William F. Bibb

An Outbreak of Gastroenteritis and Fever Due to Listeria monocytogenes in Milk

BACKGROUND After an outbreak of gastroenteritis and fever among persons who attended a picnic in Illinois, chocolate milk served at the picnic was found to be contaminated with Listeria monocytogenes. METHODS In investigating this outbreak, we interviewed the people who attended the picnic about what they ate and their symptoms. Surveillance for invasive listeriosis was initiated in the states that receive milk from the implicated dairy. Stool and milk samples were cultured for L. monocytogenes. Serum samples were tested for IgG antibody to listeriolysin O. RESULTS Forty-five persons had symptoms that met the case definition for illness due to L. monocytogenes, and cultures of stool from 11 persons yielded the organism. Illness in the week after the picnic was associated with the consumption of chocolate milk. The most common symptoms were diarrhea (present in 79 percent of the cases) and fever (72 percent). Four persons were hospitalized. The median incubation period for infection was 20 hours (range, 9 to 32), and persons who became ill had elevated levels of antibody to listeriolysin O. Isolates from stool specimens from patients who became ill after the picnic, from sterile sites in three additional patients identified by surveillance, from the implicated chocolate milk, and from a tank drain at the dairy were all serotype 1/2b and were indistinguishable on multilocus enzyme electrophoresis, ribotyping, and DNA macrorestriction analysis. CONCLUSIONS L. monocytogenes is a cause of gastroenteritis with fever, and sporadic cases of invasive listeriosis may be due to unrecognized outbreaks caused by contaminated food.

An Outbreak of Escherichia coli O157:H7 Infections Associated with Leaf Lettuce Consumption

In July 1995, 40 Montana residents were identified with laboratory-confirmed Escherichia coli O157:H7 infection; 52 residents had bloody diarrhea without laboratory confirmation. The median age of those with laboratory-confirmed cases was 42 years (range, 4- 86); 58% were female. Thirteen patients were hospitalized, and 1 developed hemolytic-uremic syndrome. A case-control study showed that 19 (70%) of 27 patients but only 8 (17%) of 46 controls reported eating purchased (not home-grown) leaf lettuce before illness (matched odds ratio, 25.3; 95% confidence interval, 3.9-1065.6). Pulsed-field gel electrophoresis identified a common strain among 22 of 23 isolates tested. Implicated lettuce was traced to two sources: a local Montana farm and six farms in Washington State that shipped under the same label. This outbreak highlights the increasing importance of fresh produce as a vehicle in foodborne illness. Sanitary growing and handling procedures are necessary to prevent these infections.

The United States National Prospective Hemolytic Uremic Syndrome Study: Microbiologic, Serologic, Clinical, and Epidemiologic Findings

The frequency of Shiga toxin-producing Escherichia coli (STEC) serotypes associated with postdiarrheal hemolytic uremic syndrome (HUS) cases among children and adults in the United States and the proportion with IgM or IgG lipopolysaccharide antibodies to E. coli O157 were determined by use of a nationwide sample from January 1987 through December 1991. Among 83 patients, STEC were isolated from 30 (43%) of 70 whose stool cultures yielded bacterial growth (25 E. coli O157 isolates and 5 non-O157 STEC isolates). Fifty-three (80%) of 66 patients with serum samples had positive O157 lipopolysaccharide antibody titers. Of the 83 patients, 60 (72%) had evidence of STEC infection, including 6 of 8 adults whose illnesses also met criteria for thrombotic thrombocytopenic purpura. Data from a subset of patients suggest that E. coli O157 was the cause of > or = 80% of the STEC infections. All 3 women who were postpartum had evidence of E. coli O157 infection. STEC infection should be considered the likely cause for all persons with postdiarrheal HUS.

A Waterborne Outbreak of Escherichia coli O157:H7 Infections and Hemolytic Uremic Syndrome: Implications for Rural Water Systems

In the summer of 1998, a large outbreak of Escherichia coli O157:H7 infections occurred in Alpine, Wyoming. We identified 157 ill persons; stool from 71 (45%) yielded E. coli O157:H7. In two cohort studies, illness was significantly associated with drinking municipal water (town residents: adjusted odds ratio=10.1, 95% confidence intervals [CI]=1.8-56.4; visitors attending family reunion: relative risk=9.0, 95% CI=1.3-63.3). The unchlorinated water supply had microbiologic evidence of fecal organisms and the potential for chronic contamination with surface water. Among persons exposed to water, the attack rate was significantly lower in town residents than in visitors (23% vs. 50%, p<0.01) and decreased with increasing age. The lower attack rate among exposed residents, especially adults, is consistent with the acquisition of partial immunity following long-term exposure. Serologic data, although limited, may support this finding. Contamination of small, unprotected water systems may be an increasing public health risk.

Evaluation of Rapid Diagnostic Tests for Typhoid Fever

ABSTRACT Laboratory diagnosis of typhoid fever requires isolation and identification of Salmonella enterica serotype Typhi. In many areas where this disease is endemic, laboratory capability is limited. Recent advances in molecular immunology have led to the identification of sensitive and specific markers for typhoid fever and technology to manufacture practical and inexpensive kits for their rapid detection. We evaluated three commercial kits for serologic diagnosis of typhoid fever. Patients presenting with ≥ 4 days of fever were enrolled at two hospitals in Southern Vietnam. Cases were patients with serotype Typhi isolated from blood samples, and controls were patients with other laboratory-confirmed illnesses. Serotype Typhi isolates were confirmed and tested for antimicrobial susceptibility at the Pasteur Institute in Ho Chi Minh City. The Widal test was run at the hospitals and the Pasteur Institute. Sera were shipped frozen to the Centers for Disease Control and Prevention and tested by using Multi-Test Dip-S-Ticks, TyphiDot, and TUBEX to detect immunoglobulin G (IgG), IgG and IgM, and IgM, respectively. Package insert protocol instructions were followed. We enrolled 59 patients and 21 controls. The sensitivity and specificity findings were as follows: 89 and 53% for Multi-Test Dip-S-Ticks, 79 and 89% for TyphiDot, 78 and 89% for TUBEX, and 64 and 76% for Widal testing in hospitals and 61% and 100% for Widal testing at the Pasteur Institute. For all assays, the sensitivity was highest in the second week of illness. The Widal test was insensitive and displayed interoperator variability. Two rapid kits, TyphiDot and TUBEX, demonstrated promising results.

Analysis of Listeria monocytogenes by multilocus enzyme electrophoresis and application of the method to epidemiologic investigations

We examined 310 strains of Listeria monocytogenes by multilocus enzyme electrophoresis. Fifty-six electrophoretic types (ETs) of the organism were defined: 10 for serovar 4b strains, 11 for serovar 1/2b strains, and 30 for serovar 1/2a strains. Strains of serovars 1/2c, 3a, and 3b, and a non-typable strain were distributed among the remaining five ETs. The mean genetic diversity of the species was 0.41. Principal coordinate analysis revealed a sharp division among ETs which divided the species into two major clusters. ETs containing serovar 1/2a strains were in one cluster while all ETs containing serovar 4b, 1/2b, and 3b strains were in the second cluster. Except for two ETs that contained strains from both serovar 1/2b and serovar 3b, no ET contained strains from more than one serovar. Multilocus enzyme electrophoresis facilitated the analysis of epidemiologic data. In three separate epidemiologic investigations electrophoretic typing confirmed a common source as a cause of an outbreak; in a fourth investigation a single common source as a cause of an outbreak was effectively ruled out. Electrophoretic typing was also useful in documenting potential links between Listeria contaminated foods and persons with listeriosis who consumed those foods.

Outbreak of Shiga Toxin—Producing Escherichia coli O111:H8 Infections among Attendees of a High School Cheerleading Camp

Few US clinical laboratories screen stool specimens for Shiga toxin-producing Escherichia coli (STEC) other than E. coli O157. An outbreak of STEC O111:H8 infections indistinguishable from E. coli O157:H7 at a youth camp highlights the need to improve non-O157 STEC surveillance. Interviews of 521 (80%) of 650 attendees revealed 55 (11%) were ill; 2 developed hemolytic-uremic syndrome. Illness was associated with consuming salad during the camps first lunch meal (hazard ratio [HR], 4.68; P<.01), consuming ice provided in barrels on the camps final day (HR, 3.41; P<.01), eating cob corn (HR, 3.22; P<.01), and eating a dinner roll (HR, 2.82; P<.01). Cultures of 2 of 11 stools yielded E. coli O111:H8. Results of serologic testing and additional stool cultures demonstrated no evidence of infection with other bacterial pathogens, including E. coli O157, and supported infection with E. coli O111. Clinical laboratories should routinely screen suspect specimens for non-O157 STEC and should serotype and report Shiga-positive isolates.

Diarrhea Incidence and Farm-Related Risk Factors for Escherichia coli O157:H7 and Campylobacter jejuni Antibodies among Rural Children

Serum samples were obtained from 215 farm-resident children and 396 non-farm-resident children living in a defined rural Wisconsin population. Antibodies to Campylobacter jejuni and Escherichia coli O157:H7 lipopolysaccharide (O157 LPS) immunoglobulin G were measured, and the incidence of clinic visits for diarrheal illness was determined. Risk factors were assessed in a telephone interview. There were 363 children (59%) with C. jejuni antibodies (seropositive for >or=2 immunoglobulin classes) and 86 (14%) with O157 LPS antibodies. Increasing age and farm residence were independently associated with C. jejuni seropositivity by multivariate analysis. O157 LPS antibodies were independently associated with increasing age, female sex, manure contact, and sheep contact. The incidence of clinically recognized diarrhea was similar among children with and without antibodies to C. jejuni and O157 LPS, but the clinic visit rate for diarrhea was 46% lower among farm-resident children. These results are consistent with reduced occurrence of clinical illness from repeated antigenic stimulation in a farm environment.

Multilocus enzyme electrophoresis for characterization of Listeria monocytogenes isolates : results of an international comparative study

Multilocus enzyme electrophoresis (MEE) is a standard technique that is used to elucidate the epidemiology of a variety of bacterial species. Recently, the method has been employed by several laboratories for investigations of clinical and foodborne isolates of Listeria monocytogenes. To assess the sensitivity and reproducibility of MEE in characterising L. monocytogenes isolates for epidemiological purposes and, ultimately, to agree on a standard protocol, seven laboratories participated in a blinded study of 80 strains. The strain collection included both epidemiologically related and unrelated isolates. Each laboratory used its own protocol for MEE. The number of enzymes that were assayed by the laboratories ranged from 8 to 23, and the total number of identified electrophoretic types (ETs) varied between 14 and 25. Of the II pairs of duplicate strains, the number of pairs recognised as identical by the seven laboratories ranged from 3 to 10 (median = 8). From 10 to 18 (median = 15) of the 22 groups of epidemiological related strains were recognised as homogeneous by the different laboratories. The discriminatory power of the method, calculated using Simpsons index of diversity for 69 strains (80 strains minus the 11 duplicates), ranged from 0.827 to 0.925. This relatively low discriminatory power is a consequence of a somewhat low genetic diversity of L. monocytogenes compared to other bacterial species. Efforts should be pursued to standardise the method in order to improve the intra- and inter-laboratory reproducibility.

Recognition of a genus-wide antigen ofLegionella by a monoclonal antibody

A monoclonal antibody was produced against a cytoplasmic membrane protein that appears to be common to all species of the genusLegionella. The antibody was positive in polyacrylamide gel electrophoresis and Western blotting with extracts of all of 22 species type strains ofLegionella that were tested. The apparent molecular mass of the protein varied from 57.2 to 62.1 kilodaltons for the 23 species type strains ofLegionella. An enzyme-linked immunosorbent assay (ELISA) was developed with the monoclonal antibody to enable rapid screening of clinical and environmental isolates forLegionella. All of 23 species type strains ofLegionella that were tested were strongly positive with the monoclonal antibody in the ELISA. Among 27 other bacterial species and 84 strains that were tested, onlyBordetella ssp. andAcinetobacter lwoffii were cross-reactive in the ELISA. These two cross-reactive species are readily distinguishable fromLegionella by culture characteristics. The monoclonal antibody may also be useful in tests to detect the genus-wide antigen in body fluids of patients with legionellosis.