from which seroprevalence data were obtained

Methods. Excess emergency department (ED) visits for influenza-like illness (ILI) during the pandemic period (compared to four non-pandemic years) were estimated using the ESSENCE-FL syndromic surveillance system for the four-county area.

Results. There were an estimated 44 infections for every ILI ED visit. Age-specific ratios rose from 19.7 to 1 for children aged <5 years to 143.8 to 1 for persons aged >64 years.

Conclusions. These ratios provide a way to estimate cumulative incidence. These estimated ratios can be used in real time for planning and forecasting, when carrying out timely seroprevalence surveys is not practical. Syndromic surveillance data allow age and geographic breakdowns, including for children.

Epidemic Intelligence Cyberinfrastructure: Real-Time Outbreak Source Detection and Prediction for Rapid Response


Foodborne diseases cause an estimated 48 million illnesses each year in the United States, including 9.4 million caused by known pathogens. Real time detection of cases and outbreak sources are important epidemic intelligence services that can decrease morbidity and mortality of foodborne illnesses, and allow optimal response to identify the causal pathways leading to contamination. For most outbreaks associated with fresh produce items, outbreak source detection typically occurs after the contaminated produce items have been consumed and are no longer in the marketplace.
We developed a probabilistic model for real time outbreak source detection, prediction of outbreaks, and contamination-prone area mapping with the aim of developing a cyber-infrastructure to support this activity. The model’s inputs include environmental, trade and epidemiological dynamics. Because effective distance reliably predicts disease arrival times we estimate the distance of outbreak sources from spatio-temporal patterns of foodborne outbreaks. As a case study we consider the 2013 Cyclospora outbreaks in the USA that were related to contaminated fresh produce (cilantro and fresh salad mix) from Mexico. We are able to match case distributions related to both food commodities and determine their outbreak sources with an average accuracy of 0.93. Assuming a similar pattern of contamination for 2014, with predictions of rainfall and temperature for the 2014 summer we predict a prevalence 15% higher than 2013.
The study aims to provide a methodological framework to evaluate environmentally sensitive food contamination and assess interdependencies of socio-environmental factors causing contamination. We emphasize the linkage of patterns and processes, the positive role of uncertainty, and challenge the belief that information about the whole food supply chain is needed for traceback analysis to be useful for identifying likely sources. Our specific prediction for 2014 strongly emphasizes the need for real-time surveillance to identify and respond to this pending outbreak.

Clock Rooting Further Demonstrates that Guinea 2014 EBOV is a Member of the Zaïre Lineage


While initial phylogenetic analyses concluded to Guinea 2014 EBOV falling outside the Zaïre lineage (ZEBOV), a recent re-analysis of the same dataset by Dudas and Rambaut (2014) suggested that Guinea 2014 EBOV actually is ZEBOV. Under the same hypothesis as used by these authors (the molecular clock hypothesis), we reinforce their conclusion by providing a statistical assessment of the location of the root of the Zaïre lineage. Our analysis unambiguously supports Guinea 2014 EBOV as a member of the Zaïre lineage. In addition, we also show that some uncertainty exists so as to the location of the root of the genus Ebolavirus. We release the software we used for these re-analyses. RootAnnotator allows for the easy determination of branch root posterior probability from any posterior sample of clocked trees and is freely available at

Barriers to Trace-back in a Salad-associated EHEC Outbreak, Sweden, June 2013


In June-July 2013, six counties notified the Swedish Institute for Communicable Disease Control of enterohaemorrhagic E.coli (EHEC) infections among attendees at a hotel in Dalarna, Sweden. An outbreak control team investigated to identify the source and implement control measures.

We included individuals who attended the hotel between June 19th-25th in a cohort. We asked them about animal contact, swimming, and consumption of food items during this time using a questionnaire. A confirmed case was an EHEC O157:H7 outbreak strain positive individual who developed abdominal pain or diarrhoea between June 20th-July 2nd. We described the outbreak in time, place and person, calculated risk ratios (RR) and 95% confidence intervals (CI). We investigated the kitchen, tested and traced back implicated food items.

172 individuals responded. We identified 19 confirmed cases (Median age: 17 years, 64% female) with symptom onset between June 22nd-27th. Eating green salad on June 20th was associated with illness (RR:3.7;CI:1.3–11). The kitchen mixed green salads without records and destroyed leftovers immediately. Hence we could not conduct trace-back or obtain microbiological confirmation.

Green salad contaminated before entering the kitchen was the likely outbreak source. We recommended early collaboration with food agencies and better restaurant records to facilitate future investigations.

Assessing the Origin of and Potential for International Spread of Chikungunya Virus from the Caribbean


Background: For the first time, an outbreak of chikungunya has been reported in the Americas. Locally acquired infections have been confirmed in fourteen Caribbean countries and dependent territories, Guyana and French Guiana, in which a large number of North American travelers vacation. Should some travelers become infected with chikungunya virus, they could potentially introduce it into the United States, where there are competent Aedes mosquito vectors, with the possibility of local transmission.

Methods: We analyzed historical data on airline travelers departing areas of the Caribbean and South America, where locally acquired cases of chikungunya have been confirmed as of May 12th, 2014. The final destinations of travelers departing these areas between May and July 2012 were determined and overlaid on maps of the reported distribution of Aedes aeygpti and albopictus mosquitoes in the United States, to identify potential areas at risk of autochthonous transmission.

Results: The United States alone accounted for 52.1% of the final destinations of all international travelers departing chikungunya indigenous areas of the Caribbean between May and July 2012. Cities in the United States with the highest volume of air travelers were New York City, Miami and San Juan (Puerto Rico). Miami and San Juan were high travel-volume cities where Aedes aeygpti or albopictus are reported and where climatic conditions could be suitable for autochthonous transmission.

Conclusion: The rapidly evolving outbreak of chikungunya in the Caribbean poses a growing risk to countries and areas linked by air travel, including the United States where competent Aedes mosquitoes exist. The risk of chikungunya importation into the United States may be elevated following key travel periods in the spring, when large numbers of North American travelers typically vacation in the Caribbean.

Imported Zika Virus Infection from the Cook Islands into Australia, 2014


A female resident of Townsville, Queensland, Australia has been diagnosed with Zika virus infection following a recent trip to the Cook Islands. An initial serum sample collected in March, 2014 was positive by two separate Zika virus TaqMan real-time RT-PCRs and a pan-Flavivirus RT-PCR. Nucleotide sequencing and phylogenetics of the complete Cook Islands Zika virus envelope gene revealed 99.1% homology with a previous Cambodia 2010 sequence within the Asian lineage. In addition, IgG and IgM antibody seroconversions were detected between paired acute and convalescent phase sera using recombinant Zika virus serology assays. This is the first known imported case of Zika virus infection into northern Queensland where the potential mosquito vector Aedes aegypti is present and only the second such reported case diagnosed within Australia.

Towards an Early Warning System for Forecasting Human West Nile Virus Incidence


We have identified environmental and demographic variables, available in January, that predict the relative magnitude and spatial distribution of West Nile virus (WNV) for the following summer. The yearly magnitude and spatial distribution for WNV incidence in humans in the United States (US) have varied wildly in the past decade. Mosquito control measures are expensive and having better estimates of the expected relative size of a future WNV outbreak can help in planning for the mitigation efforts and costs. West Nile virus is spread primarily between mosquitoes and birds; humans are an incidental host. Previous efforts have demonstrated a strong correlation between environmental factors and the incidence of WNV. A predictive model for human cases must include both the environmental factors for the mosquito-bird epidemic and an anthropological model for the risk of humans being bitten by a mosquito. Using weather data and demographic data available in January for every county in the US, we use logistic regression analysis to predict the probability that the county will have at least one WNV case the following summer. We validate our approach and the spatial and temporal WNV incidence in the US from 2005 to 2013. The methodology was applied to forecast the 2014 WNV incidence in late January 2014. We find the most significant predictors for a county to have a case of WNV to be the mean minimum temperature in January, the deviation of this minimum temperature from the expected minimum temperature, the total population of the county, publicly available samples of local bird populations, and if the county had a case of WNV the previous year.

Public Health Risk Communication by Text Message in Response to a Cluster of Invasive Meningococcal Infection in a Primary School


Public health risk communication during emergencies should be rapid and accurate in order to allow the audience to take steps to prevent adverse outcomes. Delays to official communications may cause unnecessary anxiety due to uncertainty or inaccurate information circulating within the at-risk group. Modern electronic communications present opportunities for rapid, targeted public health risk communication. We present a case report of a cluster of invasive meningococcal disease in a primary school in which we used the school’s mass short message service (SMS) text message system to inform parents and guardians of pupils about the incident, to tell them that chemoprophylaxis would be offered to all pupils and staff, and to advise them when to attend the school to obtain further information and antibiotics. Following notification to public health on a Saturday, an incident team met on Sunday, sent the SMS messages that afternoon, and administered chemoprophyaxis to 93% of 404 pupils on Monday. The use of mass SMS messages enabled rapid communication from an official source and greatly aided the public health response to the cluster.

Phylogenetic Analysis of Guinea 2014 EBOV Ebolavirus Outbreak


Members of the genus Ebolavirus have caused outbreaks of haemorrhagic fever in humans in Africa. The most recent outbreak in Guinea, which began in February of 2014, is still ongoing. Recently published analyses of sequences from this outbreak suggest that the outbreak in Guinea is caused by a divergent lineage of Zaire ebolavirus. We report evidence that points to the same Zaire ebolavirus lineage that has previously caused outbreaks in the Democratic Republic of Congo, the Republic of Congo and Gabon as the culprit behind the outbreak in Guinea.