High prevalence of type 41 and high sequence diversity of partial hexon gene of human adenoviruses in municipal raw sewage and activated sludge.

AIM: This study was aimed to assess seasonal/geographical distribution and sequence diversity of partial hexon gene for human adenoviruses (HAdVs) within raw sewages (RS) and activated sludges (AS). METHODS AND RESULTS: Assessments were based on high-throughput sequencing (HTS) for polymerase chain reaction (PCR)-amplified 128-bp partial hexon gene fragments and followed by principal coordinate analyses (PCoA) for revealed sequences. Sequencing results showed that the majority of sequences (>90%) for the RS or AS samples were identical to HAdV type 41 of species F, while rest of few sequences belonged to HAdV species-D and -C were only occurred rarely without significant seasonal/geographical variation. The partial hexon genes were highly diverse as many sequence types and operational taxonomic unit groups were noticed among the matched sequences. CONCLUSIONS: This study demonstrated that HAdV-41 was constantly appeared in the RS and AS samples from Taiwan throughout the year without significant seasonal or geographical variations; but, had high sequence diverse noticed for the 128-bp partial hexon gene fragments. SIGNIFICANCE AND IMPACT OF THE STUDY: High-throughput-sequencing results provided better insights of HAdV distribution and genetic diversity for raw sewage and AS samples allowing some probable biases for cloning-sequencing approach to be defeated and further providing public health awareness regarding viral-contaminated sewages or sludges.

All-cause mortality in hospitalized patients with infectious diarrhea: Clostridium difficile versus other enteric pathogens in Austria from 2008 to 2010.

BACKGROUND: Clostridium difficile infection is the leading cause of gastroenteritis-associated deaths in the industrialized world, followed by infection with norovirus. METHODS: Using a cohort study design, we compared 90 inpatients with diarrhea due to C. difficile infection (CDI) with 180 inpatients with diarrhea due to other infectious agents (including 55% with norovirus infection) with respect to complications and all-cause mortality. The effects of age, severity of underlying diseases and additional infections were assessed by stratified analyses. RESULTS: Diarrhea recurrence occurred 8.9 (95%CI: 2.9-27.3) times more often in CDI independent of age and severity of comorbidities. The all-cause mortality in CDI patients pre-discharge and at 30 and 180 days, respectively, was 20.0%, 17.0% and 42.3% versus 7.2%, 6.7% and 22.5% in non-CDI diarrhea patients. Among those patients with low comorbidities, who were younger than 65 years and without additional infections, the all-cause pre-discharge, 30-day and 180-day mortality risks were significantly higher for the CDI diarrhea patients than the non-CDI diarrhea patients. This association was not observed among patients with an older age, more severe comorbidities or additional infections. CONCLUSION: CDI results in higher all-cause mortality than diarrhea due to other infectious agents in younger patients with low comorbidities.

Sex-age differences in association with particulate matter and emergency admissions for cardiovascular diseases: a hospital-based study in Taiwan.

OBJECTIVE: To explore the association between short-term exposure to particulate matter (PM) and cardiovascular diseases (CVDs) emergency room visits. STUDY DESIGN: Case-control study. METHODS: 2785 Emergency visits with presented cardiovascular diseases and 24,572 controls from ten hospitals in 2005 were obtained from a Taiwan's National Health Database. Daily PM10 data and meteorological information collected from an air monitoring station near the ten hospitals were used to calculate the exposure levels. Using multiple logistic regression analysis, adjusted odds ratios (AOR) were estimated for the associations of PM and temperature with ischaemic heart disease (IHD) and hypertension heart disease (HHD). RESULTS: A positive association (AOR = 1.05-1.75) between IHD emergency admission among women older than 65 and exposure to daily levels of PM10 pollution standard index (PSI) ≥50 compared with respondents exposed to PM10 PSI <50. CONCLUSIONS: To prevent exacerbation of IHD, people, especially elderly women, should be urged to reduce exposure to unhealthy PSI levels.

Surveillance of avian influenza A(H7N9) virus infection in humans and detection of the first imported human case in Taiwan, 3 April to 10 May 2013.

On 3 April 2013, suspected and confirmed cases of influenza A(H7N9) virus infection became notifiable in the primary care sector in Taiwan, and detection of the virus became part of the surveillance of severe community-acquired pneumonia. On 24 April, the first imported case, reported through both surveillance systems, was confirmed in a man returning from China by sequencing from endotracheal aspirates after two negative throat swabs. Three of 139 contacts were ill and tested influenza A(H7N9)-negative.

A prospective cohort study on hospital mortality due to Clostridium difficile infection.

PURPOSE: Although an increase in burden of disease has frequently been reported for Clostridium difficile infection (CDI), specific data on the effect of CDI on a patient's risk of death or overall hospital mortality are scarce. Therefore, we performed a prospective cohort study to analyse the effect of CDI on the risk of pre-discharge all-cause death in all inpatients with CDI compared to all inpatients without CDI during 2009 in a single hospital. METHODS: Clostridium difficile infection was defined as by the European Society of Clinical Microbiology and Infectious Diseases. Data were collected from the medical charts of CDI patients and from the hospital discharge data of non-CDI and CDI patients. The effect measures of CDI used to compute the risk of pre-discharge all-cause death were risk ratio, attributable risk, mortality fraction (%) and population attributable risk percentage. Co-morbidity was categorized using the Charlson co-morbidity score in which a value of ≤2 was defined as low co-morbidity and that of >2 as moderate/severe co-morbidity. A stratified analysis and a Poisson regression model were applied to adjust for the effects of the risk factors sex, age and severity of co-morbidity. RESULTS: A total of 185 hospitalized patients with CDI were compared to 38,644 other hospitalized patients without CDI admitted between 1 January 2009 and 31 December 2009. The mean age of the CDI and non-CDI patients was 74.3 (range 72.3-76.4) and 51.9 (range 51.6-52.1) years, respectively. Of the 185 CDI, 136 (73.5%) and 49 (26.5%) were categorized with low and high co-morbidity, respectively, versus 32,107 (83.4%) and 6,352 (16.5%), respectively, in non-CDI patients. Overall, 24 of the 185 CDI patients (13%) versus 1,021 of the 38,459 non-CDI patients (2.7%) died during their hospital stay, resulting in a relative risk of pre-discharge death of 4.89 [95% confidence interval (CI) 3.35-7.13] for CDI patients, a CDI attributable risk of death of 10.3 per 100 patients and a CDI attributable fraction of 79.5 % (95% CI 70.1-86 %). After adjustment for age, sex and co-morbidity the relative risk of pre-discharge death was 2.74 (95% CI 1.82-4.10; p < 0.0001) for patients with CDI, and the proportion of hospital deaths due to CDI was 1.72 (95% CI 1.22-2.05). CONCLUSION: The results of this study lead to the conclusion that hospitalized patients with CDI are--independent of age, sex and co-morbidity severity--2.74-fold more likely to die during their hospital stay than all other hospitalized patients. The eradication of CDI in the hospital could have prevented 1.72% of in-hospital deaths in our study population during the 1 year of the study.

Hospital-acquired Clostridium difficile infection: determinants for severe disease.

Risk factors of severity (need for surgical intervention, intensive care or fatal outcome) were analysed in hospital-acquired Clostridium difficile infection (CDI) in a 777-bed community hospital. In a prospective analytical cross-sectional study, age (≥ 65 years), sex, CDI characteristics, underlying diseases, severity of comorbidity and PCR ribotypes were tested for associations with severe CDI. In total, 133 cases of hospital-acquired CDI (mean age 74.4 years) were identified, resulting in an incidence rate of 5.7/10,000 hospital-days. A recurrent episode of diarrhoea occurred in 25 cases (18.8%) and complications including toxic megacolon, dehydration and septicaemia in 69 cases (51.9%). Four cases (3.0%) required ICU admission, one case (0.8%) surgical intervention and 22 cases (16.5%) died within the 30-day follow-up period. Variables identified to be independently associated with severe CDI were severe diarrhoea (odds ratio [OR] 3.64, 95% confidence interval [CI] 1.19-11.11, p=0.02), chronic pulmonary disease (OR 3.0, 95% CI 1.08-8.40, p=0.04), chronic renal disease (OR 2.9, 95% CI 1.07-7.81, p=0.04) and diabetes mellitus (OR 4.30, 95% CI 1.57-11.76, p=0.004). The case fatality of 16.5% underlines the importance of increased efforts in CDI prevention, in particular for patients with underlying diseases.

Foodborne gastroenteritis outbreak in an Austrian healthcare facility caused by asymptomatic, norovirus-excreting kitchen staff.

An outbreak of norovirus GGII.4 2006b affected an Austrian 600-bed healthcare facility from 15 to 27 March 2009. A total of 204 patients, residents and staff fitted the outbreak case definition; 17 (8.3%) were laboratory-confirmed. Foodborne origin was suspected in the 114 patient and resident cases with onset 15-18 March. A case-cohort study was performed to test the hypothesis that consumption of dishes offered on 14, 15 and 16 March (risk days) was associated with increased risk of infection. Data on food exposure of 62% (317/510) of the patient and resident cohort were available for a simultaneous retrospective cohort study. The case-cohort analysis revealed that consumption of sliced cold sausage offered on 15 March [odds ratio (OR): 3.98; 95% confidence interval (CI): 1.18-14.1], a meat dish with salad (adjusted OR: 2.2; 95% CI: 1.19-4.08) and a rolled spinach pancake (adjusted OR: 2.17; 95% CI: 1.27-3.71) on 16 March were independent risk factors. It is likely that one of the five asymptomatic excretors among the kitchen staff on duty on the risk days was the source of food contamination. The case-cohort study design was found to be a valid alternative to the retrospective cohort study design for the investigation of a suspected foodborne outbreak in a large cohort.

Classical reflux symptoms, hiatus hernia and overweight independently predict pharyngeal acid exposure in patients with suspected reflux laryngitis.

BACKGROUND: Gastro-oesophageal reflux disease (GERD) has been associated with reflux laryngitis. AIMS: To investigate the risk factors and the predictors of pharyngeal acid reflux (PAR) in Taiwanese patients with suspected reflux laryngitis. METHODS: With referral from ENT physicians, 104 patients with symptoms and signs suggestive of reflux laryngitis completed a validated symptom questionnaire, an upper endoscopy exam and ambulatory 24-h pH tests with three sensors located at the hypopharynx, proximal and distal oesophagus. Patients with one or more episodes of PAR were considered abnormal. RESULTS: Pharyngeal acid reflux was identified in 17% (18/104) of patients. In multivariate logistic regression analysis, PAR was independently associated with classical reflux symptoms [adjusted odds ratio (aOR) = 3.5, 95% confidence interval (CI): 1.0-12.8], hiatus hernia (aOR = 6.7, 95% CI: 1.5-30.2) and overweight (aOR = 3.4, 95% CI: 1.0-11.0). In predicting PAR, classical reflux symptoms had a sensitivity of 78% and hiatus hernia had a specificity of 95%. With all three factors, the positive predictive value for PAR was 80%. Classical reflux symptoms included heartburn, chest pain, dyspepsia and acid regurgitation. CONCLUSIONS: Classical reflux symptoms, hiatus hernia and overweight are independent risk factors that may predict pharyngeal acid reflux in patients with suspected reflux laryngitis.

Measles outbreak linked to a minority group in Austria, 2008.

We report on a measles outbreak originating in an anthroposophic community in Austria, 2008. A total of 394 (94.9%) cases fulfilled the outbreak case definition including 168 cases affiliated to the anthroposophic community. The source case was a school pupil from Switzerland. The Austrian outbreak strain was genotype D5, indistinguishable from the Swiss outbreak strain. A school-based retrospective cohort study in the anthroposophic school demonstrated a vaccine effectiveness of 97.3% in pupils who had received a single dose of measles-containing vaccine and 100% in those who had received two doses. The vaccination coverage of the cases in the anthroposophic community was 0.6%. Of the 226 outbreak cases not belonging to the anthroposophic community, the 10-24 years age group was the most affected. Our findings underline the epidemiological significance of suboptimal vaccination coverage in anthroposophic communities and in older age groups of the general population in facilitating measles virus circulation. The findings of this outbreak investigation suggest that the WHO European Region is unlikely to achieve its 2010 target for measles and rubella elimination.

Ongoing rubella outbreak in Austria, 2008-2009.

Since October 2008, a total of 143 cases of rubella have affected the two Austrian provinces Styria and Burgenland. The index case occurred in mid-October 2008, but was not notified to the public health authorities until February 2009, when the Austrian Agency for Health and Food Safety was asked to investigate a cluster of 32 rubella cases (24 laboratory-confirmed and eight clinically suspected cases). No case of rubella had been reported in the two affected provinces between February 2007 - when statutory notification for rubella was implemented - and mid-October 2008. 113 of the 143 cases (79%) were confirmed: 101 (89.3% of the 113 cases) clinical-laboratory confirmed and 12 clinical-epidemiological confirmed. Thirty cases fulfilled the criteria of a probable outbreak case only (laboratory results or data on epidemiological link are pending). For 140 outbreak cases data on age was known; the median age was 19 years (range: 2-60 years). 20 cases occurred in soldiers in seven military camps in the area. 55 cases (38.5 %) were female. One case of a laboratory-confirmed rubella infection, affecting an unvaccinated pregnant 18-years old native Austrian in the early first trimenon of pregnancy, led to voluntary abortion

Liver transplantation for biliary atresia in Taiwan: a national study.

A national database for orthotopic liver transplantation (OLT) among biliary atresia (BA) cases in Taiwan has not been reported. Using the National Health Insurance (NHI) database to investigate the prognostic features of patients with BA receiving OLT, we studied the prognosis of this procedure for BA. The NHI in Taiwan covers most of the population (>99%). From 1996-2004, 106 BA patients underwent transplantation. A linear time trend analysis was performed to estimate the annual slope for BA patients to receive OLT. The rate of increase per year of 2.6 cases was significant (R(2) = .649; P = .029). The 5-year overall survival after OLT was 97.1% +/- 1.6%, which was not different between those who had or had not previously undergone portoenterostomy (94.9% vs 97.8%; P = .160). It was not different among patients undergoing transplantation during the various seasons (P = .505). Our data confirmed the effectiveness of OLT for the treatment of BA in children with or without KP in Taiwan.

An outbreak of multidrug-resistant tuberculosis among refugees in Austria, 2005-2006.

SETTING: In 2005-2006, the Austrian reference laboratory for tuberculosis (TB) identified multidrug-resistant (MDR) isolates from four cases of TB showing genotypes indistinguishable from each other. OBJECTIVE: To clarify the chain of transmission of this MDR-TB strain. DESIGN: An epidemiological case series investigation by reviewing TB notification reports and hospital discharge letters. RESULTS: The 38-year-old primary case of the MDR-TB cluster had initially been identified as a case of non-MDR pulmonary TB in June 2004, 7 months after being detained for illegal immigration. In March 2005, he was lost to follow-up for 4 months. In June 2005, he presented with pulmonary and laryngeal TB due to MDR-TB. After discharge, the case was again lost to follow-up until April 2006, when he was readmitted with recurrent MDR-TB. A three-case cluster of pulmonary MDR-TB sharing the same strain as the primary case was detected in April 2006: the index case's 5-month-old daughter and a 25-year-old friend with a 6-month-old son. CONCLUSION: As MDR-TB has originated in the human immunodeficiency virus seronegative community in Austria, there is a clear need to implement national guidelines for the management of drug-resistant TB in Austria.

Age at first birth, parity, and risk of death from ovarian cancer in Taiwan: a country of low incidence of ovarian cancer.

This study was undertaken to examine whether there is an association between parity and age at first birth and risk of ovarian cancer. The study cohort consisted of all women with a record of a first and singleton childbirth in the Birth Register between 1978 and 1984. We tracked women from the time of their first childbirth to December 31, 2003, and their vital status was ascertained by linking records with the computerized mortality database. Cox proportional hazard regression models were used to estimate the relative risks (RR) of death from ovarian cancer associated with parity and age at first birth. There were 322 ovarian cancer deaths during 27,402,995.5 person-years of follow-up. The mortality rate of ovarian cancer was 1.18 cases per 100,000 person-years. A trend of increasing risk of ovarian cancer was seen with increasing age at first birth. The adjusted RR was 0.69 (95% CI = 0.52-0.90) for women who bore two children, and 0.30 (95% CI = 0.21-0.42) for women with three or more births, respectively, when compared with women who had given birth to only one child. There was a significant decreasing trend in the adjusted RR of ovarian cancer with increasing parity. This study provides evidence that parity may confer a protective effect on the risk of ovarian cancer.

Abnormal liver function associated with occupational exposure to dimethylformamide and glutathione S-transferase polymorphisms.

Dimethylformaide (DMF) is a major solvent predominately used in synthetic leather and resin production. Many human and animal studies have linked the cause of hepatoxicity to DMF. Previously, the authors demonstrated the significant dose-response relationship between abnormal liver function tests and DMF exposure and the interaction with hepatitis B virus (HBV) infection in Taiwanese workers. Because the toxic effect of various chemicals can be modified by metabolic traits, the study also investigated the influence of the glutathione S-transferases (GSTM1 and GSTT1) on the toxic effect of DMF. The average DMF exposure concentration was 23.87 ppm (range 5.2-86.6 ppm) in the high-exposure (>/=5 ppm) group and 2.41 ppm (range 0.9-4.3 ppm) in the low-exposure (<5 ppm) group. There were 13 of 44 (29.6%) abnormal liver function tests (elevations of either glutamate oxaloacetate transaminase (GOT) or glutamate pyruvate transaminase (GPT)) among the high DMF exposure workers, two of 22 (9.1%) abnormal liver function tests among the low DMF exposure workers. Chronic liver disease as determined by ultrasonography was present in seven of 44 (15.9%) high DMF exposure workers, and 0 of 22 (0%) low DMF exposure workers. There were 11 of 34 (32.4%) abnormal liver function tests among the GSTT1 null genotype workers, and four of 32 (12.5%) abnormal liver function tests among the GSTT1-positive genotype workers. Compared with the low DMF exposure workers, the adjusted odds ratio and 95% confidence intervals for abnormal liver function tests was 6.78 (0.94-48.7) for the high DMF exposure workers. Compared with the GSTT1-positive genotype workers, the adjusted odds ratio and 95% confidence intervals for abnormal liver function tests was 4.41 (1.15-16.9) for the GSTT1 null genotype workers. Compared with the low DMF group with GSTT1-positive genotype workers, the odds ratio (adjusted for HBV status) of abnormal liver function test was 12.38, 95% CI=(1.04-146.9) for the high DMF group with GSTT1 null genotype workers. This study indicates that abnormal liver function and chronic liver disease are associated with DMF exposure, and there are more than multiplicative interaction effects on abnormal liver function tests between the DMF exposure and the GSTT1 genotype.

Emergence of competitive dominant ammonia-oxidizing bacterial populations in a full-scale industrial wastewater treatment plant.

Ammonia-oxidizing bacterial populations in an industrial wastewater treatment plant were investigated with amoA and 16S rRNA gene real-time PCR assays. Nitrosomonas nitrosa initially dominated, but over time RI-27-type ammonia oxidizers, also within the Nitrosomonas communis lineage, increased from below detection to codominance. This shift occurred even though nitrification remained constant.

Chromium (VI) induced oxidative damage to DNA: increase of urinary 8-hydroxydeoxyguanosine concentrations (8-OHdG) among electroplating workers.

AIMS: To investigate the concentration of urinary 8-hydroxydeoxyguanosine (8-OHdG) among electroplating workers in Taiwan. METHODS: Fifty workers were selected from five chromium (Cr) electroplating plants in central Taiwan. The 20 control subjects were office workers with no previous exposure to Cr. Urinary 8-OHdG concentrations were determined using high performance liquid chromatography with electrochemical detection. RESULTS: Urinary 8-OHdG concentrations among Cr workers (1149.5 pmol/kg/day) were higher than those in the control group (730.2 pmol/kg/day). There was a positive correlation between urinary 8-OHdG concentrations and urinary Cr concentration (r = 0.447, p < 0.01), and urinary 8-OHdG correlated positively with airborne Cr concentration (r = 0.285). Using multiple regression analysis, the factors that affected urinary 8-OHdG concentrations were alcohol, the common cold, and high urinary Cr concentration. There was a high correlation of urinary 8-OHdG with both smoking and drinking, but multiple regression analysis showed that smoking was not a significant factor. Age and gender were also non-significant factors. CONCLUSION: 8-OHdG, which is an indicator of oxidative DNA damage, was a sensitive biomarker for Cr exposure.

Determination of urinary and salivary cotinine using gas and liquid chromatography and enzyme-linked immunosorbent assay.

The objective of this study was to compare cotinine concentrations in urine and saliva using gas chromatography (GC), high-performance liquid chromatography (HPLC) and enzyme-linked immunosorbent assay (ELISA). Ninety-four subjects were selected (27 smokers and 67 non-smokers) and interviewed using questionnaire. Of the non-smokers, 39 had been exposed to environmental tobacco smoke (ETS) and 28 had not been exposed to ETS. Cotinine levels among smokers were highest using all three measurements, followed by ETS exposed subjects and non-smokers. Cotinine levels in urine, using HPLC, correlated significantly with levels measured using ELISA (r=0.92) and GC-nitrogen-phosphorus detection (NPD) (r=0.92). Salivary cotinine levels measured using ELISA did not correlate significantly with either HPLC (r=0.37) or GC-NPD (r=0.33) measurements. Multiple regression models were used to adjust for age, gender, drug use and health status, and it was found that cotinine levels in urine and saliva were significantly correlated with smoking pack-year. The authors conclude that urinary cotinine concentration is a more accurate biomarker for ETS than salivary cotinine concentration.