Mycobacterium abscessus post-injection abscesses from extrinsic contamination of multiple-dose bottles of normal saline in a rural clinic.

BACKGROUND: We investigated an outbreak of gluteal abscesses following intramuscular (IM) injections given at a clinic in rural China to identify the causative agent, source, and method of exposure. METHODS: We defined a case as an abscess that appeared at the site of an injection given since June 1, 2006. We compared case rates by injection route, medication, and diluents. We reviewed injection practices, and cultured abscesses and environmental sites for mycobacteria. RESULTS: From October through December 2006, 5.8% (n=35) of 604 persons who had received injections at the clinic developed a case. All 35 cases occurred in 184 patients (attack rate=19.0%) who had received IM injections with various drugs that had been mixed with normal saline (NS); risk ratio=infinity; p<0.0001. No cases occurred in the absence of NS exposure. We identified Mycobacterium abscessus from eight abscesses and from the clinic water supply, and observed the inappropriate reuse of a 16-gauge needle left in the rubber septum of 100 ml multiple-dose bottles of NS in the clinic. Fourteen percent (n=527) of the 3887 registered residents of this village had been treated with IM drugs over a three-month period, often for minor illnesses. CONCLUSIONS: This outbreak of M. abscessus occurred from exposure to extrinsically contaminated NS through improper injection practices. Frequent treatment of minor illnesses with IM injections of antibiotics was likely an important contributing factor to the size of this outbreak.

Detection of serum neopterin for early assessment of dengue virus infection.

OBJECTIVE: Neopterin is generated and released in increased amounts by macrophages upon activation by interferon-gamma during Th1-type immune response. The potential usefulness of neopterin in early prognostic information of dengue virus infection was investigated. METHODS: Neopterin concentrations were determined in serum samples from 110 dengue fever (DF) patients. The neopterin levels were compared with those in 50 measles and 40 influenza patients; 155 healthy blood donors served as controls. RESULTS: In acute sera of DF patients mean neopterin concentration was 48.2 nmol/L, which was higher than that in patients with measles (mean: 36.3 nmol/L) and influenza (18.8 nmol/L) and in healthy controls (6.7 nmol/L; P<0.001). In the patients with confirmed DF, an early neopterin elevation was detected already at the first day after the onset of symptoms and rose to a maximum level of 54.3 nmol/L 4 days after the onset. Higher increase of neopterin level in DF patients was associated with longer duration of fever and thus predicted the clinical course of the disease. CONCLUSIONS: Neopterin concentrations were found significantly higher in DF patients compared with healthy controls and also with other viral infections (P<0.001) and may allow early assessment of the severity of DF.

[Study on human case of avian influenza in Guangzhou 2006 without causing human-to-human transmission among close contacts].

UNLABELLED: Study on human case of avian influenza in Guangzhou 2006 without causing human-to-human transmission OBJECTIVE: To explore the possibility of transmission from a human case of avian influenza to his close contacts. METHODS: Close contacts of the human case of avian influenza in Guangzhou 2006 were found out according to the definition and methods publicized by the Ministry of Health, People's Republic of China. Epidemiological investigation and medical observation were carried out. Serum antibodies were tested in some of the close contacts. RESULTS: The avian influenza patient had never left Guangzhou in the month prior to disease onset. No contact history with dead or diseased poultry was found. A total of 56 close contacts, including his girl friend, relatives, friends and medical staff who had taken care of him, were brought under medical observation for 7 days but none of them showed signs of infection. CONCLUSION: Unlike SARS, direct contact with patient contracted with avian influenza at the end of incubation period and in the stage of illness through flying droplets, saliva, mucous membrane and skin injuries will not lead to human-to-human transmission, indicating the virus' ability to pass from human to human is limited.

Food markets with live birds as source of avian influenza.

A patient may have been infected with highly pathogenic avian influenza virus H5N1 in Guangzhou, People's Republic of China, at a food market that had live birds. Virus genes were detected in 1 of 79 wire cages for birds at 9 markets. One of 110 persons in the poultry business at markets had neutralizing antibody against H5N1.

[The effects of 4 laboratory test kits in early detecting of severe acute respiratory syndrome coronavirus].

OBJECTIVE: To compare the 4 test kits on severe acute respiratory syndrome coronavirus (SARS-CoV) gene, antigen and antibody for early diagnose of SARS patients. METHODS: Three enzyme linked immunosorbent assay (ELISA) kits were used to detect SARS-CoV IgG, IgM and N protein and fluorescent polymerase chain reaction (F-PCR) kit was used to detect SARS-CoV RNA. RESULTS: In 162 serum samples, 90.2% (55/61) became N protein positive in 1 - 5 days and 92.8% (13/14) became positive IgM and IgG in 15 - 18 days after the onset of disease, respectively. On 82 gorgling samples, the positive rates of F-PCR were 56.3% (14/24) in 1 - 5 days and 71.4% (10/14) in 6 - 9 days after the onset. CONCLUSION: Other than F-PCR, N protein had good effect in the early detection on dubious patients which could lead to effective prevention and control of the epidemic.

Cross-host evolution of severe acute respiratory syndrome coronavirus in palm civet and human.

The genomic sequences of severe acute respiratory syndrome coronaviruses from human and palm civet of the 2003/2004 outbreak in the city of Guangzhou, China, were nearly identical. Phylogenetic analysis suggested an independent viral invasion from animal to human in this new episode. Combining all existing data but excluding singletons, we identified 202 single-nucleotide variations. Among them, 17 are polymorphic in palm civets only. The ratio of nonsynonymous/synonymous nucleotide substitution in palm civets collected 1 yr apart from different geographic locations is very high, suggesting a rapid evolving process of viral proteins in civet as well, much like their adaptation in the human host in the early 2002-2003 epidemic. Major genetic variations in some critical genes, particularly the Spike gene, seemed essential for the transition from animal-to-human transmission to human-to-human transmission, which eventually caused the first severe acute respiratory syndrome outbreak of 2002/2003.

Monoclonal antibody-based antigen capture enzyme-linked immunosorbent assay reveals high sensitivity of the nucleocapsid protein in acute-phase sera of severe acute respiratory syndrome patients.

Accurate and timely diagnosis of severe acute respiratory syndrome coronavirus (SARS-CoV) infection is a critical step in preventing another global outbreak. In this study, 829 serum specimens were collected from 643 patients initially reported to be infected with SARS-CoV. The sera were tested for the N protein of SARS-CoV by using an antigen capture enzyme-linked immunosorbent assay (ELISA) based on monoclonal antibodies against the N protein of SARS-CoV and compared to 197 control serum samples from healthy donors and non-SARS febrile patients. The results of the N protein detection analysis were directly related to the serological analysis data. From 27 SARS patients who tested positive with the neutralization test, 100% of the 24 sera collected from 1 to 10 days after the onset of symptoms were positive for the N protein. N protein was not detected beyond day 11 in this group. The positive rates of N protein for sera collected at 1 to 5, 6 to 10, 11 to 15, and 16 to 20 days after the onset of symptoms for 414 samples from 298 serologically confirmed patients were 92.9, 69.8, 36.4, and 21.1%, respectively. For 294 sera from 248 serological test-negative patients, the rates were 25.6, 16.7, 9.3, and 0%, respectively. The N protein was not detected in 66 patients with cases of what was initially suspected to be SARS but serologically proven to be negative for SARS and in 197 serum samples from healthy donors and non-SARS febrile patients. The specificity of the assay was 100%. Furthermore, of 16 sera collected from four patients during the SARS recurrence in Guangzhou, 5 sera collected from 7 to 9 days after the onset of symptoms were positive for the N protein. N protein detection exhibited a high positive rate, 96 to 100%, between day 3 and day 5 after the onset of symptoms for 27 neutralization test-positive SARS patients and 298 serologically confirmed patients. The N protein detection rate continually decreased beginning with day 10, and N protein was not detected beyond day 19 after the onset of symptoms. In conclusion, an antigen capture ELISA reveals a high N protein detection rate in acute-phase sera of patients with SARS, which makes it useful for early diagnosis of SARS.

SARS-CoV infection in a restaurant from palm civet.

Epidemiologic investigations showed that 2 of 4 patients with severe acute respiratory syndrome (SARS) identified in the winter of 2003-2004 were a waitresss at a restaurant in Guangzhou, China, that served palm civets as food and a customer who ate in the restaurant ashort distance from animal cages. All 6 palm civets at the restaurant were positive for SARS-associated coronavirus (SARS-CoV). Partial spike (S) gene sequences of SARS-CoV from the 2 patients were identical to 4 of 5 Sgene viral sequences from palm civets. Phylogenetic analysis showed that SARS-CoV from palm civets in the restaurant was most closely related to animal isolates. SARS cases at the restaurant were the result of recent interspecies transfer from the putative palm civet reservoir, and not the result of continued circulation of SARS-CoV in the human population.

Laboratory diagnosis of four recent sporadic cases of community-acquired SARS, Guangdong Province, China.

Four cases of severe acute respiratory syndrome (SARS) that occurred from December 16, 2003, to January 8, 2004, in the city of Guangzhou, Guangdong Province, China, were investigated. Clinical specimens collected from these patients were tested by provincial and national laboratories in China as well as members of the World Health Organization SARS Reference and Verification Laboratory Network in a collaborative effort to identify and confirm SARS-associated coronavirus (SARS-CoV) infection. Although SARS-CoV was not isolated from any patient, specimens from three patients were positive for viral RNA by reverse transcription-polymerase chain reaction assay, and all patients had detectable rises in SARS-CoV-specific antibodies. This study shows the effectiveness of a collaborative, multilaboratory response to diagnose SARS.

[An investigation on nosocomial infection with severe acute respiratory syndrome in health-care workers at 13 key hospitals in Guangdong Province].

OBJECTIVE: To analysis the risk factors influencing nosocomial infection of severe acute respiratory syndrome (SARS) in health-care workers and to evaluate effectiveness of its control and preventive measures in 13 key hospitals caring for SARS patients. METHODS: Number of SARS patients, clinical conditions of them, its attack rate in health-care workers, and characteristics of hospitals, including their environment, isolating measures, etc. were investigated at the 13 hospital in Guangzhou to analyze the risk factors influencing nosocomial infection of SARS and its attack rates in health-care workers before and after implementation of preventive measures and to evaluate their effectiveness. RESULTS: Totally, 841 patients with SARS were treated at the 13 hospitals in Guangzhou and 285 health-care workers caring for them infected nosocomially. Attack rate in health-care workers was higher at general hospitals, hospital accepting more cases in critical conditions and hospitals with poor precautious measures, and lower in hospitals with isolated wards or areas, or department of infection, specially caring for SARS patients, and those with effective intervention measures to prevent secondary infection. CONCLUSION: Nosocomial infection of SARS in health-care workers was affected by clinical condition of SARS patients, characteristics and environment of hospitals and their personal protective measures adopted.

[Effectiveness of personal protective measures in prevention of nosocomial transmission of severe acute respiratory syndrome].

OBJECTIVE: To evaluate the effectiveness of personal protective measures of health care workers (HCWs) against severe acute respiratory syndrome (SARS). METHODS: A case-control study from ten hospitals in Guangdong, with 180 non-infected and 77 infected staff members that accessed the isolation unit every day, and participated in direct first aid for severe SARS patients. All participants were surveyed about how they were using personal protective equipment (PPE), protective drugs and hygiene habits when caring for patients with SARS. Statistical analysis was done with either chi(2) or Fisher's exact test for univariate analysis, whereas we used forward stepwise selection (Waldesian) for logistic regression. RESULTS: Univariate analysis showed that mask, gown, gloves, goggles, footwear, "hand-washing and disinfecting", gargle, "membrane protection", "taking shower and changing clothing after work", "avoid from eating and drinking in ward", oseltamivir phospha tall had protective effects (P < 0.05), but stepwise logistic regression showed significant differences for mask (OR = 0.78, 95% CI: 0.60 - 0.99), goggles (OR = 0.20, 95% CI: 0.10 - 0.41) and footwear (OR = 0.58, 95% CI: 0.39 - 0.86). Analysis for linear trend in proportions showed that dose response relationship existed in mask, gown, gloves, goggles, footwear, gargle, "membrane protection" and "taking shower and changing dree after work" (P < 0.01). The attack rate of HCWs who were rescuing severe SARS patients without any PPE was 61.5% (16/26). It seemed that the more the protective measures were used, the higher the protective effect was (P < 0.001), and could reach 100% if mask, gown, gloves, goggles, footwear, "hand-washing and disinfecting" were all used at the same time. CONCLUSIONS: Nosocomial infection of SARS can be prevented effectively by precautions against droplets and personal contact. HCWs must take strict protection according to the guidance of WHO or Chinese MOH and pay attention to personal hygiene.

[Analysis on the characteristics of blood serum Ab-IgG detective result of severe acute respiratory syndrome patients in Guangzhou, China].

OBJECTIVE: To probe blood serum Ab-IgG characteristics of severe acute respiratory syndrome (SARS) patients in Guangzhou and investigate the related factors. METHODS: The serum of such population diagnosed as SARS convalescent patients, non-SARS patients, family consanguineous contraction persons, wild animal and vegetable salesman and community common people was collected. The lab detective method of ELISA was adopted for these serum samples. And the epidemic investigations for the SARS patients were also carried out. RESULTS: Of these populations, the detective rate of Ab-IgG for the clinic diagnosed SARS patients, which was 53.7%; That for the wild animal salesman and community common people were 16.7% and 0.9%, respectively. Among the clinic diagnosed SARS patients, the positive antibody detective rate was 90.4% for those which had specific contact history or infectivity, which was higher than that for other population. Among the specific contact history or infectivity cases, the antibody positive rate for the young and the old was lower than that for the adult. Meanwhile the difference did not exist among other cases. The antibody positive rate was identical between the male and the female. And the antibody detective rate was decreased by the month. CONCLUSION: As a whole SARS-CoV Ab-IgG detective rate for the clinic diagnosed SARS patients was 53.7% only. The reasons for that mainly lie in the wrong clinic diagnosis besides these factors such as age, hormone use and reagent and so on. The combination of lab detection results and epidemic investigation was propitious to the diagnosis veracity. It was impossible for the sub-clinic infection of SARS-CoV virus. The importance in the virus transmitting course need to be further studied.

[Epidemiological study on severe acute respiratory syndrome in Guangdong province].

OBJECTIVES: To understand the epidemiological characteristics of severe acute respiratory syndrome (SARS) outbreaks in some areas of Guangdong province and to provide scientific basis for prevention and control measures against it. METHODS: Standardized questionnaire was used on individual cases. Data on the epidemiological characteristics as time, place, persons and aggregation status of SARS cases, development of the epidemics, were analyzed with software EPI 6.0. RESULTS: The incidence of SARS in Guangdong province was 1.72/100,000 with case fatality rate as 3.64%. Most cases of SARS occurred between the last ten days of January and the first ten days of February with the peak (61.88% of the patients) occurred in the first ten days of February. As to the distribution of place, Pearl river delta region-economically developed with great number of mobile population-was heavily affected areas (account for 96.66% of the total patients). The majority of patients were young adults and medical staff seemed to be the most affected subgroup (account for 24.9% of the patients in total). Family and hospital aggregation of patients comprised the another two important characteristics of SARS (account for 37.1% of the total patients). CONCLUSION: Current knowledge on SARS suggested that it was an air-borne infectious disease with human beings served as the source of infection. The incubation period of the disease was from 1 to 12 days with a median of 4 days. Respiratory secretions and close contact contributed to person-to-person transmission. Most cases were distributed in Pearl river delta region, an area famous for its economic development and heavy flow of mobile population.

[Study on the epidemiology and measures for control on severe acute respiratory syndrome in Guangzhou city].

OBJECTIVE: To analyze the epidemiological characteristics, related risk factors, measures for its control of severe acute respiratory syndrome (SARS). METHODS: Data on epidemiological features, pathogens and measures for control were collected and analyzed. RESULTS: Since Jan 2003, infectious atypical pneumonia (AP) has become epidemic in Guangzhou city. The first autochthonous case was identified on Jan 2nd. Number of cases started to increase since February and reached peak in the early 10 days of February. Hereafter the epidemic tended to decline in March and since early April, the average number of new cases began to decrease, less than 10 per day. Epidemiological studies revealed that the number of cases aged between 20 and 50 was higher than that below the age of 20. Of the total 966 cases, 429 were males versus 537 females. Geographically, the epidemics covered all 13 districts of Guangzhou, but 95% of the cases concentrated in 7 urban districts. As for professional distribution, health care workers accounted for 28.67% of the total cases. There were 36 deaths, aged from 5 to 89, with half of them older than 60. Out of the victims, 38.9% of them had complications as hypertension, diabetes, heart diseases and COPD etc. Data regarding the clustering features of cases showed that there were 42 families having 2 or more cases in one family, while 277 health workers suffered from SARS were concentrated in 28 hospitals. Only one outbreak took place in a public setting but no outbreak was reported in schools. Relevant research also indicated that SARS could be classified as an air-borne infectious disease, transmitted through aerosol and droplets, but close contact also played an important role in the mode of transmission. The disease was highly infectious, suggesting that people who had close contact with patients in the place with poor ventilation was in greater risk of getting infection. The incubation period ranged from 1 to 11 days (mainly from 3 to 8 days), with an average of 5 days. According to our observation, the following measures might be effective such as: early diagnosis, isolation and treatment provided to the patients, and suspected cases under medical observation should also be put in separate places. Improving ventilation and regular disinfection over air and stuff in hospital wards were also recommended. In order to prevent iatrogenic infection, sense on self-protection among health care workers must be strengthened. Patients were not allowed to be visited by any one other than hospital staff. CONCLUSION: SARS is a preventable disease and can be under control. It is of great importance to prevent clustered SARS cases and the prevention of iatrogenic infection is essential.