Global rotavirus surveillance: determining the need and measuring the impact of rotavirus vaccines.

Rotavirus remains the most common cause of severe childhood diarrhea worldwide and of diarrheal mortality in poor countries. In 2003, the GAVI Alliance launched the Rotavirus Vaccine Program and the Accelerated Development and Introduction Plan to close the gap of access to rotavirus vaccines in industrialized and developing countries by generating data on rotavirus disease burden, projected impact, and cost-effectiveness of vaccination and by conducting clinical trials of existing vaccines in impoverished settings. By the end of 2008, rotavirus vaccines were licensed in >100 countries, although only 17 countries have introduced routine rotavirus vaccination. Increased uptake of the vaccine by countries with the highest childhood mortality will depend in part on a solid evidence base of estimated burden and cost of rotavirus illness. Since 2001, regional surveillance networks worldwide have generated burden and strain data from 196 sites in 59 countries. Among children aged <5 years who are hospitalized for severe diarrhea in different regions of the world, a regional median of 39% (range by country, 20%-73%) test positive for rotavirus. Rotavirus vaccines are a cost-effective intervention and may be cost saving with a GAVI Alliance subsidy from the health care perspective. Punctual vaccination and high coverage of populations at highest risk of mortality will maximize the impact of vaccination. Surveillance platforms will allow measurement of the rapid impact of rotavirus vaccine introduction on the heavy burden of rotavirus on child health worldwide.

Typhoid fever in the United States, 1999-2006.

CONTEXT: Typhoid fever in the United States has increasingly been due to infection with antimicrobial-resistant Salmonella ser Typhi. National surveillance for typhoid fever can inform prevention and treatment recommendations. OBJECTIVE: To assess trends in infections with antimicrobial-resistant S. Typhi. DESIGN: Cross-sectional, laboratory-based surveillance study. SETTING AND PARTICIPANTS: We reviewed data from 1999-2006 for 1902 persons with typhoid fever who had epidemiologic information submitted to the Centers for Disease Control and Prevention (CDC) and 2016 S. Typhi isolates sent by participating public health laboratories to the National Antimicrobial Resistance Monitoring System Laboratory at the CDC for antimicrobial susceptibility testing. MAIN OUTCOME MEASURES: Proportion of S. Typhi isolates demonstrating resistance to 14 antimicrobial agents and patient risk factors for antimicrobial-resistant infections. RESULTS: Patient median age was 22 years (range, <1-90 years); 1295 (73%) were hospitalized and 3 (0.2%) died. Foreign travel within 30 days of illness was reported by 1439 (79%). Only 58 travelers (5%) had received typhoid vaccine. Two hundred seventy-two (13%) of 2016 isolates tested were resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole (multidrug-resistant S. Typhi [MDRST]); 758 (38%) were resistant to nalidixic acid (nalidixic acid-resistant S. Typhi [NARST]) and 734 NARST isolates (97%) had decreased susceptibility to ciprofloxacin. The proportion of NARST increased from 19% in 1999 to 54% in 2006. Five ciprofloxacin-resistant isolates were identified. Patients with resistant infections were more likely to report travel to the Indian subcontinent: 85% of patients infected with MDRST and 94% with NARST traveled to the Indian subcontinent, while 44% of those with susceptible infections did (MDRST odds ratio, 7.5; 95% confidence interval, 4.1-13.8; NARST odds ratio, 20.4; 95% confidence interval, 12.4-33.9). CONCLUSION: Infection with antimicrobial-resistant S. Typhi strains among US patients with typhoid fever is associated with travel to the Indian subcontinent, and an increasing proportion of these infections are due to S. Typhi strains with decreased susceptibility to fluoroquinolones.

Multistate outbreak of Salmonella Typhimurium and Saintpaul infections associated with unpasteurized orange juice--United States, 2005.

BACKGROUND: Infection due to Salmonella species causes an estimated 1.4 million illnesses and 400 deaths annually in the United States. Orange juice is a known vehicle of salmonellosis, for which regulatory controls have recently been implemented. We investigated a nationwide outbreak of Salmonella infection to determine the magnitude of the outbreak and to identify risk factors for infection. METHODS: We identified cases through national laboratory-based surveillance. In a case-control study, we defined a case as infection with Salmonella serotype Typhimurium that demonstrated the outbreak pulsed-field gel electrophoresis pattern in a person with illness onset from 1 May through 31 July 2005; control subjects were identified through random digit dialing. RESULTS: We identified 152 cases in 23 states. Detailed information was available for 95 cases. The median age of patients was 23 years; 46 (48%) of the 95 patients were female. For 38 patients and 53 age-group matched control subjects in 5 states, illness was associated with consuming orange juice (90% vs. 43%; odds ratio, 22.2; 95% confidence interval, 3.5-927.5). In a conditional logistic regression model, illness was associated with consuming unpasteurized orange juice from company X (53% vs. 0%; odds ratio, 38.0; 95% confidence interval, 6.5-infinity). The US Food and Drug Administration found that company X was noncompliant with the juice Hazard Analysis and Critical Control Point regulation and isolated Salmonella serotype Saintpaul from company X's orange juice. CONCLUSIONS: Unpasteurized orange juice from company X was the vehicle of a widespread outbreak of salmonellosis. Although the route of contamination is unknown, noncompliance with the juice Hazard Analysis and Critical Control Point regulation likely contributed to this outbreak. Pasteurization or other reliable treatment of orange juice could prevent similar outbreaks.

Juice-associated outbreaks of human illness in the United States, 1995 through 2005.

Outbreaks of illness associated with consumption of fruit juice have been a growing public health problem since the early 1990s. In response to epidemiologic investigations of outbreaks in which juice was implicated, the U.S. Food and Drug Administration implemented process control measures to regulate the production of fruit juice. The final juice regulation, which became effective in 2002, 2003, and 2004, depending on the size of the business, requires that juice operations comply with a hazard analysis critical control point (HACCP) plan. The Centers for Disease Control and Prevention (CDC) receives reports of food-associated outbreaks of illness. We reviewed fruit juice-associated outbreaks of illness reported to the CDC's Foodborne Outbreak Reporting System. From 1995 through 2005, 21 juice-associated outbreaks were reported to CDC; 10 implicated apple juice or cider, 8 were linked to orange juice, and 3 involved other types of fruit juice. These outbreaks caused 1,366 illnesses, with a median of 21 cases per outbreak (range, 2 to 398 cases). Among the 13 outbreaks of known etiology, 5 were caused by Salmonella, 5 by Escherichia coli O157:H7, 2 by Cryptosporidium, and one by Shiga toxin-producing E. coli O111 and Cryptosporidium. Fewer juice-associated outbreaks have been reported since the juice HACCP regulation was implemented. Some juice operations that are exempt from processing requirements or do not comply with the regulation continue to be implicated in outbreaks of illness.