14Th International Congress on Infectious Diseases (ICID) Abstracts

International Journal of Infectious Diseases (2010) 14S1, e2—e478

http://intl.elsevierhealth.com/journals/ijid

14th International Congress on Infectious Diseases (ICID) Abstracts

Plenary 1 (Invited Presentation) Climate change, security issues, economic fluctuations, demographic shifts and the threat of emerging diseases will 01.001 also reshape the future of travel and mobility trends. All The Challenges of Travel Medicine in the 21st Century will influence travelers’ health and pose new challenges to travel medicine in the forthcoming decades. L. Loutan Geneva University Hospitals, Geneva, Switzerland doi:10.1016/j.ijid.2010.02.1476 Travel medicine has emerged as a new field of medicine, moving to an evidence based body of knowledge concerning ABC of travel medicine (I) (Invited Presentation) risk assessment and measures to protect the health of trav- 02.001 ellers. Most of travel medicine concentrates on tourists from Development of Travel Medicine in Latin America North America and Europe leaving for international destinations, many being low or middle income countries involving A. Lepetic a higher risk of acquiring infectious diseases. This paradigm is changing rapidly. With the increasing mobility of popu- GSK, Buenos Aires, Argentina lations, whether migrants, tourists, businessmen, students, No abstract received. soldiers, humanitarian workers, pilgrims, refugees or medical tourists, it is becoming evident that the diversification doi:10.1016/j.ijid.2010.02.1477 of globally mobile travelers is posing new challenges to the travel medicine community. Perception of risk, behaviour, 02.002 exposure to risks and access to health services vary enor- Approach to pre-travel consultation mously. Nonetheless all contribute to the global circulation and potential spread of known or emerging pathogens. From G. Acuna˜ an epidemiological and public health perspective a more Santiago, Chile global encompassing approach to health issues related to population mobility is urgently needed. La consejería pre-viaje debe considerar varios aspec- With globalisation new emerging economies are growing tos: la persona que consulta por lo general no está in many parts of the world, new patterns of travel and mobil- enferma, no entiende muy bien la necesidad de una consulta ity appear. The sharpest increases in travel are observed in médica. Asian and in Latin American regions where intra-regional and El Médico debe considerar condiciones del viajero (edad, in-country travel is rising. The majority of these new trav- sexo,posible embarazo, patologías previas y condiciones ellers are urban dwellers often unaware of the existing risks actuales, medicamentos que ingiere alergias, etc). gradients within their own country when they move to rural Es relevante el itinerario antes de llegar al destino y destinations. Thus travel medicine has to expand from the actividades en zona a visitar, condiciones de alojamiento, current international/across boarders approach to a prac- comida, y transporte. tice based on risk assessment analysis and prevention across El Centro debe contar con Vacunatorio ad-hoc, productos different prevalence gaps, wherever and for whomever they necesarios para profilaxis de Malaria, picadura de mosquitos, are of relevance. botiquín del viajero, purificadores de agua.

1201-9712/$32.00 doi:10.1016/j.ijid.2010.02.003 14th International Congress on Infectious Diseases (ICID) Abstracts e3

Se debe estar en conocimiento de la geografía del destino tury saw an increase in both anticipated and actual life y los posibles riesgos de salud y la maneras de prevenirlos expectancy figures, a phenomenon described as the ‘aging population’. In the year 2020, life expectancy at birth is pre- doi:10.1016/j.ijid.2010.02.1478 dicted to reach 70. Travel satisfies old age people needs for adventure in many ways. Most personal problems stem from 02.003 rushing to meet a schedule of pleasure and joy. And during Traveling with Kids travels everything is permitted, specially food and sedentary activities, most of them due to physical and health limits. C. Perret But how far can they go traveling? If they have to share Pontificia Universidad Catolica de Chile, Santiago, Chile their travel with prescribed medicines; diabetes; neurological problems; obesity and diets; vision and hearing loss; Travelling with kids is a great adventure that offers walking limitations versus jet lag; altitudes problems; air- opportunities for fun and to possibility to broaden ones cul- port/aircraft long stay/ pulmonary thromboembolism risks; tural outlook. But travel is not just fun, some risks related lazy attitudes during cruises; infection disease risks and to the travel exist and the whole family should be prepared adult immunization status. to prevent them or to have early treatment. Preparing a trip with kids involves considering several aspects, such as age, doi:10.1016/j.ijid.2010.02.1480 underlying diseases and destination. The main aspects we are going to review are: safety travel (motor vehicles, safety water and food, air travel, sun Epicenters of major diseases (I) (Invited Presenta- protection, motion sickness, high altitude, animal bites), tion) immunization, prevention of arthropods borne diseases and 03.001 diarrhea. Air transportation can produce boredom and ear pain. No pharmaceutical interventions have been proved to Central America and the Caribbean: Dengue and P.Vivax be good at preventing painful earache. Sedation is contro- malaria versial but if it is required, diphenhydramine is considered J. Torres a safe drug. Children should have their immunization schedule Tropical Medicine Institute, Caracas, Venezuela updated at the time of the trip. Insect borne disease can In recent decades, the incidence, distribution and clini- be prevented by using DEET repellents. DEET concentration cal severity of dengue have increased dramatically in most 30-35% is safe for use in children. It should not be applied tropical and subtropical areas worldwide. As a consequence, around the eyes, mouth or on the hands and forearms of and due to the expanding international tourism, health young children. Malaria chemoprophylaxis can be used in care providers in travel clinics of developed countries are children and are licensed for infants. increasingly confronted with dengue, reflecting its global Mefloquine, chloroquine and malarone are the alterna- impact. No specific prophylactic or therapeutic agents exist tives for children under 9 years old. for dengue infections. All four serotypes of dengue viruses Doxycicline can be used after that age. Maternal chemo- are widespread in Central America and the Caribbean basin. prophylaxis is not enough for breastfed infants. Difficulties Dengue is most common in cities but can be found in rural for children using chemoprophylaxis include bad taste, luck areas. It is rarely found in mountainous areas above 4,000 in pediatric preparations and toxicity risks. Diarrhea preven- feet. Dengue fever is the most common cause of fever in tion includes safety in water and food consumption. Therapy travelers returning to the USA from the Caribbean and Cen- should center on oral hydration. Self-treatment of trav- tral America. In some case studies, dengue has been the elers’ diarrhea with antibiotics should be considered, but second most common cause of hospitalization (malaria is antimotility agents should be avoided. Travel offers good the most common) among travelers returning from the trop- experiences for children and their families. Pre-travel eval- ics. Infection rates (based on anti-dengue serology) among uation and protective interventions can reduce the health febrile travelers returning from those areas may range from risks of travel. 2.9% to 8.0%. Similar results have been reported in travelers returning to Europe. Persons travelling to areas where doi:10.1016/j.ijid.2010.02.1479 dengue is endemic should avoid exposure to mosquitoes, 02.004 and health care providers should consider dengue as a differential diagnosis in febrile travelers returning from the The Elderly Traveler tropics after discounting malaria. Surveillance of imported S. Lemos Hinrichsen dengue is crucial to monitor the risk of infection for travelers and to strengthen clinical awareness of the disease. Universidade Federal de Peranbuco, and Universidade de The risk for a traveler acquiring malaria differs substantially Pernambuco, Sao Paulo, Brazil from different areas within the region and from traveler to Old age has been divided into different groups: biolog- traveler, even within a single country. In a large series of ical, physiological, emotional and functional. Advances in 10,745 cases of malaria among U.S. residents reported to science and technology, as well as improvements in health CDC from 1997 through 2006, 1,427 (13.3%) were acquired services available, have played an important role in the in the Caribbean and Centra/South America. Malaria has increasing number of elderly in the world. The 20 th cen- been reported in about 1 per 100,000 European travelers to Central America and the Caribbean. The risk of vivax e4 14th International Congress on Infectious Diseases (ICID) Abstracts malaria may be relatively high in some Central American graphic expansion into southeast, south and midwestern countries, including several large or middle size cities. Trav- region - Federal District, Goias, Sao Paulo, Minas Gerais, elers to malaria-risk areas, including infants, children, and Parana and Rio Grande do Sul states — related to out- former residents of Mexico and Central America, should take breaks in areas that were silent for several decades and an antimalarial drug. There is no chloroquine resistance in outside Amazon area. This study describes the re-emergence Central America, so this drug can still be recommended for of YF virus in enzootic cycles involving mosquitoes, pri- travelers to these countries. Malaria is not a risk in most of mates and humans cases in midwestern, southeast and the Caribbean islands, but P. falciparum is endemic to most south region during 2008 and 2009. During this period of Haiti and some areas of the Dominican Republic, where and explosive recording of monkey’s death was registry there is variable to low risk. Malaria in these areas is still by health authorities with laboratory confirmed epizootics. sensitive to chloroquine, which is therefore recommended Human cases were associated with leisure and work activ- for prevention. ities in rural areas and occurred among unvaccinated person. Brazilian Ministry of Health considered it as a public doi:10.1016/j.ijid.2010.02.1481 health event of national concern according to the Inter- national Health Regulations (2005). Epidemiological control 03.002 measures were adopted including entomologic control Hantavirus and Bartonellosis and assessments, monkey deaths surveillance investigation and mass vaccination campaigns were implemented. YF E. Gotuzzo vaccine-associated viscerotropic and neurotropic disease Universidad Peruana Cayetano Heredia, Lima, Peru were reported. Those activities were important to establish an effective intervention to control and prevent future No abstract received. outbreaks. Public health authority’s interest has been awak- ened by reporting early identification of YF virus circulation doi:10.1016/j.ijid.2010.02.1482 to understand the potential geographic virus expansion and reemergence.

doi:10.1016/j.ijid.2010.02.1483 03.004 The Amazon II: Leishmaniasis and Chagas Diseases 03.003 S. Sosa Estani Yellow Fever transmission in Brazil Institute for Clinical Effectiveness and Health Policy, M. Mascheretti Buenos Aires, Argentina Centro de Vigilância Epidemiológica CVE/CCD/Secretaria Chagas disease and leishmaniasis are the most impor- de Estado de Saúde de São Paulo, Sao Paulo, Brazil tant vector-borne protozoan NTDs. Almost all of the 8-9 Yellow fever (YF) is an arboviral disease caused by a million cases of Chagas disease (with approximately 50,000 virus from Flaviviridae family and genus Flavivirus endemic new cases annually) occur in poor rural and, increasingly, in tropical regions of Africa and South America. Transmis- many new urban and peri-urban areas of Latin America. Of sion occurs after infected mosquito bite, genera Aedes these cases, an estimated 5.4 million people will develop and Haemogogus. Urban YF was eradicated in Brazil in chronic Chagas heart disease, while 900,000 will develop 1942, since than sporadic wild transmission has been main- megaesophagus and megacolon. In LAC, the burden of dis- tained in country endemic area. From 1989 to 2008, 546 ease caused by Trypanosoma cruzi infection is between five human confirmed cases YF were reported including 241 to ten times greater than malaria. Chagas disease is dis- deaths (case fatality rate 44, 1%) in Brazil. During this proportionately represented among people living in poverty. period north and midwestern region were responsible for The disease has also emerged or re-emerged in areas of the highest number of cases registering human cases almost conflict in Chiapas State, Mexico and Colombia. The major every year. Beginning in 1999, YF virus underwent a geo- approaches to control including improved case manage- 14th International Congress on Infectious Diseases (ICID) Abstracts e5 ment and vector control programs, together with housing Diarrhea remains the most frequent illness among trav- improvement through regional programs. In LAC, both cuta- elers visiting Latin America. Dengue is a reemerging illness neous and visceral forms of leishmaniasis result primarily in the region as well and is the main cause of viral from zoonotic transmission from either canine or sylvatic fever in returned travelers. Malaria should be considered if reservoir hosts. The most important determinants for the exposures and clinical findings are consistent with the diag- emergence of both new world zoonotic cutaneous leishma- nosis. Initial laboratory investigation should be performed niasis (ZCL) and zoonotic visceral leishmaniasis (ZVL) include depending upon exposure and other factors that prompt poverty, urbanization, and human migration. Leishmania consideration of a particular disease. mexicana, L. amazonensis, L. braziliensis, L panamensis, L. peruviana, and L. guyanensis are the major species that doi:10.1016/j.ijid.2010.02.1485 cause new world ZCL. Approximately 62,000 cases of ZCL occur primarily in Brazil, Colombia, and Venezuela, where 04.002 urbanization near Lutzomyia sandfly breeding sites have led Fever and their etiologies to an increase in the number of cases. In addition, the T. Orduna emergence of ZCL n Colombia is linked to several decades of armed and guerilla internal conflict fueled by cocaine F.J.Muniz˜ Infectious Diseases Hospital, Buenos Aires, production and trafficking. In northeastern Brazil, ZVL (L. Argentina chagasi) has become an important infection in the favelas of Forteleza, Salvador do Bahia, and other urban centers; The practice of Travel Medicine (TM) has 3 stages at which ZVL has also emerged in Rio de Janeiro and Belo Horizonte. you can work: the pre-travel, the intra-trip and the post A regional leishmaniasis control action plan is now being travel assistance. Many services only deal with pre-travel, implemented. strongly related to preventive measures, including vaccinations and malaria prophylaxis, and transfers to centers of Tropical Medicine, Internal Medicine Clinic or the Infectious doi:10.1016/j.ijid.2010.02.1484 Diseases Consultations ill patients encountered during the trip or upon returning. The need to cover all these stages The ill-returned traveler (Invited Presentation) in the centers of TM is controversial, even within their own 04.001 ISTM. Our service, in the context of an Infectious Disease Hospital, allows comprehensive care of travelers in any of Assessment in travelers coming from Latin America the 3 instances. J. Dabanch Pena The most frequent reasons for consultation in returning travelers are the dermatological disease, fever,diarrhea and Universidad de Los Andes, Santiago, Chile eosinophilia. The fever is about 30% of all searches, and the In recent years has been an important increase in inter- most common etiology is for malaria, followed by dengue, national travel including Latin America. typhoid fever and rickettsial diseases. The diagnoses may Travelling involves a series of risk depending of the travel vary according to geographic destination and the traveler’s destination, the standards of accommodation as well as the risk exposure. It is important not to forget cosmopolitan dis- lifestyle and host characteristic (healthy versus pre existing ease and non-infectious causes in the differential diagnosis. condition, pregnancy, infants). Most illnesses reported by The febrile syndrome after a trip to tropical areas is a ill travelers are mild but some are serious enough to seek medical emergency, because it can be falciparum malaria, medical attention. or a viral hemorrhagic fever among others etiologies, which A systematic approach to the assessment of the ill can endanger both the patient and health staff involved with returned traveler with knowledge of the most common, him, and potentially to the community of the host country region-specific pathogens and recent outbreaks of infection of the traveler. will aid diagnosis and treatment. The detailed travel history is the cornerstone of the doi:10.1016/j.ijid.2010.02.1486 post travel screening process, including travel destination, 04.003 the particular area within a country, urban or rural areas were visited, season (dry or rainfall), purpose of travel, After a trip: the souvenirs in the skin hygiene standard (food and water exposures), duration of S. Lloveras stay, accommodation, pre-travel vaccination, prophylaxis adherence and personal protection measures, illness of any Hospital de Enfermedades Infecciosas F. J. Muniz,˜ Buenos travel companions, history of unprotected sexual contacts Aires, Argentina with new partners or casual sex, date of return in relation Dermatoses are one of the most common reason for to onset of symptoms and type of symptoms. The physical medical consultation after returning from a trip. The first examination may yield useful information. consideration to take into account is that the spectrum of According GeoSentinel surveillance, the most common skin diseases that affect immigrants, long term travelers and syndromes in returned travelers from Latin America are expatriates may be different than those suffering from other chronic and acute diarrhea especially parasitic causes (Giar- travelers. diasis), dermatological problems (larva migrans, myasis and According to two large scale international studies per- leishmania), respiratory tract illness and fever (dengue and formed by the GeoSentinel Surveillance Network involved malaria). e6 14th International Congress on Infectious Diseases (ICID) Abstracts

17,353 and 25,500 ill returned traveler encounters respec- a binding legal instrument, which aim to provide a proper tively at globally dispersed travel or tropical medicine public health response to the international spread of dis- clinics, between 1996 and 2006, the dermatosis were the ease avoiding unnecessary interference with international third reason for consultation in frequency, after fever and traffic and trade. The new IHR, which have been enforced diarrhoeal illness, and represented 17-18% of all diagnoses. since June 2007, holds a broader framework, shifting its Independently of these studies and other series, der- focus from a small list of notifiable diseases to any event matoses are likely to have higher incidence because they that can become a public health emergency of international often resolve spontaneously or sometimes the patients concern (PHEIC). Furthermore, the new IHR established a require medical assistance outside the Travel medicine global sensitive mechanism to detect PHEICs using both offi- or Tropical disease units which have conducted the most cial notification and media news. research on these topics. The study analyses the events considered as potential In assessing dermatoses in travelers, it is important to international concern for the Americas under the IHR 2005 consider some factors such as the geographical destination framework, from June 2007 to December 2009. The source of visited,places visited en route, length of stay, purpose of data was the World Health Organization Event Management travel and activities. System (WHO-EMS). Dermatoses can be noninfectious and infec- During the period studied, 243 events were considered as tious/infestation, which can be cosmopolitan or from PHEIC in the region of the Americas. tropical origin. Despite the political commitment provided by the coun- The most common diagnoses are cutaneous larva tries to approve the new IHR, 39.9% were initially detected migrans, soft tissue bacterial infection, arthropod bite, through news media and 30.0% were notified by the National allergic reaction, myiasis, cutaneous leishmaniasis and tun- Focal Point (NFP) within the Ministries of Health. These fig- giasis. ures reflect the countries’ remaining tendency to hold the It is important to remember that skin lesions may be man- notification until finishing the verification process. 189/243 ifestations of systemic infectious diseases such as dengue (77.8%) were infectious disease outbreaks, 8.2% were food rash, Chicungunya viruses, rickettsial infection, or non- safety events and 7.8% were animal health (epizootics) infectious diseases such as those related to previous medical events. The study analyzes the main characteristics of these history, drug allergies, climate or sea related dermatoses. events and their implication for global health. Appropriate investigations and consultation with tropical The IHR 2005 provides a useful framework for early detec- or tavel medicine experts may be needed in order to make tion and risk assessment of EID with potential international the correct diagnosis and provide correct management of spread. Each country needs to accomplish the core capaci- these diseases. It is also necessary to emphasize preventive ties to perform surveillance and response activities in order measures related to skin diseases in pre-travel advice. to strengthen the global health security. doi:10.1016/j.ijid.2010.02.1487 doi:10.1016/j.ijid.2010.02.1489 04.004 Session: ABC of travel medicine (II) (Invited Presen- Ten Most Common Imported Diseases in Florida tation) J. Murillo 06.001 University of Miami, Miami, FL, USA Customizing Immunization to Travelers No Abstract Received. A. Macchi doi:10.1016/j.ijid.2010.02.1488 Centros Medicos Dr. Stamboulian, Buenos Aires, Argentina Immunization of travelers is a very important challenge Plenary 2 (Invited Presentation) for travel medicine practitioners. It should be tailored to each particular situation. Destination, duration of stay, 05.001 activities and individual health, among others, influence Emerging infectious diseases in Latin America these recommendations. The key point is to determine the travel risk. Selection of recommended immunizations should J. Barbosa da Silva Jr. be based on epidemiological evidence, taking into account Pan American Health Organization, Washington DC, DC, USA incidence rates and severity of certain infections. Other factors to influence recommendations include: time, shots, In the last four decades new infectious diseases have availability, costs, interactions and vaccine side effects. Yel- been recognized almost every year, assuring emerging infec- low fever remains the only required vaccine by Who. Special tious diseases (EID) as a priority for global health. Some requirements are taken for those pilgrims on Hajj, where of these diseases, such as AIDS, SARS and the influenza vaccination against meningococcal ACWY is mandatory and pandemic, have threatened the global health due to their also polio vaccine is required to some travelers. capacity to cross geopolitical boundaries. To respond to Routine vaccines are always updated in pre travel eval- this new scenario the countries affiliated with the World uation. Influenza remains one of the most frequent vaccine Health Organization (WHO) approved a new revision of the preventable infections. Recommended immunization for International Health Regulations (IHR) in 2005. The IHR is travelers includes common vaccine preventable diseases, as 14th International Congress on Infectious Diseases (ICID) Abstracts e7 the main food and drinks related infections like hepatitis 06.003 A and typhoid fever, as well as the life threatening disease Vaccines Recommended for Global Travelers rabies. Protection against hepatitis B is high through vaccination and should be considered in long term and frequent T.S. Chaves travelers. Our experience in Travel Vaccines will be showed. Institute for Infectious Diseases Emilio Ribas, Sao Paulo, Brazil doi:10.1016/j.ijid.2010.02.1490 Individuals travel for many reasons, including holidays, 06.002 recreation, business, visiting friends and relatives, health Routine Immunization treatments, educational experiences or others purposes. The World Tourism Organization predicts that international A. Rísquez Parra tourist travel may top 1 billion by 2010. Given the growth of Universidad Central de Venezuela, Department of Preven- international travel, the area travel medicine has expanded tive and Social Medicine, Caracas, Venezuela of the worldwide. The vaccination is one of the steps that health providers for giving travelers, and the vaccines rec- Routine immunization has become among the most com- ommended prior to international travel can be divided into mon preventive tools use by medical practitioners all over three fases: those that are routine, those that may be the World. Vaccinations have proven to eradicated and con- required and those that are recommended on the basis an trol many preventable diseases such as smallpox, polio, individual risk assessment for the traveler. Considerations in measles, tetanus and diphtheria among others. Globally, choosing vaccines include destination; season and duration children vaccines calendars are most familiar for all devel- of travel; activities planned; severity of disease; whether oped and underdeveloped countries. However, only until the trip will be urban, rural, or remote from medical care; recently that adolescents and adult vaccinations are known time remaining before departure; vaccine availability, cost, for many underdeveloped countries. Travel medicine is a and the number of doses needed; history of allergy to good way to promote immunization calendars for all and vaccines or their components; medications currently being should be a goal for our performance because there is an taken; pregnancy; chronic illness; and underlying medical intrinsic synergistic relationship between them. The World conditions such as a compromised immune system. Vac- Health Organization (WHO) has an important role in rec- cines recommended for travelers and that will be discussed: ommending routine immunizations for all groups of ages cholera, hepatitis A, Typhoid fever, Japanese encephalitis, (children, adolescents and adults), diverse regions, and cer- meningococcal disease, rabies and Tick-borne encephali- tain risk populations. WHO initial main program was the tis. Conclusion: Vaccination is a highly effective method Expanded Program in Immunization which included vaccines of preventing certain infectious diseases. Travel medicine for the maternal and children population under one year practitioners must be care when to evaluate immunization of age. Now among other goals are integrating immuniza- status of the traveler with goal to consider or not to vaccine tions’ in the health systems and immunizing within a global for patient. Travelers should be informed about the risks of health interdependence context are global objectives. Most contracting disease, as well as, the risks of adverse events countries follow the basic program for children and must from immunizations. comply with mandatory travel vaccines by the new Inter- national Health Regulations (2005). However, still the risk doi:10.1016/j.ijid.2010.02.1492 of lifethreatening illness is very high especially in underdeveloped regions because still the vaccines coverage is 06.004 low, therefore; the risk for reemerging diseases and spread- Yellow fever vaccine ing consequently with illnesses, disability and deaths. Also, there are new technologies and vaccines available which C. Biscayart make difficult to financially provide the service for all. New Centros Médicos Dr. Stamboulian, Buenos Aires, Argentina biological products developments and technologies, vaccines primary series, interval of doses, and boosters must The purpose of this talk is to briefly address some high- be learned by travel medicine practitioners. Also, adverse lights about the illness and its burden in relation to travel, reactions and contraindications, particularly for those trav- new epidemiological aspects, particularly focusing on the elers with special needs or conditions in order to provide Caribbean and South American situation in 2008-9. Concep- good advice during their pre-travel consultation. tual points regarding yellow fever vaccine will be reviewed, focusing specially on severe adverse events described in the doi:10.1016/j.ijid.2010.02.1491 last 10 years, which have put the actual vaccine risk/benefit relation under close scrutiny. Some practical situations regarding its indication that could lead to controversy will be also discussed.

doi:10.1016/j.ijid.2010.02.1493 e8 14th International Congress on Infectious Diseases (ICID) Abstracts

Travel medicine and the influenza pandemic In the outpatient group, 97% had fever, 97% headache, 93.5% (Invited Presentation) myalgias, 90% cough, 88.3% sore throat, 84% rhinorrhea, 43.8% join pain, 36% nausea, 29.4% diarrhea. Time between 07.001 onset symptoms and second case was 3.6 days (range1—9). From the Americas to the World Of the 1585 admitted to hospital, 52% were females, median age 33 years (range11 to 94), 56% had underlying J. Sotelo Morales medical condition, average time from the onset of illness National Autonomous University of Mexico, Mexico City, to hospital admission was 3.6 days. Symptoms at presenta- Mexico tion included fever 83%, cough 92.7%, dyspnea 83%, myalgias 63%, hypoxia 50.8%, cyanosis 27.4%, hypotension 18.6%, and In April, 2009 a new influenza virus, from porcine ori- 8.3% seizures. gin, was detected in Mexico City and blamed as responsible Pneumonia was the diagnosis in 77% patients. for the death of young adults with pneumonia. The patients 130 patients died, all has been admitted to and ICU. The were seen within the brief lapse of a week at the National median age was 44 years (range 4 months to 89 years), 87.5% Institute of Respiratory Diseases of Mexico; three main fac- had underlying medical condition. The cause of death was tors contributed to trigger the awakening call from the severe respiratory failure in 34%, septic shock in 19%, bilat- Mexican Health authority that evolved, within a few weeks, eral pneumonia 17% and multi organic failure in 16%. Almost into an unprecedented international epidemiological alert all patients received antiviral treatment. orchestrated by the World Health Organization which cul- Surveillance in Chile of the 2009 influenza A H1N1 cases minated with the ‘‘Pandemic alert grade VI’’; it meant that allow to characterize the clinical spectrum of the disease in the disease had already disseminated worldwide; the factors this first pandemic wave. were: a) the presence of various cases of severe influenza in healthy adults, b) the presence of the disease in the doi:10.1016/j.ijid.2010.02.1495 middle of spring, an abnormal timing for seasonal influenza and c) the identification by molecular methods of a brand 07.003 new influenza virus from porcine origin infecting humans. Interim lessons from 2009 According to the standards settled by the WHO these characteristics represented the much feared possibility of an J. Alves influenza pandemic of potential catastrophic consequences; Institute for Infectious Diseases Emilio Ribas, Sao Paulo, thus, the Ministry of Health of Mexico implemented at mea- Brazil sures which had already been planned two years before in the case of facing such event. The Minister of Health Through the epidemiological week 37/2009, WHO appeared on national TV indicating the closure of schools reported more than 300,000 confirmed cases and almost at all levels in Mexico City and various other actions aiming 4,000 deaths produced by pandemic influenza H1N1 in 191 to social distancing and medical alert in all health institu- affiliated countries. tions, together with the development of technical skills for During the peak of transmission in 2009, the Southern the reliable detection of the new virus in specialized labora- Cone countries, Chile, Argentina and Southern regions of tories. Through the epidemic in Mexico several new factors Brazil, reported the highest number of cases. According were learned, the capacity of society to deal with similar to PAHO, through the week 20/2009, 92,773 H1N1 cases events was put to test. From this experience, several scien- were confirmed in Latin America as well as in Caribbean tific reports from our Institutes have been published; they islands and a total of 2,494 deaths had been reported. Brazil provide a new framework for more efficient responses in accounted for the highest number of deaths and an elevated future events. mortality rate when compared to countries like Chile. Initial containment measures, such as screening symptomatic peo- doi:10.1016/j.ijid.2010.02.1494 ple in airports and aircrafts and isolating patients who had recently traveled and presented flu-like symptoms, proved 07.002 ineffective. Different strategies developed in each coun- Clinical Spectrum of Disease. Influenza AH1N1 2009 try showed that the early identification and treatment of high risk patients were responsible for reducing mortality. J. Dabanch Pena Although some demographic differences and distinctive clin- Hospital Militar de Santiago, Santiago, Chile ical outcomes were noticed in different countries, various reports demonstrated that patients with underlying condi- In Chile, the first case of 2009 pandemic influenza A tions such as asthma, diabetes, cardiac and lung diseases as H1N1 virus infection was detected on May 17. Since then all well as pregnant women were more susceptible to complica- influenza like illness cases were notified to Chilean Health tions. General experience made the benefit of early use of Secretary. A total of 367.041 cases were reported, 1585 antiviral drugs clear. Based on what had been learnt dur- required hospitalization (0.56%) and 130 died. ing the pandemic and in line with WHO directives, Latin The surveillance in Chile shows that the majority of those America countries are working on a vaccination program infected had a mild disease. targeting the most vulnerable populations. These countries The most affected age group was between 5 and 14. had to deal with a high number of cases earlier than other Febrile respiratory infection was the most common clinical regions and before the impact on health care systems could manifestation and range from self limited to severe illness. be observed. Cooperation between countries requires clear 14th International Congress on Infectious Diseases (ICID) Abstracts e9 and quick exchange of information in order to control any ventional 5-dose Essen im regimen by deleting the day 28 disease that presents the risk of spreading internationally. dose. Economical multi-site intradermal vaccination: eco- doi:10.1016/j.ijid.2010.02.1496 nomical and rapidly-immunogenic multisite intradermal regimens such as a new 4-site id regimen can be used. Less 07.004 than 2 vials of vaccine and only 3 clinic visits are required. Prospects on Influenza Vaccines Pre-exposure prophylaxis in travellers: In USA, the vaccine shortage prevented pre-exposure prophylaxis and, in G. Baracco these circumstance, id use may be condoned in the future. University of Miami, Miami, FL, USA Cure of human rabies encephalomyelitis: recovery of an un-immunised American girl infected by a bat was attributed The influenza pandemic of 2009 has brought renewed to the ‘‘Milwaukee regime’’, but this approach has failed in interest in the development of new technologies for the at least 17 subsequent cases. production of influenza vaccine. This presentation will discuss the traditional production methods and available doi:10.1016/j.ijid.2010.02.1498 clinical data of monovalent H1N1 influenza vaccine. New advances in the field of influenza vaccine manufacture 08.002 include increasing the speed of production and delivery Envenomation by Latin American arthropods and expanding the breadth of immunologic coverage in the search for a ‘‘universal target’’. We will discuss different C. Malaque strategies being developed to achieve those goals, includ- Vital Brazil Hospital, Sao Paulo, Brazil ing the use of adjuvants, utilization of reverse genetics, and DNA vaccines. Lastly, we will discuss barriers to successful In Latin America, the most dangerous venomous arthro- immunization coverage and strategies to overcome them. pods are scorpions, spiders, bees and caterpillars. Scorpion stings are especially common in urban areas of Mexico, Ama- doi:10.1016/j.ijid.2010.02.1497 zonia and Brazil. Although intense local pain is often the only symptom, scorpion stings can cause death from heart Rabies, bites and envenomations (Invited Presenta- failure/acute pulmonary edema, especially in children. In tion) cases of systemic involvement, antivenom and symptomatic treatment must be administered quickly. Loxosceles spider 08.001 bite can cause dermonecrosis or, more rarely, intravascular Rabies, the Emerging Challenge hemolysis and renal failure. Accidents can occur when a spider is compressed against the body of a person, especially D. Warrell during dressing or sleeping. The timing of administration University of Oxford, John Radcliffe Hospital, Oxford, and the effectiveness of specific antivenom in neutralizing United Kingdom local effects are controversial. Accidents with Phoneutria (the ‘‘armed’’ or ‘‘banana’’ spider) are most common in Classic rabies (genotype 1) and 6 other rabies-related southern and southeastern Brazil. Phoneutria are found near lyssaviruses have proved capable of infecting humans. Anti- dwellings, under logs, in crevices, in woodpiles and among bodies to unspecified lyssaviruses are being discovered in bananas. Most victims suffer only local pain. Autonomic bats in Europe, Asia and Africa. A case of Duvenhage (geno- nervous system involvement (requiring administration of type 4) infection acquired from a bat in Kenya illustrated the specific antivenom) is most common in children. Latrodec- hidden menace, unlikely to be revealed except by chance tus bite can cause local, regional, remote or generalized exposure of ‘‘sentinel humans’’ in whom a precise diagnosis pain, occasionally causing muscle cramps/spasms. Specific is possible. antivenom is reserved for severe cases. Mass bee attacks Wild mammal vectors/reservoirs: New wild mammal vec- occur in warmer Central and South American regions, tors and reservoirs are being identified, such as ferret potentially causing rhabdomyolysis, intravascular hemoly- badgers (Melogale moschata) in SE China. The importance sis, renal failure, respiratory distress, hepatic dysfunction of bats is increasingly recognised. Bites by rodents and mon- or myocardial damage. Lonomia caterpillar accidents can keys are generally considered to carry a negligible risk of produce hemorrhagic disorders (effectively reversed with rabies but in Brazil, pet marmosets (Callithrix jacchus) have Lonomia-specific antivenom), acute kidney injury, chronic transmitted rabies. renal failure or death. Whole blood/fresh frozen plasma Rabies control in domestic dogs: This is the most econom- transfusion has been associated with worsening and slower ical way of preventing human rabies. Potent and inexpensive recovery of the hemorrhagic syndrome. Most Lonomia acci- tissue culture vaccines (TCVs) are available. In India, a sin- dents occur in Venezuela and southern Brazil. Since Lonomia gle injection may protect stray dogs throughout their short often cluster on fruit trees, accidents are most common lives. Oral vaccination is being extended from wild mammals near rural residences. Ecotourism has increased Lonomia to feral dogs. accident rates in parks/reserves. Although most arthropod Tissue culture vaccines for human use: Phasing out ner- accidents have a benign course, travelers to endemic areas vous tissue vaccines has encouraged manufacture of TCVs should be aware of the risks associated with envenomation. in India, China and Brazil but quality regulation is difficult. Vaccine shortages in USA forced a shortening of the con- doi:10.1016/j.ijid.2010.02.1499 e10 14th International Congress on Infectious Diseases (ICID) Abstracts

08.003 Plenary 3 (Invited Presentation) Diagnostic and Treatment of Snake Bites 09.001 F. Franca The Discovery of HIV Vital Brazil Hospital in Butantan Institute, Sao Paulo, Brazil F. Barre-Sinoussi Snake bites are very common in many rural areas of Institut Pasteur, Paris, France Africa, Asia and Latin America. The victims, in general, are young adult males bitten during agricultural activities. Edward H. Kass Lecture Snake bites envenoming is one of the major neglected dis- Soon after, the first report of AIDS in the United States in eases of the 21st century. The data about the morbidity and 1981, similar cases were observed in France. In December mortality are limited but it’s estimated, globally, at least 1982, a working group of clinicians contacted retrovirolo- 421,000 envenoming and 20,000 deaths each year and also gists at the Institut Pasteur to work on the hypothesis that a that almost 1.2 million to 5.5 million snake bites could occur retrovirus might be the cause of AIDS. Together, they define annually. The snakes related with the most severe cases of a successful strategy to isolate HIV from a patient at risk of snake bite envenoming belong to Elapidae (cobras, kraits, AIDS. This discovery was the start of a collective adventure, mambas, Australasian species and sea snakes) and Viperi- which mobilized clinicians, multidisciplinary researchers dae (rattlesnakes, lance-headed pit vipers and true vipers) and patients, altogether. Such a networking turned out to be families. The families Atractaspididae and Colubridae are very efficient for providing scientific evidences and for trans- responsible for a small fraction of the snake bites with med- lating them rapidly into diagnosis, prevention and treatment ical importance in Africa, Middle East and Central Asia. The of HIV infection. Since these early days, we have learnt that genus Echis sp. (saw-scaled vipers) in northern Africa, Naja HIV infection is much more complex than initially thought. sp. (cobras) and Bungarus sp. (kraits) in Asia and Bothrops We have gained significant insights into the HIV biology sp. in Latin America are responsible for significant numbers and pathogenesis. Early virologic and immunologic events, of severe cases and deaths. The snake venoms are a com- particularly at mucosal sites, including the early virus dis- plex mixture of many families of toxins as haemorrhagins, semination, the establishment of viral reservoirs and the neurotoxins, serinoproteases, phospolipases, myotoxins and very rapid immune dysfunctions are critical in both HIV others. The most frequent emergencies in snake bites are acquisition and/or disease progression. caused or a consequence a result of clotting and bleed- Despite all the enormous progress made during the last 27 ing disturbances, rhabdomyolisis, intravascular haemolysis, years at international level, HIV/AIDS epidemic still there. muscle paralysis, local and systemic acute inflammation and Research priorities still remain care, treatment and preven- consequent complications like severe hemorrhage, acute tion. One of the major scientific challenges is to develop renal failure, acute respiratory failure, hypotension and an efficient HIV/AIDS vaccine. Conventional immunization shock, septicemia and severe local complications as com- strategies may not be sufficient to elicit protection. We partmental syndrome, necrosis and amputation. The correct clearly need to elucidate the precise mechanisms that are quantity of specific antivenom by the intravenous route, as governing the induction of protective immunity against HIV, soon as possible and supportive treatment are essential. The taking into consideration the most recent advances in innate main challenges to control snake bites accidents are the pro- immunity and insights on early innate effectors that HIV duction and large distribution of high quality antivenoms and can alter, including at mucosal sites. Lessons learned from extensive and systematic training of the health care workers distinct models of protection in human and non-human pri- about diagnosis and treatment of snake bites. mates and new approaches, including systems biology will certainly contribute to novel concepts for future HIV vaccine research and development. doi:10.1016/j.ijid.2010.02.1500 08.004 doi:10.1016/j.ijid.2010.02.1502 Immunobiologicals in South America MRSA: Disease mechanisms and control (Invited Pre- J. Murillo sentation) University of Miami, Miami, FL; USA 10.001 No Abstract Received. Inducible Dormant MRSA

1,∗ 2 2 3 doi:10.1016/j.ijid.2010.02.1501 G. Bearman , A. Rosato , K. Elam , M. Edmond 1 Richmond, VA, USA 2 Virginia Commonwealth University, Richmond, Va, USA 3 Medical College of Virginia Campus, Richmond, VA, USA Inducible Dormant (ID) MRSA are mecA gene-positive S.aureus isolates that change from initial MSSA phenotype to CA-MRSA phenotype after !-lactam antibiotic exposure .They can be identiﬁed by SCC mec type. ID-MRSA has been reported in both hospital and community settings. 14th International Congress on Infectious Diseases (ICID) Abstracts e11

In healthcare facilities, transmission of ID-MRSA from abscess formation as well as more severe disease such as a HCW to a patient has been postulated. In an earlier necrotising pneumonia, necrotising fasciitis and osteomyeli- report, a HCW was colonized with MRSA after treatment with tis. cephalexin. Exposure to the antibiotic was the purported inducer of phenotypic resistance. Until recently, there have doi:10.1016/j.ijid.2010.02.1504 been no prior epidemiological reports of ID-MRSA in the non- healthcare setting. A prospective epidemiologic surveillance 10.003 study identified ID MRSA in a cohort of healthy university MRSA Control Programs in the UK: Impact on Quality of students. The potential impact of ID-MRSA colonization on Care, Nosocomial Infection, and Public Perception CA-MRSA colonization and subsequent development of skin I. Gould and soft tissue infections or invasive disease is not known. As in the hospital setting, ID-MRSA colonization may serve Royal Infirmary, Aberdeen, Saudi Arabia as a reservoir, thereby promoting cross-transmission within a household, dormitory, athletic team or social unit. Colo- Driven largely by public and hence political pressure, nized individuals may theoretically cross transmit ID-MRSA the NHS has made good progress in reducing MRSA bacter- isolates to close contacts. Additionally, ID-MRSA colonization aemia. By the end of June 2009, they had fallen to 26% or transmission may result in MRSA phenotypic conversion if of 2003-04 levels in England and Wales. Little data how- the appropriate selective antibiotic pressure is applied. Fur- ever, is available on background MRSA colonisation rates or thermore, individuals persistently colonized with ID-MRSA other types of infection although HAI audits suggest MRSA may play an important role in households with high rates is still the dominant cause of postoperative wound infec- of CA-MRSA infections. Further studies are needed to better tion. Signifiant resource is now being invested in universal define both mechanisms of resistance and the epidemiologic admission screening and early signs are that this is being significance of ID-MRSA. successful with signigicant reduction in colonization rate at admission, overall burden on isolations rooms, clincially diagnosed infections and laboratory clinical isolates. The doi:10.1016/j.ijid.2010.02.1503 little evidence available suggests that the public is happy 10.002 with screening programmes. Nevertheless, significant con- The Role of PVL in Severe Disease - What is the Evidence? cerns remain at public health level about the use of these resources for MRSA screening and at an ethical level about K. Christiansen the enforced isolations of patients with possible detrimental effects on quality of care. Royal Perth Hospital, Perth, Australia ST8-MRSA-IV (USA300), ST80-MRSA-IV (European clone), doi:10.1016/j.ijid.2010.02.1505 ST59-MRSA-IV (Taiwan clone) and in Australia ST93-MRSA- IV (Queensland clone) and ST30-MRSA-IV (Oceania clone) 10.004 are all PVL positive. Data from Australia where CA-MRSA MRSA epidemiology and Control in Developing Countries has been described since the late 1980’s show that disease V. Rosenthal severity and demographics vary widely between PVL positive and negative clones. International Nosocomial Infection Control Consortium Demonstrating the actual role of PVL in disease has been (INICC), Buenos Aires, Argentina controversial. Mouse and rat animal models using PVL positive and negative clones or PVL deleted mutants have International infection control consortium (INICC) provided some support for a role in muscle damage, skin reported data from January 2003 through December 2008 abscess and lung necrosis but there are studies that fail in 173 ICUs in Latin America, Asia, Africa, and Europe. to show any association of PVL with pathogenesis of CA- During the 6-year study, using CDC NNIS/NHSN definitions MRSA disease. In contrast rabbit models have demonstrated for device-associated healthcare-associated infection, we a role in lung necrosis, dermatonecrosis and osteomyelitis collected prospective data from 155,358 patients hospital- - a reflection of the greater sensitivity of rabbit polymor- ized in the consortium’s hospital ICUs for an aggregate of phonuclear (PMN) leucocytes to PVL than murine PMNs. 923,624 days. As with most biological systems one single factor is rarely Although device utilization in the developing countries’ the explanation for a complex disease. Other virulence ICUs was remarkably similar to that reported from U.S. factors have been described for CA-MRSA including core ICUs in the CDC’s NHSN, rates of device-associated noso- genomic factors such as alpha haemolysin, secreted pro- comial infection were markedly higher in the ICUs of the teases, phenol-soluble modulins (PSMs), increased expres- INICC hospitals: the pooled rate of CVC-associated BSI in sion of the accessory gene regulator (agr) and especially for the INICC ICUs, 7.6 per 1000 CVC days, is nearly three- USA300 the possession of the arginine catabolic mobile ele- fold higher than the 2.0 per 1000 CVC-days reported from ment (ACME) that has a role in pH homeostasis, fitness and comparable U.S. ICUs, and the overall rate of ventilator- possibly transmission. More recently PSMs that are associ- associated pneumonia (VAP) was also far higher, 13.6 vs ated with the SCCmec have been described. 3.3 per 1000 ventilator-days, as was the rate of catheter- Conclusion: PVL is not necessarily a driver of the CA- associated urinary tract infection (CAUTI), 6.3 vs. 3.3 per MRSA epidemics being seen worldwide but is more likely a 1000 catheter-days. determinant of significant skin and soft tissue infection with e12 14th International Congress on Infectious Diseases (ICID) Abstracts

Most strikingly, the frequencies of resistance of Staphy- Current influenza vaccines are safe in all age and risk lococcus aureus isolates to methicillin—–MRSA (84.1% vs groups and quite effective in healthy children and younger 56.8%), Klebsiella pneumoniae to ceftazidime or cef- adults. Lower effectiveness among seniors and persons triaxone (76.1% vs 27.1%), Acinetobacter baumannii to with chronic medical conditions, and lower immunogenicity Imipenem (46.3% vs 29.2%), and Pseudomonas aeruginosa (requiring 2 doses) among previously unvaccinated infants to piperacilline (78.0% vs 20.2%) were also far higher in and children highlight unmet challenges. More effective vac- the consortium’s ICUs, and the crude unadjusted excess cines are needed that can be more rapidly produced and can mortalities of device-related infections ranged from 23.6% overcome challenges such as immunosenescence, annual (CVC-associated BSI) to 29.3% (VAP). revaccination, and lower protection against drifted viruses. Ideally, better vaccines would stimulate longer-lasting cross- doi:10.1016/j.ijid.2010.02.1506 reactive immunity against multiple strains. Vaccines must be effective in protecting the very young, Seasonal flu vaccines: Current status and future the chronically ill, and the elderly, who bear the largest directions (Invited Presentation) burden of influenza illness. Also needed is a better understanding of how to motivate people to seek annual influenza 11.001 vaccination. Influenza vaccination: Where do we stand? doi:10.1016/j.ijid.2010.02.1507 A.E. Fiore 11.002 National Center for Infectious Diseases, CDC, Atlanta, GA, USA Overcoming limitations of seasonal vaccines In the United States, influenza causes an average of A.S. Monto 36,000 deaths and 226,000 hospitalizations yearly. Rates of University of Michigan School of Public Health, Ann Arbor, infection are highest among children. Rates of serious ill- MI, USA ness and death are highest among persons aged ‘‘65 years, children aged <2 years, and persons of any age with medical Among the limitations of seasonal influenza vaccines are conditions that place them at higher risk for complications limited breadth of immunity, short duration of protection, from influenza. lower protection in older individuals and immunocompro- Annual influenza vaccination is the most effective mised patients, problems with needle inoculation such as method for preventing influenza virus infection and its needle phobia and medical waste disposal, and dependence complications. Influenza viruses undergo frequent antigenic on the egg supply. Because antigenic drift (poor antigenic change (antigenic drift); patients need an annual vacci- match between the vaccine and circulating strains) is asso- nation against the influenza viruses that are predicted on ciated with a fall in efficacy, there is a need for vaccines the basis of viral surveillance data. Trivalent inactivated that will induce an immune response to both identical and influenza vaccine (TIV) can be used for any person aged related strains. In an effort to produce broadened immunity, ‘‘6 months, including those with high-risk conditions. Live, new adjuvanted vaccines with different oil components have attenuated influenza vaccine (LAIV) may be used for healthy, been formulated, and the concept of a universal influenza nonpregnant persons aged 2—49 years. vaccine continues to be explored. It is not clear whether The 2009 novel influenza A (H1N1) pandemic required producing a higher titer postvaccination will result in longer a separate monovalent vaccine to be rapidly developed, duration of protection, as that requires specific evaluation with different vaccination recommendations from those for involving major practical difficulties. Improved technology seasonal vaccines. The initially limited supply of vaccine for influenza vaccines may result in vaccines intended for required that early vaccination efforts target children and specific population segments, such as younger children and young adults, adults <65 years old with chronic medical the elderly. A quadrivalent vaccine may be developed con- conditions, pregnant women, and healthcare personnel. By taining the two A subtypes and the two B lineages, which January 2010, monovalent vaccine supply had increased suf- would be most useful in children. To combat the issue of ficiently to allow all persons who wanted vaccination to immunosenescence, a high-dose vaccine has recently been receive it. approved for use in older patients. Some studies suggest that Vaccination coverage has remained low in most groups unvaccinated older individuals may be more ill but because for a variety of reasons, including the need for annual revac- of their disability, underutilize the healthcare system; in cination, the complexity of vaccination recommendations, contrast, vaccinated older individuals may be healthier and a lack of knowledge among patients and healthcare because they are in care, indicating bias in analyses. It may providers. In recent years, simpler age-based recommen- be possible that these new vaccines will produce protec- dations have been added for persons 50-64 years old, and tion in the immunocompromised, but this will need to be children ages 6 months through 18 years, and in 2009, >85% evaluated specifically. To address problems associated with of the US population had an indication for annual vacci- needle inoculation, new delivery systems and alternative nation. As more manufacturers have entered the market, routes to intramuscular administration have been devel- seasonal vaccine supply has met demand. A universal vac- oped, such as a nasal vaccine approved in the United States cine recommendation for all persons aged 6 months or older in 2007 and an intradermal vaccine approved recently in is feasible and has been proposed as a way to increase vac- Europe. Cell culture production of influenza vaccines may cine coverage in all age groups. improve vaccine efficacy and would reduce the system’s 14th International Congress on Infectious Diseases (ICID) Abstracts e13 dependence on the egg supply and provide greater produc- 12.002 tion flexibility. Traveler’s Diarrhea: Prevention and Treatment doi:10.1016/j.ijid.2010.02.1508 R. Steffen 11.003 University of Zurich, Zurich, Switzerland Emerging Trends: Vaccines in late development Different options for the prevention of travelers’ diarrhea (TD) exist. Risk reduction is possible by implementing the R.L. Atmar Hazard Analysis Critical Control Point System or by improve- Baylor College of Medicine, Houston, TX, USA ment of the local infrastructure. To abandon travel plans or to abstain from potentially contaminated food and bev- A number of strategies are being pursued to increase the erages is not attractive. Both a cholera and a candidate availability of and to improve the immunogenicity, efficacy, LT-ETEC transcutaneous patch vaccine have been shown to and effectiveness of seasonal influenza vaccines. Many of prevent TD by LT-ETEC strains, possibly by other pathogens. these approaches have led to vaccine candidates that are Among drugs suggested for chemoprophylaxis, probiotics in the late stages of clinical evaluation (i.e., Phase 3 trials) showed at best a low protective efficacy rate; bismuth sub- or that have been recently licensed. Approaches to increase salicylate was modestly effective. Many older antibacterial the availability of influenza vaccines in the United States agents are obsolete because of antimicrobial resistance by include the licensure of vaccines approved in other countries prevalent enteric bacterial pathogens. The fear of systemic and the production of influenza virus antigens by cell cul- reactions has limited the prescription of fluoroquinolones. ture (eg, canine kidney cells and Vero cells) rather than by Poorly absorbed antibiotics, mainly rifaximin, are more growth in embryonated eggs. Some cell culture-derived vac- attractive for compliant travelers. cines are approved in Europe. The influenza hemagglutinin is As no current prophylactic measure is satisfactory, (self)- partially purified from whole virus in currently licensed vac- therapy of TD remains an important option (travel kit!). Only cines. Another approach is the production of influenza virus few still recommend to wait for spontaneous cure; rapid hemagglutinin with a baculovirus expression system. Alter- relief is often important as incapacitation and the necessity native routes of immunization have also been explored, and to change travel plans have a great impact. Probiotics and an intradermally administered vaccine has recently been charcoal have been demonstrated to offer no clinically rel- approved for use in persons 60 years of age and older in evant benefit. Oral rehydration solutions have no effect on Europe. Improved vaccine immunogenicity and efficacy may the duration or amount of diarrhea, but they are essential in be attained through the use of adjuvants or higher doses paediatric patients and senior travelers. Antimotility agents of hemagglutinin. Although several adjuvanted influenza offer fast relief, but they are contraindicated in dysentery, virus vaccines are approved in other countries, none are also they are often followed by a period of constipation. licensed in the United States. However, oil-in-water adju- Antimicrobial agents, mainly quinolones and particularly vants are in advanced stages of evaluation. A high-dose (60 in SE-Asia also azithromycin, have been used in this decade, mcg hemagglutinin) trivalent influenza vaccine has recently although there is only limited recent data on the frequency been licensed based upon its superior immunogenicity com- of resistance from analysis of TD stool samples on all con- pared with the standard dose (15 mcg hemagglutinin), to be tinents. The non-absorbed rifamycin-derivative rifaximin — used in persons 65 years of age and older. Phase 4 studies of with a broad antimicrobial spectrum and a tolerance pro- the high-dose vaccine are under way to determine whether file similar to placebo — has been demonstrated in patients the improved immunogenicity is associated with increased with TD to be as effective as ciprofloxacine, but this only in vaccine efficacy and effectiveness. non-invasive cases of TD. doi:10.1016/j.ijid.2010.02.1509 doi:10.1016/j.ijid.2010.02.1511

Traveler’s diarrhea and enteric diseases of Latin 12.003 America (Invited Presentation) Helminths of Latin America 12.001 C. Coyle Epidemiology of Traveler’s Diarrhea Albert Einstein College of Medicine, Bronx, NY, USA A. McCarthy This session will focus on intestinal helminths. Ascaris Ottawa Hospital, Ottawa, ON, Canada lumbricoides is among the most prevalent of parasitic infections in humans. Most patients are asymptomatic or This presentation will provide a review of etiologies and experience mild abdominal pain. Children have the high- risk factors for diarrhea in those visiting Latin America and est intensity of infections and generally present with more will provide some comparison with travelers to other desti- severe clinical manifestations. The most common clinical nations. syndromes of ascariasis are pneumonitis, intestinal, bil- iary and pancreatic obstruction. Ascariasis adversely affects doi:10.1016/j.ijid.2010.02.1510 growth, development, and nutritional status of children. Another helminth, Hookworm, is particularly troubling for children and women of reproductive age who are vulnerable e14 14th International Congress on Infectious Diseases (ICID) Abstracts to the effects of hookworm anemia. Trichuris is an important Heavily infected, susceptible individuals are at risk for helminth in which most cases of are asymptomatic. Heavy developing hepatosplenic disease. Pulmonary involvement infections can result in the Trichuris dysentery syndrome in S. mansoni is reported in acute schistosomiasis and in (TDS). This syndrome includes chronic dysentery, rectal pro- chronic disease. Recent studies from Brazil suggest that pul- lapse, anaemia, poor growth, and clubbing of the fingers. monary hypertension may be more common than previously The severe stunting in TDS now appears likely to be a reac- thought in individuals with hepatosplenic disease due to S. tion at least in part to a chronic inflammatory response and mansoni. Similarly, recent studies suggest that hepatopul- concomitant decreases in plasma insulin, plasma insulin- monary syndrome also occurs in patients with S. mansoni like growth factor-1 (IGF-1), increases in tumor necrosis who also have periportal fibrosis and portal hypertension. factor-␣(TNF-␣) in the lamina propria of the colonic mucosa Although CNS involvement is rare, it is well described. Trans- and peripheral blood (which likely decreases appetite and verse myelitis or seizures have been described in both acute intake of all nutrients) and a decrease in collagen synthe- and chronic infection. sis. Improvements in cognitive performance have been found after treatment for relatively heavy infections in school doi:10.1016/j.ijid.2010.02.1512 age children. Synergistic associations between hookworm and other helminths has been described. In a recent study 12.004 from Brazil, 61% of individuals harbored mixed helminth Food-borne Toxins infections. Multivariate analysis indicated significant pos- V. Ansdell itive associations for co-infection with hookworm and S. mansoni and for co-infection with hookworm and A. lum- Kaiser Honolulu Clinic, Tropical and Travel Medicine, Hon- bricoides. Co-infection with hookworm and Ascaris resulted olulu, HI, USA in higher egg counts for both, suggesting a synergistic relationship between these species, although, the intensity of Food-borne toxins are an important cause of morbidity S. mansoni or A. lumbricoides co-infection did not differ in the unwary traveler. In rare situations, deaths may occur. from that of mono-infection. Another study from from Brazil Education is the key to prevention and a careful history is looking at Hookworm and Ascaris infection and the impact usually the key to diagnosis. of polyparasitism on cognitive performance in Brazilian Ingestion of contaminated fish and shellfish is one of the schoolchildren suggested that hookworm may be associated commonest causes of poisoning and the risk from marine with poorer concentration and information processing skills toxins appears to be increasing as a result of multiple fac- while A. lumbricoides infection may be associated with tors such as global warming, coral reef damage and spread poorer general intelligence. Polyparasitized children seem of toxic algal blooms. Important examples include ciguatera to experience worse outcomes that children with only one poisoning from ingestion of large carnivorous coral reef fish, helminth infection. In yet another study, multivariate anal- puffer fish poisoning and various shellfish poisonings such as ysis revealed that stunting was significantly associated with paralytic shellfish poisoning. Scombroid poisoning occurs in ascaris infection among children and adolescents, whereas open ocean fish such as tuna and mahi mahi that contain his- low body mass was significantly associated with hookworm tidine in the flesh. Inadequate chilling after capture results infection among adults and the elderly. in conversion of histidine to histamine and symptoms that Strongyloides stercoralis can cause acute infection, resemble an acute allergic reaction. chronic infection and hyperinfection syndrome. Hyperinfec- In most cases the presence of toxin does not affect the tion syndrome has been associated with a variety of risk appearance, smell or taste of seafood and it is not destroyed factors and predisposing conditions, including new immuno- by cooking, smoking, freezing or drying. Onset of illness typ- suppressive therapy therapies; HTLV-1 infection; cadaveric ically occurs soon after ingestion of contaminated food and transplantation; immune reconstitution syndrome; hema- produces gastrointestinal symptoms such as diarrhea, nau- tological malignancies (especially lymphoma). Co-infection sea, vomiting and abdominal pain often followed by a variety with with HTLV-1 results in decreases in IL-5, and parasite of neurological and cardio respiratory symptoms. Paradoxi- specific IgE responses in patients with strongyloidiasis con- cal dysesthesiae such as temperature reversal (hot objects sistent with a relative switch from Th1 to Th2 response feel cold and cold objects feel hot) are very characteristic leading to an increased risk of autoinfection resulting in of ciguatera and neurotoxic shellfish poisoning. hyperinfection syndrome. Co-infected patients with HTLV-1 Treatment is usually symptomatic and supportive. In the and strongyloides may not respond as well to anti-helminth case of scombroid poisoning antihistamines provide specific treatment. In addition to HTLV-1, corticosteroid use remains treatment and in the case of ciguatera poisoning intravenous one of the most frequent risk factors for hyperinfection mannitol may reduce the severity and duration of some of syndrome. Hyperinfection syndrome presents with diverse the neurological features. Diagnosis is usually based on a symptoms and signs often leading to misdiagnosis on the careful history. Test kits that detect ciguatoxin in contami- clinicians part. It is associated with a high mortality rate nated fish are commercially available. (15-87%). Therefore, increased recognition is important for Ackee poisoning and cassava poisoning are examples of clinicians caring for at-risk patients. food poisoning from non-marine sources. Ackee poisoning Of the five major species of Schistosomiasis pathogenic occurs after eating unripe ackee fruit and results in vomit- to humans the only one endemic in South America is Schisto- ing and life threatening hypoglycemia. Acute and chronic soma mansoni. Despite the efforts in carrying out integrated cyanide poisoning may occur after ingesting cassava root control programs during the last 25 years, there are still products containing cyanogenic glycosides. Acute poison- regions where the prevalence of S. mansoni is over 50%. ing causes diarrhea, vomiting, mental confusion and death. 14th International Congress on Infectious Diseases (ICID) Abstracts e15

Chronic intoxication causes abnormal thyroid function and varies widely,depending on the population on treatment, various neurological disorders. therapeutic agent s, treatment duration and less clearly from genotype. Since 1992,eigth therapeutic agents have doi:10.1016/j.ijid.2010.02.1513 been approved worlwide (INF alfa, lamivudine, adefovir, entecavir, PegINF alfa-2a thymosin alfa1, ,telvibudine and Viral hepatitis (Invited Presentation) tenofovir) but only some of them are used in different countries according to national regulation.. When and how to 13.001 treat an CHB depends on the HBV DNA levels, ALT and status Epidemiology of Chronic Viral Hepatitis in Latin America of HBeAg. For HBeAg(+) patients,the endpoint of treatment is HBeAg seroconvertion. Therapy is considered in GHB with D. Diament HBV DNA leves of 20.000 IU/ml or higer (HBeAg positive Instituto de Infectologia Emilio Ribas, Sao Paulo, Brazil patient) or 2.000 IU/ml (HBeAg negative), although lower HBV DNA levels migth be selected when evidences of pro- Chronic viral hepatitis caused by Hepatitis B or C viruses gresive disease are identified. ALT normalization and HBV are major health problems in this beginning of the 21st DNA suppression are the measures of reponse to therapy. century. Estimated prevalence in the world population in Oral nucleoside analogs (NA) is a significant contribution for different regions range between less than 1% to more than treatment in the last years,but a major concern with this 3% for HCV and between less than 2% to more than 8% for agents is the selection of antiviral resistant mutations. This HBV, affecting more than 400 million people in the world. In may be identified prior to virological breakthrough or at the Latin America, prevalence estimates are flawed. For HCV it same time. Peginterferon alfa-2a, entecavir and tenofovir varies from less than 1% to 2%, and for HBV from less than are currently included in the first-line treatment choice on 1% to more than 8%. Numbers can be as high as 15% in the the basis of their potency as well as the low rate of antiviral Amazon region. drug resistance. The strategy of drugs combination in CHB In Latin America, some surveys report HBV prevalence treatment for achieving a sustained virological response and as high as 21.4% in Dominican Republic and 7.9% in Brazil, some end points has beeen explored and the level of HBV followed by 3.2% in Venezuela and 2.1% in Argentina. Low DNA suppression. This combination theraphy is encouraging prevalence was found in Mexico (1.4%) and Chile (0.6%). For in some clinical trials. HCV, rough estimates project more than 10 million infected people. Many surveys were conducted by blood banks, but doi:10.1016/j.ijid.2010.02.1515 results are biased by sampling problems. In Brazil, HCV prevalence studies estimates had found a 13.003 wide range, varying from 0.4% to 5.9%. A population based Hepatitis C Treatment Today and the Future study in 2007 found a HCV antibodies prevalence of 0.28% to 2.61% and a HCV-RNA from 0.02% to 0.9% in different R. Sarmento e Castro regions of the country. From 1994 to 2005, the Ministry of Hospital Joaquim Urbano, Porto, Portugal Health database has registered 52,440 HCV cases. Recently, a national survey was conducted by the Ministry of Health, Therapy of chronic HCV infection is based on the use but results are not published yet. of the combination of pegylated interferon and ribavirin. In São Paulo state, there were 30,299 HCV cases regis- Sustained virological response (SVR), a negative HCV RNA tered from 2002 to 2008 and 14,810 HBV cases in the same 24 weeks following discontinuation of therapy, is the most period. In the city of São Paulo it is estimated a mean important surrogate parameter to achieve. Actually, SVR is prevalence of 1.42% (95% confidence interval 0.7 — 2.12%). obtained in about 50% of patients with genotypes 1/4 and in Diagnosis can be done with blood tests, but availability is a 80% of the patients with genotypes 2/3. concern in poor countries. Patients infected with genotypes 1 or 4 must be treated Treatment is expensive and fairly effective, implying in for 48 weeks. But, if the patient achieves a rapid virological high morbidity, mortality and costs. Chronic hepatitis is a response (RVR), defined as a negative HCV RNA at week 4, we great challenge for the health systems in Latin America. can consider a shortening of treatment. In patients with a slow response to treatment (HCV RNA only negative between doi:10.1016/j.ijid.2010.02.1514 weeks 12 and 24) the length of therapy must be extended to 72 weeks. For patients infected with genotypes 2 or 3 13.002 treatment should be planned for 24 weeks. Update on Hepatits B Therapy New drugs are needed for non-responders and for those who are not good candidates to treatment. E. Savio Several new oral agents, more potent, less toxic and Universidad de la Repùblica, Montevideo, Uruguay allowing for shorter duration of treatment are being developed. These new drugs are designed to inhibit several viral Tha main goal for the treatment of chronic hepatitis enzymes. Results of recent clinical trials using inhibitors of B (CHB) is to prevent advanced hepatic disease: cirro- NS3/4A protease or inhibitors of NS5B polymerase in com- sis,hepatic failure and hepatocellular carcinoma (HCC). bination with peginterferon/ribavirin are promising. These The first aim of treatment is to achieve sustained suppre- studies demonstrated that adding telaprevir or boceprevir sion of HBV replication as well as the remission of liver (the protease inhibitors in the most advanced phases of eval- disease.The sustained supression of virological replication uation) to peginterferon/ribavirin improved the rates of SVR e16 14th International Congress on Infectious Diseases (ICID) Abstracts in treatment-naïve and treatment-experienced patients. acquired either nosocomially or environmentally. Sev- From these and other trials it was possible to conclude that eral studies have suggested that Gram-negative bacteria the use of these new agents in monotherapy, owing to its are more prevalent than Gram-positive bacteria. A high relative low genetic barrier, was associated with a rapid incidence of colonisation and infection with extended development of resistance to the drugs and that the use spectrum ␤-lactamase-producing bacteria, multi-resistant of ribavirin was always necessary. These new agents will be non-fermenting Gram-negative rods and difficult to treat available for general clinical use in the next years but they fungal infections are found in these patients and may pose must be used as a complement of current therapy. challenges in routine hospital care. According to published date and our own experience, doi:10.1016/j.ijid.2010.02.1516 we recommend pre-emptive contact isolation for victims of natural disasters during hospitalisation until results of 13.004 microbiological cultures become available. If respiratory Management of HIV and Hepatitis C Co-infection symptoms are present, droplet isolation must be included. These measures should also be applied during the air M. Brito transportation of these patients. Considering the differ- University of Illinois, Chicago, IL, USA ent multi-resistant colonisers, cohorting patients must be avoided whenever possible. In cases of life-threatening The rate of coinfection of HIV with Hepatitis C is high infections, empiric antibiotic therapy must cover multi- in countries where the mode of transmission is predomi- resistant non-fermenting Gram-negative rods. Clinicians nantly intravenous drug abuse. The success of highly active must be aware of unusual microbiological findings in these antiretroviral therapy (HAART) in decreasing HIV related patients. morbidity and mortality has shifted the focus of care for people living with HIV. More attention is being paid to the doi:10.1016/j.ijid.2010.02.1518 management and prevention of chronic ailments such as cardiovascular, liver and renal disease. Thus, it is important 14.002 for the clinician treating HIV infected patients to recog- Infectious diseases and war conflicts in the Middle East nize the clinical presentations, spectrum of disease, efficacy of treatment and principles of management for coinfected A. Shibl patients. Patients coinfected with the HIV and Hepatitis C King Saud University, Ryadh, Saudi Arabia viruses have an increased risk of liver related morbidity and a more rapid progression to end-stage liver disease. The Infectious diseases and war have been witnessed for as treatment of these patients is complex owing to the signifi- long as human life. Historically, infectious diseases have cant side effects and limited efficacy of Peg Interferon and been responsible for the majority of deaths during war; Ribavirin. This lecture will review the epidemiology, nat- however, numerous medical and military advances have ural history, diagnosis, management and newer treatment reversed this trend, resulting in more deaths from bat- modalities in HIV/HCV coinfection. tle than infectious diseases in the 20th century. Wounds incurred in war are grossly contaminated with bacteria and doi:10.1016/j.ijid.2010.02.1517 most will become infected unless appropriate treatment is initiated quickly.Common infections include respiratory as Infectious diseases following catastrophes (Invited well as gastrointestinal infections. Endemic diseases are also Presentation) reported during the war and they include Brucella, Q-fever, Malaria, Sandfly fever and Leishmaniasis. Non-battle injuries 14.001 such as mental and combat stress are common; while battle Infectious diseases and infection control after natural dis- associated infections such as trauma- related complications asters are extensively reported. Multidrug resistances (MDR) Gram negative bacilli have ∗ J. Ambrosioni , D. Lew, I. Uçkay been reported in war wound infections, particularly Acine- University Hospitals of Geneva, Geneva, Switzerland tobacter spp, Enterobacter spp.and Pseudomonas spp. and therefore empirical treatment for infected war wounds Infections are frequent complications after natural should be given to cover MDR. Other war related infec- catastrophes. Previous reports suggest a high prevalence tions such as malaria, MDR tuberculosis, chronic Q fever and of colonisation and infection with multi-resistant Gram- brucellosis may become apparent after returning home and negative pathogens in victims of natural disasters. therefore they should be considered due to their lengthy Literature regarding infections and infection control reactivation periods. In addition to this, vaccines have measures after natural disasters was reviewed from 1986 proven to be an important breakthrough to help prevent the through the end of 2009, with special emphasis on the 2004 spread of several infectious diseases. tsunami. Local microbiology of patients followed in our insti- War wounds are predisposed to infection due to envi- tution was also reviewed. ronmental conditions on the battlefield, devitalized tissue, Patients admitted after natural disasters often have and foreign bodies in the wound as well as delays in polymicrobial infections with atypical bacteria and fungi. evacuating causalities. Knowledge of likely pathogens for Moreover, they are usually colonised or infected with particular infections and sites, as well as optimal antibi- multi-drug resistant organisms. These pathogens are otics to eradicate those pathogens will aid battlefield 14th International Congress on Infectious Diseases (ICID) Abstracts e17 healthcare providers in averting and treating infections Update on fungal infections (Invited Presentation) appropriately. 15.001 doi:10.1016/j.ijid.2010.02.1519 Treating Resistant Filamentous Fungi Infections 14.003 R. Graybill Infectious diseases and earthquakes in Peru University of Texas Health Science Center, San Antonio, TX, E. Gotuzzo USA Universidad Peruana Cayetano Heredia, Lima, Peru Resistance to treatment can be caused by intrinsic resistance to antifungal drugs, and also by the angioinvasive Because of the presence of the Nazca tectonic plate, nature of some of these mycoses, which causes distal pul- Peru is a risk area for earthquakes. The surveillance system monary infarction. As blood flow is blocked, antifungal for infectious diseases confirms that respiratory infections drug penetraiton is decreased. Both considerations must be (bronchitis, pneumonia, etc.) are frequent. This probably addressed. occurs because people sleep in provisional places and in With the development of infarction, there is decreased unsanitary conditions. Cutaneous infections (pyodermitis, penetration of polyenes and presumably all antifungal drugs cellulitis, etc) are therefore also frequent. Allergy to dust is into tissue. Inadequate delivery of antifungal drugs is one sometimes confused with respiratory infections. reason which causes in vitro susceptible pathogens, like If there is sufficient water of good quality, there are no Aspergillus species (triazoles) or zygomycetes (polyenes) outbreaks of cholera, typhoid fever or salmonellosis. In Peru, to progress in the presence of antifungal therapy which although there have been more than 15 earthquakes over ‘‘should be effective’’. the past 20 years, there were not any outbreaks of food- or Management of clinical resistance in these patient can be vector- borne diseases. improved at the outset, by accelerating the speed of diag- It takes time to mount a vaccination campaign: it is very nosis and initiating treatment more promptly. Tools for this difficult to vaccinate during the first weeks after a disaster include a) rapidlly identifying patients at high risk and b) and there is no immediate effect. No vaccination plan has intensive surveillance with serum (and now bronchoalveolar shown to be useful. On the contrary, vaccinations can be lavage) galactomannan, beta-D-glucan, and PCR. The former associated to unusual or adverse effects. The experience of allows identification of groups for antifungal prophylaxis, vaccination against yellow fever in Ica- Peru in 2007, which and the latter allows for identifcation of patients ever ear- was motivated only by the possibility of ecological change, lier in the course of disease. There is room for considerable showed more adverse effects than benefits. improvement in rapid diagnosis. Intrinsically high resistance to antifungals can be pre- doi:10.1016/j.ijid.2010.02.1520 dicted for many (not all) isolates simply by identifying the 14.004 fungal species. This is straightforward for polyene resistance of Aspergillus terreus, or almost pan-antifungal resistance Disaster Relief in Haiti of Scedosporium prolificans. Others, such as Fusarium or V. Krcmery ∗, M. Philippe Paecilomyces species, are very challenging, but may respond to high levels of certain antifungals. For these patients ani- St. Elizabeth University College of Health and Social Sci- mal studies and small clinical series may provde guidance. ences, Bratislava, Slovakia There is great temptation to use combinations of antifungal Hurricanes hits Caribbean region every year, strangest drugs, especially when synergy is suggested by in vitro stud- rains are excepted in August and September. Year 2008 ies. This area is complicated by the rarity of such isolates was catastrophic because the Hispaniola Island (Haiti and and inability to collect large series of infected patients. Dominican Republic) have been affected twice in a start For some, recommendations may need to be individualls period (2 weeks). First hurricane hit south of Haiti in mid- tailored. dle and second whole island at the end of august 2008 and caused subsequent floads which persistent in north, doi:10.1016/j.ijid.2010.02.1522 affecting mainly the city Gonaives with more than 100 000 15.002 people for several month. During this period, non-falciparum malaria and diarrhoeal disease increased 2,5 - 3 times. How- The endemic systemic Fungal Infections in Latin America ever, no major outbreaks of hepatitis and leptospirosis have A. Restrepo been noted in this area because of Governmental UN humanitarian assistance and reconstruction of water supply. Our Corporacion para Investigaciones Biologicas (CIB), Medellin, hospital in Mole st. Nicolas and clinic in Baiedes Hennes Antioquia, Colombia have noted increasing incidence of malaria but not signif- Three endemic mycoses, coccidioidomycosis (C), histo- icant increase of diarrhoeal disease, because in rural area, plasmosis (H) and paracoccidioidomycosis (P), have rele- where are located, are wells protected against floads. Large vance in Latin America as they occur in most countries of cities/urban areas near rivers are much more affected by the region although their distribution is not homogenous. hurrican related floads then coastal regions. The etiologic agents are the soil-related dimorphic fungi doi:10.1016/j.ijid.2010.02.1521 Coccidioides immitis, Histoplasma capsulatum and Para- e18 14th International Congress on Infectious Diseases (ICID) Abstracts coccidioides brasiliensis, which in their saprophytic mold of antifungals; whereas those caused by bacteria, actino- form and under certain environmental conditions produce mycetomas, respond to a range of antibacterials such as microconidia (< 5 m␮). These propagules become air-born dapsone, amikacin, fusidic acid, imipenem etc unless they and are accidentally inhaled by man; once in the lungs are very extensive. There is only limited reporting of the they convert to the tissue e forms. Most patients are adult use of newer azoles, posaconazole and voriconazole in these males engaged in aerosol-generating activities (agriculture, mycoses. Mycoses where there have been changes in epi- forestry, masonry, speleology), with women and children demiology, suggesting, spread include tinea capitis. Spread being afflicted less often. The three mycoses initiate their of Trichophyton tonsurans infections to South America and pathologic expression in the lungs but extra-pulmonary dis- West Africa are examples. Whereas HIV in many countries semination is common mainly to mucous membranes, skin, is controlled through the use of antiretrovirals in infected lymph nodes, liver, spleen, adrenals, bones, CNS and oth- individuals late recognition is a feature in many areas of ers; these entities are systemic and one-organ affection the tropics and therefore there is a continuing risk of sys- is rare. Signs and symptoms may be related to the res- temic fungal infections presenting with skin lesions as their piratory tract but are more often referred to secondary first and most obvious clinical manifestation. Being alert to lesions making it difficult to confirm suspicion on clinical evi- these changes provides a rapid means of dealing with these dence alone. Image studies vary depending on the diseases’ infections. course and include infiltrates, nodules, cavities, pleural retraction, fibrosis and calcifications. Definitive diagnosis doi:10.1016/j.ijid.2010.02.1524 is established only on mycological grounds through biopsies, direct examinations and cultures. The three etiologic 15.004 agents’ differential characteristics under the microscope Prevention and Treatment of Nosocomial Candidiasis plus the type of propagules produced in cultures, allow M. Nucci their precise identification. Availability of several indirect tests to determine circulating antibodies and antigens and University Fed. Rio de Janeiro, Rio de Janeiro, Brazil also of several DNA-based tests serve to confirm diagnosis and facilitate follow-up studies. These mycoses are diffi- Candidemia is an important nosocomial infection, with cult to treat requiring prolonged courses and careful medical high incidence and mortality rates. Strategies for the man- supervision. Treatment has greatly improved with the advent agement of candidemia include prophylaxis and treatment of the new triazoles (itraconazole, voriconazole, posacona- of established infection. Prophylaxis is more likely to ben- zole) but amphotericin B remains a major therapy; recovery efit groups of patients with high incidence of candidemia, is contingent on prompt diagnosis, patient’s immune status such as premature neonates, allogeneic hematopoietic stem and stage of the mycosis at therapy initiation. cell transplant recipients and high-risk liver transplant recipients. For the treatment of candidemia, various studies have been conducted comparing different drugs, such doi:10.1016/j.ijid.2010.02.1523 as fluconazole, voriconazole, deoxycholate and liposomal 15.003 amphotericin B, and the echinocandins caspofungin, mica- Fungal Skin Infections in the Tropics fungin and anidulafungin. In general, the echinocandins represent the best option for the initial treatment of can- R. Hay didemia. In addition to prophylaxis and treatment, attempts to define a group of patients that may benefit from early International Foundation of Dermatology, London, United empiric or preemptive have been developed. These include Kingdom the development of prediction rules and the use of serum The main challenges confronting us in the tropical biomarkers such as 1,3-beta-D-glucan and polymerase chain mycoses are 1) rapid and accurate diagnosis 2) the avail- reaction-base techniques. ability of appropriate therapy and 3) a rising incidence of certain infections. Diagnosis is dependent on the logical doi:10.1016/j.ijid.2010.02.1525 association between the clinical appearances and appropriate laboratory steps. However key features of fungi that aid Plenary 4 (Invited Presentation) their recognition are their size and the simple cultural and histological techniques used to detect them. Use of con- 16.001 ventional histopathology or immunopathological techniques The Changing Patterns of Global Migration and the Impact is highly effective in many cases but molecular tools are on Infectious Diseases now used for some conditions including dermatophytosis and sporotrichosis. With some mycoses the process is simpler. In M. Cetron mycetomas, for instance, histological or cultural evidence CDC, Atlanta, GA, USA can be obtained directly from sinuses or by biopsy. Most new antifungals have not been profiled with trop- Human migration has always been associated with dis- ical mycoses in mind and there are few evidence-based ease translocation. Over the last century the speed and clinical trials to establish usage or duration of therapy. volume of international travel and migration has reached The commonest of these infections that present major unprecedented levels bringing the impact of globalization therapeutic problems are the mycetomas and chromoblasto- into every sector of society- economic, environmental, mycosis. Fungal mycetomas seldom respond to normal doses political, socio-cultural, and health. As a consequence, the 14th International Congress on Infectious Diseases (ICID) Abstracts e19 threat of geographic expansion from emerging and tradi- sion persists for up to 1 year in the peripheral circulation, tional infectious diseases has increased. UNESCO defines and is associated with more aggressive containment of HIV- an international migrant as a person living outside their viral replication in vitro, these NK cells exhibit a more birth country for >= 12 months. The global patterns of polyfunctional cytokine profile, and kill MHC class 1 target human migration have changed substantially in the last cells more more aggressively than NK cells from individuals half century: 1) increased # countries sending and receiving that do not have the protective KIR/HLA combined geno- migrants, 2) accelerated rates of migration, 3) bi-directional type. However, despite this early epansion of NK cells in the migration and migration transitions, 4) diversification of periphery, these cells do not gain access to secondary lym- migrant types, and 5) changes in gender patterns of phoid organs, thus providing a safe haven within which the migrants. Along with these profound changes in demography, virus is able to replicate unabated by the innate immune volume, speed, and purpose of migration come unique chal- system, potentially allowing the virus to establish a chronic lenges in detection, diagnosis, response and management infection. These data strongly suggest durable control of HIV of infectious diseases. Even in the 21st Century infectious infection is associated with an early aggressive deployment diseases account for ∼25% of the global mortality burden of highly licensed antiviral NK cells in the periphery that as well as substantial morbidity. Increasingly these diseases may provide specific and non-specific control of HIV viral are blind to geopolitical borders. Cyclical pandemics like replication in acute infection, while producing large quanti- influenza traverse the globe more rapidly than ever; newly ties of cytokines and chemokines required for the induction emerged pathogens like SARS represent a constant challenge of high quality adaptive immune responses that may then to public health preparedness and response. Even old dis- maintain control of HIV replication most likely in contained eases like tuberculosis emerge in more lethal drugresistant tissue sites. forms e.g. XDR-TB. These challenges demand new paradigms to global disease control in governance, surveillance and doi:10.1016/j.ijid.2010.02.1527 response. The 2005 International Health Regulations and a range of newly formed international networks and partner- 17.002 ships are a testament to the challenges posed by the new The Role of T Cell Immunity in the Control of HIV Infection era of migration. Our success in combating these microbial N. Goonetilleke 1,∗, M.K. Liu 2, V. Ganusov 3, E. Giorgi 3,J. threats will depend on our collective effort to organize and Salazar 4,H.Li5, J. Kirchner 6, E. Turnbull 1, V. Bourne 1,S. respond on ‘‘supra national’’ level. Moore 1, H. Yang 7, B. Keele 4, P. Borrow 1, M. Cohen 8,A. Perelson 3, F. Gao 6, B. Hahn 4, G. Shaw 4, B.T. Korber 3, A.J. doi:10.1016/j.ijid.2010.02.1526 McMichael 1 Will the next generation end AIDS? (Invited Presen- 1 University of Oxford, Oxford, United Kingdom 2 tation) Oxford University, Oxford, United Kingdom 3 LANL, Santa Fe, NM, USA 17.001 4 University of Alabama, Birmingham, AL, USA Role of innate immunity in the control of HIV infection 5 University of Alabama, Birmingham, AB, USA 6 Duke University, Durham, NC, USA G. Alter 7 Unversity of Oxford, Oxford, United Kingdom 8 MGH, Boston, USA UNC Chapel Hill, Chapel Hill, NC, USA While the immunological correlates that contribute to The window between transmission and peak viremia, slower HIV disease progression are still unknown, epi- prior to the establishment of viral reservoirs, is the narrow demiologic data strongly suggest that particular major but critical period in which a HIV-1 vaccine must control histocompatibility complex (MHC) class 1 alleles (including viral replication, prevent extensive CD4 T cell destruction -B27, -B57, and others that fall within the HLA-Bw4 fam- and curb generalised immune activation. We recently pub- ily of HLA-class I B alleles) are highly enriched in subjects lished the results of T cell studies in 4 patients, showing that who maintain undetectable viral loads in the absence of the first HIV-1 specific T cells detectable just prior to peak antiretroviral therapy, Elite controllers. While these MHC viremia can select for complete virus escape in as little as molecules interact with T-cell receptors found on cytotoxic 14 days. CD8+ T cells, they also interact with innate immune recep- Mathematical modeling of these very rapid rates of T cell tors, such as the Killer Immunoglobulin like receptors (KIR) escape showed that the contribution of CD8+ T cell mediated found on the surface of innate cytotoxic Natural Killer (NK) killing of productively infected cells was earlier and signif- cells. Furthermore, the protective effect of MHC class I alle- icantly greater than previously described; calculating that les is amplified in subjects that co-express particular KIRs, T cells in acute HIV-1 kill as much as 35% of virus-infected with which they are able to interact, resulting in slower pro- cells per day. These first T cell responses often waned rapidly gression to AIDS in these individuals compared to those that following virus escape leaving, or being succeeded by, T cell only possess the KIR or MHC allele alone. Thus it is plausible responses to epitopes that escaped slowly or were invari- that NK cells may play a central role in the control of HIV ant. Here, we present data from an additional 10 patients infection. NK cells expand rapidly following acute infection, that extend these observations and demonstrate that early and specific populations of KIR+ NK cells expand preferen- rapid escape from primary HIV-1-specific T cell responses tially in subjects that co-express protective KIR/MHC class 1 occurs in the majority of patients studied, suggesting that combinations. This specific KIR3DS1+ NK cell clonal expan- T cells are major contributors to the control of viremia in e20 14th International Congress on Infectious Diseases (ICID) Abstracts acute HIV-1 infection. Additional data will be presented on 17.004 functional avidity, phenotyping and kinetics across the group The Hope and Progress in Microbicides and Pre-Exposure over the first 6 months of infection. Discussion will focus on Prophylaxis to Prevent HIV how these results, together with the studies investigating ,∗ new immunogens may direct more effective design of HIV-1 P. Ndase 1 , S. Hillier 2, C. Celum 3 T cell vaccines. Supported by the NIAD Center for HIV/AIDS 1 Infectious Diseases Institute, Kampala, Uganda Vaccine Immunology grant # U19 AI067854. 2 Magee-Womens Hospital„ Pittsburgh, PA, USA 3 University of Washington, Seattle, WA, USA doi:10.1016/j.ijid.2010.02.1528 Even with a growing recognition that HIV doesn’t dis- 17.003 criminate by race, gender, socioeconomic status or sex Understanding Anti-HIV Antibody Targets orientation, the developing world accounts for 90% of the global HIV burden. Sub-Saharan Africa, which accounts for P. Moore 1,∗, E. Gray 2, M. Madiga 2, N. Ranchobe 2,B. two-thirds of the global HIV infections, Injecting Drug Users, Lambson 2, M.-R. Abrahams 3, G. Bandawe 3, D. Sheward 3, Men who have Sex with Men, and Commercial Sex Workers R. Thebus 3, K. Mlisana 4, S. Abdool Karim 4, C. Williamson 3, bare a disproportionate burden of the HIV epidemic. Recent L. Morris 2 HIV surveillance studies in African countries at best show 1 Johannesburg, South Africa stabilization of the epidemic or at worst, slight increases in 2 NICD, Johannesburg, South Africa countries like Uganda. 3 Institute of Infectious Disease and Molecular Medicine, Clearly, the HIV research community recognizes that University of Cape Town, Cape Town, South Africa additional new biomedical prevention modalities are 4 Centre for the AIDS Programme of Research in South Africa required to augment existing HIV prevention strategies. (CAPRISA), University of KwaZulu Natal, Durban, South Incidence modeling based on as relatively low efficacy Africa as 30% for a Pre-Exposure Prophylaxis (PrEP) regimen or a topical Microbicide has provides a glimmer of hope based on HIV-1 subtype C viruses elicit potent but highly type- number of new HIV infections prevented through such new specific neutralizing antibodies within the first year of modalities. However, scientists need to prove efficacy for infection. In order to determine the specificity and evolution these new regimens first. of these autologous neutralizing antibodies, we examined Several international collaborations with the develop- neutralization escape in four individuals infected with HIV- ing world have been formed to enable us conduct clinical 1 subtype C from the CAPRISA 002 cohort in Durban, South research that meets international standards. Phase IIB and Africa. Early neutralizing responses recognized a very lim- phase III HIV PrEP and Microbicide trials are being conducted ited number of epitopes, with antibodies that recognize new in nine countries globally, involving over 20,000 participants epitopes evolving sequentially. In addition, only two regions in the various high risk groups and across different HIV of the envelope were targeted by these antibodies, sug- transmission routes. Each study is being overseen by regula- gesting there might be common vulnerabilities in the HIV-1 tory agencies both within the developing and the developed subtype C transmitted envelope. We have shown that type- world. specific responses have a short term affect on viral load The major lessons learned to date are that; North-South which is lost with the emergence of viral escape mutants. collaborative partnerships are critical to realizing the hope Factors that contribute to the development of broadly cross- of finding new prevention modalities to be added to the HIV reactive neutralizing antibodies, those which would ideally prevention tool kit for the most-at-risk groups. Secondly, be elicited by an HIV vaccine, are largely unknown. We with these collaborations, the developing world has devel- have examined the evolution of neutralization breadth in oped capacity to conduct of clinical research that conforms the CAPRISA 002 cohort, and shown that cross-neutralizing to international standards for licensure of new products or antibodies develop in about a quarter of infected individuals change of indication of existing drugs/products in the devel- by 3 years post-infection. Generally breadth develops incre- oping world. mentally suggesting the possibility that multiple antibodies mediate breadth, and/or that breadth is conferred by the doi:10.1016/j.ijid.2010.02.1530 maturation of a single specificity. In one case, the development of breadth could be attributed to a single neutralizing antibody specificity. In the CAPRISA 002 cohort, as well as in The H1N1 influenza pandemic (Invited Presenta- a cross-sectional cohort of chronically infected individuals, tion) we have explored the targets of cross-reactive antibodies 18.001 which mediate breadth using an array of methodologies including peptide and protein adsorptions and the use of Historical perspective: Lessons Learned from past Pan- chimeric viruses. We have shown that multiple epitopes on demics the envelope glycoprotein are involved in the cross-reactive D. Morens neutralization elicited during natural HIV-1 infection, many of which are yet to be determined. NIAID, NIH, Bethesda, MD, USA It has been exactly 500 years since the first recognized doi:10.1016/j.ijid.2010.02.1529 influenza pandemic appeared and spread around the world in 1510. Since that time, at least 13 additional influenza 14th International Congress on Infectious Diseases (ICID) Abstracts e21 pandemics have been studied by countless historians, physi- number of cases, with growth during June and July due to a cians and scientists. Influenza and its complications have high number of cases in the southeast region. More recently, been well characterized clinically, much has been learned another wave of increased transmission was present in the about pandemic epidemiology, and a lore about influenza metropolitan area. pandemic behavior has developed over these past five A significant feature of this outbreak has been the centuries. This includes ideas about pandemic genesis, pan- increased mortality in patients between 15 and 55 years demic cycling, and pandemic wave-like behavior. However old, some previously healthy, with no increase in the young today, in the genomics era, much of what we thought we and the old population. Pregnancy and obesity have also knew is beginning to unravel, and we are quickly discard- been identified as risk factors for severity. Previous immunity ing old ideas to replace them with rapidly expanding new probably plays a role in the severity related to age. knowledge. Pandemic influenza was examined using his- Many lessons should be learned from this epidemic: Col- torical research approaches incorporating modern scientific laboration, preparedness, transparency, and the importance methods to develop a comprehensive overview. of being alert towards the unexpected. In recent years we have come to understand that there are at least several different mechanisms by which pan- doi:10.1016/j.ijid.2010.02.1532 demic influenza viruses may be generated, that pandemic cyclicity is probably partly if not wholly a myth, that pan- 18.003 demics may be regional or global, that for most of the Global Surveillance of the H1N1 Pandemic past 500 year domestic animals have played a major role in A.W. Mounts influenza epidemiology, that wave-like pandemic behavior is not inevitable and probably not wholly a viral property, WHO, Geneva, Switzerland and that influenza co-pathogenesis with common coloniz- ing nasopharyngeal bacteria probably accounts for most Pandemic surveillance can be viewed from two perspec- influenza-related deaths. tives, the need to detect the emergence of a novel strain Much remains to be learned about pandemic influenza, of influenza virus and the need to monitor the progression and we can expect an explosion of knowledge in the coming of spread of the virus. In monitoring pandemic progression, decade. It is truly a time to fasten our seatbelts, because the primary goal is to describe and detect changes in sev- the roller coaster is leaving the platform. eral important epidemiological characteristics of the event. These include severity, both in terms of virulence and impact on society, transmission dynamics, risk groups, and the clini- doi:10.1016/j.ijid.2010.02.1531 cal characteristics and spectrum of disease. Several methods 18.002 are used for doing this at the global level. These include The H1N1 Outbreak in Mexico the existing network of National Influenza Center laboratories through FluNet; monitoring of reports from ministries of S. Ponce de Leon health both on web sites and formal submissions; monitoring of media reports, formal communications through WHO Mexico, Mexico country offices and national focal points for International On April 23rd 2009, health authorities in Mexico informed Health Regulations; formal networks of epidemiologists, that a new virus was causing an increasing number of severe virologists, and clinicians; and through informal networks pneumonia cases in adults with unusually high mortality. of friends, colleagues, and acquaintances. Several short- After three weeks of intensive clinical and epidemiologi- comings have been highlighted by the current pandemic cal research, a new influenza virus was identified as the including lack of standardization for reporting of a vari- unknown pathogen in most of the clinical samples sent by ety of parameters, lack of standard surveillance methods Mexico to labs in Winnipeg and Atlanta. The WHO was noti- for severe disease, lack of a requirement for reporting of fied on the night of the 22nd, as soon as the information data once initial notification occurs, and the challenge of on etiology was available. At the same time, strict distanc- getting timely data when countries are busy responding to ing measures were initiated in Mexico City and its suburbs; a public health emergency. WHO has proposed a system of schools were closed and noncritical activities suspended. sentinel surveillance for severe acute respiratory infections The problem was first evident at the Emergency Room which will be reported country by country onto a global plat- of the National Institute of Respiratory Diseases, and con- form which will allow more systematic monitoring of both firmed by simultaneous reports received from San Luis Potosi pandemic and seasonal influenza. and Oaxaca. We focused our analysis on cases with severe viral pneumonia and thus overestimated the mortality of the doi:10.1016/j.ijid.2010.02.1533 virus during the first weeks of the outbreak — the full picture was apparent only afterwards. The initial response was timely as oseltamivir, educational materials, and protective medical equipment were ready to be sent thanks to Mex- ico’s national preparedness plan for a pandemic. 1340 cases fulfilled the case definition during the first month. Mexico’s strict social distancing measures had a significant impact on the number of cases but were later relaxed. The epidemic curve shows a sharp increase, followed by a decrease in the e22 14th International Congress on Infectious Diseases (ICID) Abstracts

18.004 Strategy in 1992 and the strengthening of efforts to reduce International response to the H1N1 pandemic the global burden of the disease was catalyzed by the Roll Back Malaria Initiative (RBM) which was launched in 1998. A.S. Monto The goal of the RBM initiative was to reduce the burden of disease by 50% by 2010. The United Nations Millennium University of Michigan School of Public Health, Ann Arbor, Development Goals were launched in 2000 with Goal 6 call- MI, USA ing ‘‘to halt and begin to reverse the incidence of malaria Heightened global concern about an influenza pandemic by 2015’’. At the World Health Assembly in 2005, Resolution can be dated back to 2003, when the SARS outbreak was WHA58.2 called for an additional 25% reduction from the followed by the spread of highly pathogenic A (H5N1) infec- RBM target; with the goal of reducing the burden between tions in poultry with occasional spread to humans. These 2000 and 2015 by 75%. The burden of malaria reported in the illnesses had a high case fatality ratio, which increased the Americas by Member States decreased from over one million worry of the potential effect of a pandemic caused by this cases and over three hundred deaths in 2000 to just under subtype. The WHO developed a variety of tools for countries 573 thousand cases representing a 52% reduction in cases to use and made preparations for vaccine stockpiling. Plans and 57% reduction in malaria related deaths between 2000 were developed to contain any focal outbreak with antivi- and 2008. rals. Pandemic phases were established to define extent Plasmodium vivax is the leading cause of malaria in the of adaption of an animal virus to humans and subsequent Region, accounting for approximately 75% of all cases with spread. Severity of the pandemic was not quantified in a P. falciparum being the cause of almost all other cases and scale. Fortuitously, modification of the phases had been put a small number due to P. malariae. In the countries shar- in place well before transmission of pandemic H1N1 virus ing the Amazon rain forest, similar proportions are observed was recognized in April, 2009. while in Mexico, Central America, Argentina and Paraguay P. The H1N1 pandemic has been very different from that vivax accounts for over 90% of the cases. In Hispaniola, the anticipated based on the virulence of the H5N1 virus. Para- only endemic island in the Caribbean shared by the Domini- doxically, this was initially a problem, since some countries’ can Republic and Haiti; almost 100% of the cases are due plans were geared only to severe pandemics. Some bor- to P. falciparum. There has been a reduction in the over- ders were effectively closed for a time, even though this all malaria incidence in recent years but the disease still was against the pandemic IHR recommendation. There was constitutes a public health problem in the region with a dis- also confusion between containment and mitigation, in parity in outcome of efforts in different countries related to part because of the rapidity of spread of the virus. Over- a number of factors including variations in ecological con- all, preparations for a more severe pandemic had positive ditions, diagnostic and treatment coverage, weaknesses in results. Many developed countries had antiviral stockpiles, health systems and technical capacity issues. Operational which they used in different ways. Development of a mono- research is important for evidenced based decision making. valent pandemic vaccine moved ahead rapidly. Not only The greater part of the financial resources for national were adjuvanted and nonadjuvanted inactivated vaccines malaria efforts to combat the disease is provided by national used but live attenuated vaccines were employed as well. governments but there has also been additional resource Technology transfer will make these approaches available in mobilization in the Region including that of the Amazon more countries. The need for only one inoculation of vac- Network for Monitoring Antimalarial Drug Resistance with cine will make more vaccine available to risk or priority funding available through the United States Agency for Inter- groups in developing countries. Equity issues clearly need to national Development’s (USAID) Amazon Malaria Initiative be addressed as we go forward. The time periods between (AMI). Additionally, individual country projects in Bolivia, pandemics have been irregular, and the next might not wait Guatemala, Guyana, Haiti, Honduras, Nicaragua and Suri- 40 years to occur. name have been financed by the Global Fund to combat HIV/AIDS, Tuberculosis and Malaria (GFATM) as has been a doi:10.1016/j.ijid.2010.02.1534 multi-country Andean proposal by the Organismo Andino de Salud (ORAS) to the GFATM for Colombia, Ecuador, Peru Malaria in the Americas (Invited Presentation) and Venezuela. Towards the end of 2009, proposals by Brazil, Colombia, the Dominican Republic and Ecuador were 19.001 approved by the GFATM. The Global Environment Facility / Epidemiology and Intensity of Transmission UN Environmental Program also supported a project for the prevention of the reintroduction of DDT use in malaria vector K. Carter control in Mexico and Central America. PAHO, Washington, DC, USA With reduction of the malaria burden in different geographical regions worldwide, there have been calls for Malaria transmission was eliminated from a number of renewed efforts to eliminate malaria. The presentation territories in the Americas but still occurs in 21 countries includes suggestions for lessons learnt from the eradication in the Region. The presentation focuses on past and present era to be borne in mind. strategies and goals to combat malaria in the Region, trends, the present situation and challenges as well as on finan- doi:10.1016/j.ijid.2010.02.1535 cial resource mobilization including that for operational research. After the Global Malaria Eradication Strategy was abandoned, it was replaced by the Global Malaria Control 14th International Congress on Infectious Diseases (ICID) Abstracts e23

19.002 19.004 Need for chemoprophylaxis for travelers to the Americas: Choice of Drugs for the Prophylaxis of Malaria in the Amer- Yes icas P. Arguin A. Magill CDC, Atlanta, GA, USA Walter Reed Army Institute of Research, Silver Spring, MD, USA International travelers may sometimes acquire infectious diseases such as malaria during their journeys. This session Preparing a traveler for a trip to the Americas often will be a debate about the usefulness of malaria chemopro- includes a discussion about the prevention of malaria with phylaxis for travel to the Americas. Malaria can be a fatal personal protection measures to minimize mosquito bites disease even when it is diagnosed early and treated cor- and the recommendation to use a drug for chemoprophy- rectly. It is preferable for persons at risk of infection with laxis when appropriate. The characteristics of malaria in malaria to prevent the infection. the Americas that differ from many other areas of the world include the relatively low transmission rates, the predomi- doi:10.1016/j.ijid.2010.02.1536 nance of vivax malaria in most locations, and the relatively wide availability of quality medical care for tourists. Use 19.003 of all current approved malaria chemoprophylaxis drugs will Need for Continuous Prophylaxis for Travelers to the be discussed with special emphasis on primaquine, the only Americas: No currently available drug that can prevent vivax malaria. M. Boulos doi:10.1016/j.ijid.2010.02.1538 University of Sao Paulo, Sao Paulo, Brazil The risk a traveler becomes infected by malaria will Current issues in multi drug resistant gram- depend on the overall rate of malaria transmission in the negatives (Invited Presentation) area to be visited and the extension of the traveler’s contact 20.001 with infected mosquitoes. Topics like: 1. Wearing long-sleeve shirts and long Escherichia coli trousers; 2. Applying insect repellent; 3. Spraying M.-I. Morosini aerosolized insecticides in living and sleeping places; 4. Sleeping in a screened or airconditioned rooms; 5. Ramón y Cajal University Hospital, Madrid, Spain Sleeping on netted bed; and 6. Use mosquito coils con- Escherichia coli is a remarkably versatile organism able taining pyrethroids are consensual measures in all malaria to easily acquire antimicrobial resistance as well as viru- transmission areas, and the use of chemoprophylaxis are lence determinants. E. coli is the leading pathogen causing not consensual in low endemic areas (Wyler, NEJM 1993) urinary tract infections and one of the most common organ- My aim is convincing you that the routinely use of malaria isms implicated in bloodstream infections. Its ubiquity in chemoprophylaxis is not needed in America. the community and hospital setting, together with antibi- The use of anti-malarial chemoprophylaxis should be otic overuse, have delineated a scenario in which multidrug carefully directed at high risk travelers when the benefit resistant isolates are not infrequent and appear as a fore- of using anti-malarial drug regimens outweighs the risk of most challenge for clinicians to achieve therapeutic success. adverse events. The risk for adverse events during the anti- Beta-lactam resistance owing to the presence of malarial drugs for prophylaxis is in the range of 30-40%. extended-spectrum-beta-lactamases (ESBLs) is globally Everyone knows that malaria is a disease of low incidence spread among E. coli, particularly due to CTX-M-type in America and most of these cases are in topic areas where enzymes, and coexistence of more than one beta-lactamase tourists only occasionally reach. in the same isolate has also been observed. Moreover, A retrospective study conducted on Italian travelers co-resistance to non-beta-lactam antimicrobials is a com- found that malaria incidence was 1.5/1000 for trips to mon feature among ESBL-producers as resistance genes Africa, 0.11/1000 for trips to Asia, and 0.04/1000 for trips to to unrelated antimicrobial compounds such as aminogly- Central and South Americas. Another study among Swedish cosides, tetracyclines, sulfonamides, trimethoprim, and travelers found a number four times lesser among travelers chloramphenicol are simultaneously harboured by conjuga- to America (Croft AM. BMJ 2007). tive plasmids carrying transposons and/or integrons where The use of chemoprophylaxis against malaria in this sce- these genes are located. The prevalence of certain phy- nario, where contra-indications overlap the benefits, show logroups exhibiting these multiresistant phenotypes has us the inadequacy of routinely use of drugs to prevent recently been associated with a genetic island that com- malaria in Americas. In a restrict number of cases when the prises genes encoding antibiotic resistance and virulence travelers must stay in remote malaria transmitting areas in in particular E. coli clones such as the ST131 clone. Con- America, for long period o time, we recommend standby comitant resistance to fluoroquinolones due to mutated treatment. topoisomerases in many of these isolates is an alarming reality. doi:10.1016/j.ijid.2010.02.1537 Incidence of E. coli isolates carrying plasmid-AmpC cephalosporinases is raising in many countries and, although e24 14th International Congress on Infectious Diseases (ICID) Abstracts carbapenems are still broadly active against E. coli, the inci- 20.003 dence of carbapenemases merits strict supervision mainly Pseudomonas aeruginosa in geographic areas where this resistance appears to be endemic in other species such as Klebsiella pneumoniae. G. Cornaglia Other resistance traits have been described in E. coli University of Verona, Siena, Italy clinical isolates as plasmid-mediated quinolone resistance due to qnr and aac(6’)-Ib-cr genes, and the efflux pump NO ABSTRACT RECEIVED QepA. Moreover, production of plasmid 16S rRNA methy- lases has recently drawn attention as a novel aminoglycoside doi:10.1016/j.ijid.2010.02.1541 resistance mechanism in pathogenic gram-negative bacteria including E. coli. It confers high-level resistance to all 20.004 aminoglycosides that are currently available. Evolution of antimicrobial resistance in Acinetobacter Multiresistance in E. coli affects almost all antimicrobial baumannii: Factors affecting multiresistance families, it is easily transmitted through successful and vir- J. Vila ulent clones and can be spread from and among not only humans but animals and food. The role of continuous antimi- Hospital Clinic, School of Medicine, University of Barcelona, crobial pressure in this phenomenon is unquestionable and Barcelona, Spain requires control measures to curtail the spread and maintenance of these multiresistant isolates with high likelihood Acinetobacter baumannii are an important cause of noso- of causing serious and almost untreatable infections. comial infections mainly in patients in the intensive care units. In this presentation I will analyse the evolution of antimicrobial resistance, the molecular bases associated doi:10.1016/j.ijid.2010.02.1539 with the increase in antimicrobial resistance, the factors 20.002 affecting multiresistance and the current treatment of Multidrug resistance in Klebsiella pneumoniae Acinetobacter infections. Antimicrobial resistance has steadily increased in the last P. Nordmann decade. Nowadays A. baumannii clinical isolates resistant to all antimicrobial agents even to colistin (panresistant) have Paris, France been isolated in the nosocomial setting. Three major factors Hospital-acquired and clinically-important Gram- favour the acquisition of multiresistance: 1. Intrinsic resis- negative pathogens remain mostly Enterobacteriaceae, tance, mainly related to the interplay between decreased Pseudomonas aeruginosa and Acinetobacter baumannii. permeability (small number of porins) and constitutive Among those Gram negatives, Klebsiella pneumoniae expression of efflux pump(s) (AdeIJK, CraA); 2. Persistence remains an important source of hospital spread of multidrug in the environment, in this sense, biofilm-producing A. bau- resistance. Wide-spectrum !-lactamases are increasingly mannii clinical isolates survive in inanimate surfaces longer reported in Enterobacteriaceae being either clavulanic- than those non-producing biofilm. 3. Acquisition of genetic acid inhibited extended-spectrum !-lactamases (ESBLs) or elements. It has recently been shown that resistance islands carbapenem-hydrolyzing !-lactamases (CHBLs). Although with a variable composition of resistance determinants first reported in Klebsiella pneumoniae mostly from interspersed with transposons, integrons and other genetic 1980’s to 2000’s, ESBLs are developing rapidly among elements play an important role in the acquisition of mul- communityacquired Escherichia coli. These novel ESBLs of tiresistance. However, this is not an universal contributor the CTX-M-type are reported worldwide with important to multiresistance since target mutations, overexpression of structural and genetic diversity. Those ESBL genes may be efflux pumps, and IS elements located upstream from some transmitted from E. coli to K. pneumoniae providing a novel resistance genes have also been found to be implicated in source of hospital-acquired multidrug-resistant K. pneumo- multiresistance. Although some clinical isolates are still sus- niae since there are associated to other plasmid-mediated ceptible to carbapenems and colistin, and therefore these resistance determinants. The CHBLs identified in Enter- antimicrobial agents can continue to be used, few options obacteriaceae are mostly metallo-!-lactamases (Ambler are available to treat infections caused by this microorgan- class B enzymes) of the VIM/IMP-types in hospital-acquired ism. Tygecycline has been used to treat infections caused K. pneumoniae. The Ambler class A carbapenemases of by A. baumannii. However, emergence of resistance to this the KPC-type are also identifed mostly in K. pneumo- antimicrobial agent has been reported during treatment niae, first from the USA and then worldwide. The latest when this monotherapy. reported CHBL in K. pneumoniae is OXA-48 mostly from This microorganism, albeit with slight differences Mediterranean countries. All this carbapenemase producers depending on the country, presents resistance to multiple are difficult to detect in a clinical laboratory and may antimicrobial agents, occasionally including resistance to the source of multidrug resistance leading to therapeutic colistin, hence, it can be considered the paradigm of noso- deadend. K. pneumoniae will remain the most important comial multiresistant bacteria. enterobacterial species as a source of multidrug resistance in hospital-acquired Gram negative isolates. doi:10.1016/j.ijid.2010.02.1542 doi:10.1016/j.ijid.2010.02.1540 14th International Congress on Infectious Diseases (ICID) Abstracts e25

Pathogens in populations (Oral Presentation) 21.001 Incidence and trends of imported malaria in the Nether- lands: 2000-2007 G. Van Rijckevorsel 1,∗, G.J.B. Sonder 1, R.B. Geskus 1, P.J.J. Van Genderen 2, M. Keuter 3, R.J. Ligthelm 4, L.G. Visser 5, J.C.F.M. Wetsteyn 6, J.A.R. Van Den Hoek 1 1 Public Health Service Amsterdam (GGD Amsterdam), Ams- terdam, Netherlands 2 Harbour Hospital and Institute for Tropical Diseases, Rot- terdam, Netherlands 3 Radboud University Nijmegen Medical Center, Nijmegen, Netherlands 4 Tropvacc BV, Rotterdam, Netherlands 5 Leiden University Medical Centre, Leiden, Netherlands 6 Academic Medical Center, Amsterdam, Netherlands Background: To describe the epidemiology and trends of imported malaria in the Netherlands from 2000 until 2007. Methods: National surveillance data on all notiﬁed infections of imported malaria, diagnosed between January 2000 and January 2008 were analyzed. Incidence and trends in imported malaria were estimated using the number of Dutch travelers visiting malaria endemic countries as denominator. In addition, the annual number of prescriptions for malaria Conclusion: The annual number of imported malaria chemoprophylaxis collected from pharmacies in the Nether- shows a continuing declining trend, even with an increas- lands was used to estimate the number of unprotected ing number of travelers visiting malaria endemic countries. travelers. This decline is not readily explained by the increased use of Results: The annual number of imported malaria infec- malaria chemoprophylaxis, but could also be explained by a tions (all species) fell from 535 in 2000, to 197 infections in reduced risk of infection due to lessening local malaria trans- 2007. Most infections (72%) were acquired in Sub-Saharan mission as observed in some malaria endemic areas. VFR Africa, and 75% were caused by Plasmodium falciparum. import less malaria than previously, and contribute largely In the same period, travel to malaria endemic countries to the declining incidence seen. Although the incidence in increased from 247,000 to 384,000 travelers per year. imported malaria has decreased, the increasing number of The number of prescriptions for malaria chemoprophylaxis travelers not using malaria chemoprophylaxis remains wor- increased from 131,400 to 186,300 (53% and 48% of all trav- risome. elers respectively) per year. Yet, the absolute number of unprotected travelers rose from 115,600 to 197,700. The doi:10.1016/j.ijid.2010.02.1543 overall incidence in imported falciparum malaria per 10,000 unprotected travelers fell from 21.5 to 6.6. The incidence 21.002 of imported falciparum infections is greatest from Middle Predictors of primary multiple drug resistant tuberculosis and West Africa, and decreased from 121.3 to 36.5 / 10,000 (MDR-TB) transmission in Lima, Peru travelers. The import of malaria from this region by immi- L. Shah 1,∗, H. Choi 2, F. Krapp 3, C. Zamudio 3, C. Seas 3,A. grants visiting friends and relatives (VFR) decreased from Ciampi 1, T. Brewer 1, E. Gotuzzo 3 138 infections in 2000, to 69 infections in 2007. 1 McGill University, Montreal, QC, Canada 2 Johns Hopkins Bloomberg School of Public Health, Balti- more, MD, USA 3 Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru Background: The emergence of MDR-TB strains is considered among the greatest threats to global TB control. Despite a well-established national directly observed therapy (DOTS) TB control program with high treatment compliance rates and a low burden of HIV co-infection among cases, Peru has among the highest MDR-TB incidence rates in the Americas. Understanding primary MDR-TB transmission is essential for developing effective control strategies and preventing further emergence. e26 14th International Congress on Infectious Diseases (ICID) Abstracts

Methods: Using a semi-structured questionnaire, we con- weekly. Isolates were speciated into C. jejuni, C. coli and ducted a case-control study of risk factors for primary Campylobacter spp. and tested for antimicrobial suscepti- MDR-TB in San Juan de Lurigancho (SJL), a Lima district bility according to standard methods. with the highest TB rates in Peru. Consecutive, consent- Results: C. jejuni was most commonly found in chicken ing TB cases (drug sensitive (DS) and primary MDR-TB cases) intestine (65% of samples) and chicken meat (29%), while followed in SJL clinics and randomly selected healthy com- C.coli was frequently recovered from swine and chicken munity controls were enrolled. Questionnaire data were intestine (45% and 30%) and their retail meats (23% and analyzed using Chi-square tests and logistic regression 27%). A total of 432 diarrheal episodes occurred in infants comparing primary MDR-TB cases with DS-TB and healthy and elders, of which Campylobacter was the fourth cause community controls. of bacterial diarrhea (4.4% of all episodes) after diar- Results: Sixty MDR-TB cases, 80 DS-TB and 80 commu- rheagenic E.coli (13.4%), Salmonella (12.3%), and Shigella nity controls enrolled. MDR-TB cases were significantly more (5.3%). C. jejuni and C.coli were isolated with equal fre- likely to have a household contact diagnosed with TB com- quency from human diarrheal samples. The annual incidence pared with DSTB cases (OR 3.20 p = 0.003) and community of diarrhea of any etiology was 2.1 episodes/infant and controls (OR 16.0 p < 0.0001) in the 3 years prior to their 0.7 episodes/elder. Annual incidence of Campylobacter- own diagnosis. While MDR-TB cases and DS-TB cases were associated diarrhea was 111 episodes/1000 infants and equally likely to have had a TB diagnosis in their work- 13 episodes/1000 elders. Campylobacter- infected infants place, 40% of MDR-TB cases reported being unsure if there presented more frequent vomiting and fever than those was a TB diagnosis at work in comparison to 20% of drug infected with Salmonella and Shigella (21%vs. 10% and 14%; sensitive TB cases (OR. 3.18 p = 0.006). Spending time in and 43% vs. 18% and 38%), but less frequent bloody stools and hospitals or clinics, methods of transportation, visiting the a shorter duration of diarrhea than Shigella (21% vs. 50% and prison and geographic location within SJL were not statisti- 5 vs. 8 days). None of the episodes resulted in dehydration or cally associated with MDR-TB. Further analyses are required hospitalization. Resistance rates in human C. jejuni isolates to confirm the strength of the effect after considering poten- were 0% to gentamicin, 5% to erythromycin, 46% to tetracy- tial confounders, however preliminary multivariate models cline, and 68% to ciprofloxacin. For human C. coli isolates, show that household and workplace contact with TB remain resistance rates were 0%, 10%, 14% and 48%, respectively. significant predictors of primary MDR-TB. Conclusion: Despite continuous exposure to Campy- Conclusion: These results support ongoing community lobacter, - including fluoroquinoloneresistant strains, the transmission of primary MDR-TB in SJL. Though a basic con- incidence and health impact of symptomatic infections tact tracing program is in place for household contacts aged in this community were relatively low; this suggests an % 15 years old and others are encouraged to present for care efficient and persistent protective naturally-acquired immu- if they develop symptoms, control measures in addition to nity. Although there is a general need for containing DOTS are likely needed to stem community transmission of antimicrobial resistance in foodborne pathogens, efforts primary MDR-TB. should focus on those with the greatest public health impact. doi:10.1016/j.ijid.2010.02.1544 doi:10.1016/j.ijid.2010.02.1545 21.003 Foodborne Campylobacter infections have a low impact 21.004 on human health: A community-based cohort study in DNA-Level diversity and relatedness of Helicobacter Yucatan, Mexico pylori strains in Shantytown families in Peru and transmission in a developing-country setting M.B. Zaidi 1,∗, F.D. Campos 1, F. Martinez 1, F. Gutierrez 1,A. Polanco 1, M. Leon 1, S. Patzi-Vargas 2, T. Estrada-Garcia 2, P. Herrera Aldana 1,∗, M. Mendez 1, B. Velapatino˜ 1, L. San- J.J. Calva 3 tivanez˜ 1, J. Balqui 1, S.A. Finger 2, J. Sherman 3, M. Zimic 3, L. Cabrera 1, J. Watanabe 4, C. Rodriguez 4, R.H. Gilman 5, 1 Hospital General O’Horan, Merida, Yucatan, Mexico D.E. Berg 2 2 CINVESTAV-IPN, Mexico City, Mexico 3 Instituto Nacional de Ciencias Medicas y Nutricion 1 A.B. PRISMA, Lima, Peru ‘‘Salvador Zubiran’’, Mexico City, Mexico 2 Washington University School of Medicine, St. Louis, Mis- souri, St Louis, MO, USA Background: In recent years, antimicrobial-resistant 3 Universidad Peruana Cayetano Heredia, Lima, Peru Campylobacter has become a major public health concern. 4 Policlinico Peruano Japones, Lima, Peru There is a need for conducting community-based integrated 5 The Johns Hopkins Bloomberg School of Public Health, Bal- food chain surveillance to determine the impact of resistant timore, MD, USA Campylobacter on human health in highly endemic settings. Methods: A 15-month cohort study was conducted in Background: The efficiency of transmission of a pathogen Buctzotz, a small, well-nourished, agricultural community within families compared with that between unrelated per- in Yucatan, Mexico. Household visits were performed twice sons can affect both the strategies needed to control or a week to detect diarrheal episodes, collect fecal speci- eradicate infection and how the pathogen evolves. In indus- mens and give health education for 126 infants less than trialized countries, most cases of transmission of the gastric 3 years and 120 elders over 74 years. Ten samples each pathogen Helicobacter pylori seems to be from mother to of food-animal intestines and raw retail meat were tested child. An alternative model, potentially applicable among 14th International Congress on Infectious Diseases (ICID) Abstracts e27 the very poor in developing countries, where infection virus (BD RSV Examen, BD Japan), and the other swab for is more common and the sanitary infrastructure is often PCR targeting common respiratory viruses. Sequencing was deficient, invokes frequent transmission among unrelated performed for confirmation of PCR result as well as geno- persons, often via environmental sources typing of the viruses. Blood culture was performed for all Methods: In the present study, we compared the geno- cases, and drug sensitivity test was done for all isolates. types of H. pylori from members of shantytown households Results: The number of cases peaked in October,the rainy in Peru to better understand the transmission of H. pylori in season in the Leyte. 57% were aged under one year-old. 86% developingcountry settings. H. pylori cultures and/or DNAs recovered, but 8.5% died during hospitalization. The rhi- were obtained with informed consent by the string test (a noviruses were the most common virus (HRVA:16%, HRVB:3%, minimally invasive alternative to endoscopy) from at least HRVC11%), followed by RS virus (RSV-A:24%, RSV-B:0.6%). one child and one parent from each of 62 families. Seasonal influenzaviruses, Human metapneumovirus, human Results: The random amplified polymorphic DNA finger- coronaviruses, human WU/KI polyomovirus, and human prints of 57 of 81 (70%) child-mother strain pairs did not bocavirus were detected. The mean age for HRVB was 8 match, nor did the diagnostic gene sequences (>1% DNA month-old and that of RSV-A was 10 month-old. S. pneu- sequence difference), independent of the child’s age (range, moniae, H. influenzae, S. aureus, and Salomonella were 1 to 39 years). Most strains from siblings or other paired cultured from blood. Viral pathogens detected from fatal family members were also unrelated. cases were proportional to that among over all study popu- Conclusion: These results suggest that H.pylori infec- lation. One fatal case was positive for MRSA and RSVA. None tions are often community acquired in the society studied. of those pathogens had statistical association with wheeze, Transmission between unrelated persons should facilitate respiratory distress, or outcome (survived / died) in logistic the formation of novel recombinant genotypes by interstrain regression. DNA transfer and selection for genotypes that are well suited Conclusion: Rhinovirues and RSV may be the two major for individual hosts. It also implies that the effective preven- pathogens account for severe pneumonia among children in tion of H. pylori infection and associated gastroduodenal Leyte. We may need another integrated strategy in order to disease will require anti-H. pylori measures to be applied save children below 6 month, who should have protected by communitywide. maternal antibody. doi:10.1016/j.ijid.2010.02.1546 doi:10.1016/j.ijid.2010.02.1547 21.005 21.006 Etiology of childhood pneumonia in Tacloban, the Philip- Population-based surveillance for pneumonia, sepsis and pines meningitis in all ages in The Gambia: Implications for pneumococcal vaccine introduction and surveillance in A. Suzuki 1,∗, S. Lupisan 2, N. Fuji 1, A. Ohno 1, Y. Furuse 1,R. Africa Tamaki 3, M. Saito 3, H. Oreste 2, M. Mondoy 2, L. Sombrero 2, A. De Leon 4, R. Olveda 2, H. Oshitani 1 G. Mackenzie 1,∗, E. Usuf 1, M. Jasseh 1, D. Nsekpong 2,N. Ikumapayi 1, H. Badji 1, D. Saha 1, D. Ameh 1, U. Uchendu 1, 1 Tohoku University Graduate School of Medicine, Sendai, T. Corrah 1, P. Hill 3, S. Howie 1, B. Greenwood 4, R.A. Japan Adegbola 5 2 Research Institute for Tropical Medicine, Manila, Philip- pines 1 Medical Research Council (UK) The Gambia, Fajara, Gam- 3 Research Center for Emerging and Re-emerging Infections, bia Manila, Philippines 2 Medical Research Council (UK) Laboratories, Banjul, Gam- 4 Eastern Visayas Regional Medical Center, Tacloban, Philip- bia pines 3 University of Otago, Dunedin, New Zealand 4 London School of Hygiene and Tropical Medicine, London, Background: Pneumonia kills 3 milion children annu- United Kingdom ally, but considered as ‘‘The Forgotten Killer of Chil- 5 Bill and Melinda Gates Foundation, Seattle, wa, USA dren’’(UNICEF/WHO). Our previous study showed the presence of human metapneumovirus and human bocavirus Background: WHO recommends that introduction of among Filipino children with influenza-like illness. But their pneumococcal conjugate vaccine is accompanied by dis- clinical importance, in line with other common respiratory ease surveillance. Surveillance for pneumonia, sepsis and viruses, is yet to be elucidated. On the other hand, bac- meningitis has been established in rural Gambia and 7PCV terial may be another important pathogens in those age was introduced in August 2009. Methods: In and outpa- groups. This study is to elucidate the causative agents of tient surveillance among a population of 148,000 began May sever pneumonia among children in the Philippines. 2008 following pilot surveillance which began September Methods: From May 2008 to May 2009, 891 patients, who 2007. 24/7 surveillance for suspected pneumonia, sepsis and fulfilled diagnosis of severe pneumonia by Integrated Man- meningitis involves those aged ‘‘2 months. Suspected cases agement of Childhood Illness and visited outpatient clinic are confirmed by clinicians followed by standard investi- in Eastern Visayas Regional Medical Center in Tacloban City, gations. Pneumococcal isolates are serotyped using latex Leyte, were enrolled. Two nasopharyngeal swabs were taken agglutination. from patient; one swab for rapid antigen detection for Results: From May 2008 until March 2009, 1463 cases influenzavirus A and B (BD Flu Examen, BD Japan) and RS (1225 < 5 years, 238 ≥ 5 years) of suspected pneumonia, sep- e28 14th International Congress on Infectious Diseases (ICID) Abstracts sis and meningitis were detected. Age-specific proportions Mwanza, Singida, Dar Es Salaam, Zanzibar and Mara. Of of those <5 years with suspected disease were 43% (n = 530) recent, a cholera vaccine trial is being piloted in Zanzibar 2-11 months, 32% (n = 387) 1 year, and 25% (n = 308) 2-4 with the aim of reducing the burden of disease. The objec- years. Of those aged ‘‘5 years, 42% (n = 100) were <15 years tive of the study was to investigate the risk factors for the and 58% (n = 138) were ≥15.7% (95/1385) of blood cultures recent cholera outbreak in Zanzibar so as to plan for con- grew pathogens; 38% (36/95) pneumococcus and 20% (19/95) trol measures which will be applicable to other regions in Staphylococcus aureus. 80% (76/95) of invasive bacterial dis- Tanzania ease occurred <5 years of age. 86% (25/29) of IPD <5 years Methods: Unmatched case-control study was carried out of age was associated with pneumonia and there were seven in the West Unguja District of Zanzibar in October 2009. cases of bacterial meningitis. All cases of IPD ‘‘5 years of Stool specimen from cases and water samples from the age were associated with pneumonia and there were two nearby river, taps, boreholes and wells were collected for cases of bacterial meningitis. The estimated incidence of laboratory analysis. Data analysis was done using Epi Info. IPD per 100000 person years was 362 (2-11 months), 295 Results: Factors found to be associated with cholera (1 year), 56 (2-4 years), 4 (5-14 years) and 9 (≥15 years). infection included use of water from bore holes OR = 9.1 The serotype distribution of 90 IPD episodes since initiation (p = 0.000) and the river OR = 14.9 (p = 0.000), storage of of pilot surveillance was: serotype 1: (28), 6A: (11), 5: (9), water in buckets OR = 15.5 (p = 0.002) and jerry cans OR = 5.5 14: (9), 19A: (3), 4: (3), 23F (2), 6B (2), 7F (2), other (21). (p = 0.000) and living in a dirty environment (p = 0.000).Boil- The proportions of IPD covered by different vaccines were: ing of water OR = 0.11(p = 0.002), storage of water in plastic 7PCV 20%, 7PCV + 6A 32%, PHiD10CV 63%, PHiD10CV + 6A 76%, bottles OR = 0,1(p = 0.017), education (p = 0.000) and wash- 13PCV 79%. ing of hands after use of toilet (p = 0.000) were found to Conclusion: The burden of childhood pneumococcal dis- be protective. There was no statistically significant differ- ease in rural West Africa is substantial. The relative burden ence between those that had vaccination against cholera among older children and adults is much less. Vaccines of and others (p = 0.74). greater valence than 7PCV will cover substantially greater Conclusion: Following the conclusions of our epidemio- proportions of IPD. Ongoing high quality surveillance is criti- logical studies, a drastic change of strategy was proposed cal to document the effectiveness of vaccine introduction which concentrated in community awareness, personal and to provide data to inform immunization programs in hygiene and provision of clean and safe water. Vacci- resource limited settings. nation has never been found to be an effective public health intervention in cholera outbreak as shown in this doi:10.1016/j.ijid.2010.02.1548 study. 21.007 doi:10.1016/j.ijid.2010.02.1549 Controlling persistent cholera outbreaks in Africa: Lessons from the recent Cholera Outbreak, West District 21.008 Unguja Zanzibar, Tanzania, 2009 High-risk travelers in the Boston Area Travel Medicine Net- work: Demographics, trip plans and vaccinations S. Masauni 1,∗, M. Mohammed 1, G.H. Leyna 2, F. Mosha 1,J. Mghamba 1, K. Omar 3, H. Ali 4, F. Abdallah 5, O. Oleribe 1,P. N.S. Hochberg 1,∗, M.M. Sosa 2, J.B. Trivedi 3, M. Pfaff 1, Mmbuji 6 W.B. Macleod 1, C. Benoit 4, L.H. Chen 5, L. Kogelman 6, W.W. Ooi 7, A.W. Karchmer 2, M.E. Wilson 5, D.H. Hamer 1, 1 Tanzanian Field Epidemiology and Laboratory Training Pro- E.D. Barnett 3 gram (TFELTP), Dar Es Salaam, Tanzania, United Republic of 1 Boston University School of Public Health, Boston, MA, USA 2 Muhimbili University of Health and Allied Sciences, Tanza- 2 Beth Israel Deaconess Medical Center, Boston, MA, USA nia, Dar Es Salaam, Tanzania, United Republic of 3 Boston Medical Center, Boston, MA, USA 3 Mnazi Mmoja Referral Hospital Zanzibar, Zanzibar, Tanza- 4 Boston Medical Center, Boston, MA, USA nia, United Republic of 5 Mount Auburn Hospital, Cambridge, MA, USA 4 Ministry of Health, Zanzibar, Zanzibar, Tanzania, United 6 Tufts Medical Center, Boston, MA, USA Republic of 7 Lahey Clinic, Burlington, MA, USA 5 Zonal Medical Office, Unguja„ Zanzibar, Tanzania, United Background: Given increased international travel by high- Republic of risk groups (immunocompromised persons and those with 6 Tanzanian Ministry of Health and Social Welfare, Dar Es medical comorbidities), there is need for better characteri- Salaam, Tanzania, United Republic of zation of these travelers and their travel risks. Our objective Background: Cholera is a diarrhoeal disease caused by was to describe the demographics, travel plans and vacci- infection with the bacterium Vibrio Cholerae. It affects nation requirements of immunocompromised travelers and both children and adults. It has a short incubation period those with medical comorbidities. and potent enterotoxins resulting in severe dehydration and Methods: Boston Area Travel Medicine Network (BATMN) death within a few hours to days if treatment is delayed. is a research collaboration of five travel clinics in the In Africa, Cholera is a major cause of preventable morbidity greater Boston area that sees ∼7,500 travelers per year. We and mortality. With eight different outbreaks in 2009 alone, compared immunocompromised travelers (e.g., those with Cholera epidemics have become a recurring public health HIV/AIDS, malignancy, etc) to those with underlying medi- challenge in 7 regions of Tanzania namely Tanga, Kigoma, cal conditions (e.g., cardiovascular and pulmonary disease), 14th International Congress on Infectious Diseases (ICID) Abstracts e29 and ‘‘healthy’’ travelers (without known comorbidities) in sion/exclusion criteria while the 10 districts were selected the BATMN cohort. randomly. Stratified random sampling method was used to Results: Of 9,254 travelers evaluated, 349 (3.8%) were select health facilities. Quantitative and qualitative data immunocompromised and 969 (10.5%) had medical comor- was collected from 138 facilities in September-October bidities. In the immunocompromised group, 196/349 (64.2%) 2008. Univariate, bivariate and multivariate analysis was had cancer and other non-HIV immunodeficiencies, 79 done. (22.6%) autoimmune disease, and 53 (15.2%) HIV/AIDS. Results: The performance of IDS weekly indicators is Among those with medical comorbidities, 433/969 (44.7%) largely influenced by; Stock out of tools, facilities which had lung disease, 409/969 (42.2%) cardiovascular disorders had low stocks of reporting tools were performing better (both coronary artery disease and history of arrhythmias) than those that had stock outs 6 months before the study and 180 (18.6%) diabetes. Immunocompromised travelers (P = 0.00). Training, health facilities that had been trained and those with co-morbidites were older than healthy staff in IDSR performed better compared to those that had travelers (median 57, 47 and 33 years respectively; p- no trained staff (P = 0.017). Mode of Communication; Facili- values <0.001); 24.6% of the immunocompromised group ties that were using SMS as a mode of transmitting data were were elderly (>65 years) vs. 5.8% of healthy travelers performing better that those using other modes (P = 0.024). (p<0.001). High-risk persons traveled more for tourism and District Health Manager’s support supervisions, were not less often to visit friends and relatives than healthy trav- found effective in influencing performance. elers; they also travelled less to countries endemic for Conclusion: Trainings for health workers in IDSR at all lev- malaria (26.2% vs 30.3%) or yellow fever (YF) (23.7% vs els are necessary for successful implementation. District’s 30.1%). Among travelers to YF-endemic areas, 41/87(47.1%) support supervision had no influence on performance, the immunocompromised travelers, 126/229 (55.0%) of those quantity was adequate, but the quality was questionable. with co-morbidities, and 1407/2391 (58.8%) healthy trav- The channels of data transmission need to be refocused, elers received the YF vaccine. Among elderly travelers to new technologies on cell phone based data communica- YF-endemic countries, 15/25 (60.0%) immunocompromised tion are yielding better results. Other existing challenges travelers, 20/36 (55.6%) of those with comorbidities and include overburdened health facility staff; poor communica- 53/112 (47.3%) healthy travelers were vaccinated. tion; poor incentives; coordination capacity and insufficient Conclusion: High risk travelers tend to be older and financial resources for an effective IDSR system. are usually tourists. While fewer high-risk persons go to endemic countries, there are nevertheless moderate num- doi:10.1016/j.ijid.2010.02.1551 bers of immunocompromised and elderly patients visiting regions where immunization with YF may be required. Given 21.010 their underlying medical conditions, clinicians need to be Molecular analysis of excised valves in the diagnosis of aware of the potential risk for adverse events associated blood culture negative infective endocarditis (BCNE) in a with YF vaccination in these high risk populations. Cardiac Surgery Referral Center in Rio de Janeiro, Brazil: 1998 to 2009 doi:10.1016/j.ijid.2010.02.1550 ,∗ C. Lamas 1 , R.G. Ramos 1, G.Q. Lopes 2, W. Golebiovski 1, 21.009 M.D.S. Santos 1, C. Weksler 1, G.D. Ferrauioli 1, H. Lepidi 3, P.-E. Fournier 3, D. Raoult 3 Factors determining performance of integrated disease surveillance strategy in Kenya, 2008 1 Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil 2 ,∗ Associação Fluminense de Ensino, Duque de Caxias, Brazil C. Njuguna 1 , J.K. Onsongo 1, C.M. Nzioka 2, D. Mutonga 2 3 Faculté de la Mediterranée, Marseilles, France 1 World Health Organization, 00100, Kenya Background: BCNE remains a diagnostic and therapeutic 2 Ministry of Public Health and Sanitation, 00100, Kenya challenge, especially in developing countries, due to lack of Background: Integrated Disease Surveillance and appropriate serologies and molecular tools. We sought the Response (IDSR) is a strategy that was adopted by WHO causes of this condition on valves collected at surgery over /AFRO member countries in 1998 following the recognition a 12 year period in a reference cardiac surgery hospital. that existing disease surveillance systems in the continent Methods: Formalin-fixed valves were tested by PCR for were not working effectively to measure health impact of the detection of Coxiella burnetii, Bartonella sp., Tro- major diseases intervention programmes nor in detecting pheryma whipplei, Staphylococcus aureus, Streptococcus disease outbreaks for early response. The main aim of oralis group, Streptococcus bovis group, Enterococcus sp., IDSR strategy is to assist national health systems detect and Mycoplasma sp.Immunohistochemistry was also per- and respond to diseases of epidemic potential, public formed on all valves of the study. health importance and those targeted for eradication and Results: Forty-one patients with BCNE had surgery in the elimination. The main objective of the study was to identify 12 year study period; of those 29 (78%) had valves avail- the factors that determine the performance of Integrated able for analysis. 9/29(31%) had organisms detected by PCR: Disease Surveillance (IDS) strategy in Kenya. S.oralis 5, S.oralis + S.gallolyticus 1, S.oralis + Bartonella 1, Methods: A Comparative Cross Sectional study was car- Bartonella 1, C.burnetii 1. Mitral(M) and aortic(A) valves ried out in 10 districts. Five districts had indicators below were involved as follows: 1 native M, 2 native A, 3 native MA, the 80% target while the other five districts had indicators 1 M bioprosthesis (11 years old), 1 A bioprosthesis (1.5 y) and above the target. Four provinces were selected using inclu- 1 mechanical M (29 y). Mean patients’ age was 39.7 ± 17.0 e30 14th International Congress on Infectious Diseases (ICID) Abstracts years (amplitude 9 to 70). Five patients were male, 4 to develop new and enhanced formulations, allowing these female. All had subacute presentations and community agents to remain significant antibacterial agent in the man- acquired infections. Antibiotics were not given before blood agement of respiratory tract infections despite development culture (BC) collection in only 3 of 9 patients (C.burnetii of resistance. While intrinsic and acquired resistance is 1, S.oralis 2). Mean time of antibiotics given before valve common in respiratory pathogens, in vitro susceptibility surgery was 29 ± 15 days. Predisposing conditions were can be accurately interpreted based on PK/PD parameters. interventricular septum 1, rheumatic valvulopathy 4, pros- PK/PD principles can be used to develop effective dosing thesis 3. All transesophageal echocardiograms showed major regimens, develop new formulations and dosage regimens, criteria, but all cases were only clinically possible by the contribute to guideline recommendations, establish suscep- modified Duke criteria. All cases were definite by surgical tibility breakpoints, and validate bacteriologic outcome in and histopathological and immunohistochemistry findings. clinical studies. However, PK/PD principles do not relate Clinical features showed fever in 4/9, new valvar regurgi- to length of therapy, which is mainly influenced by disease tation in all, splenomegaly in 1/9, emboli to skin in 1/9, severity, presence of comorbid conditions and patient com- elevated CRP in 6/6, and elevated ESR in 5/7 patients. Two pliance. patients died, both in refractory heart failure. Conclusion: The gold standard to establish the etiology doi:10.1016/j.ijid.2010.02.1553 of BCNE is study of the excised valves. Nearly a third of cases of BCNE in this cardiac surgery hospital had its eti- 22.002 ology defined by PCR of paraffin-embedded valves. This is What Are the Benefits of Short Antibiotic Treatment? the first data from Brazil relying on molecular biology of H. Goossens valves for the diagnosis of BCNE, with viridans, Coxiella and Bartonella documented. Of note, 7 of the 9 cases involved University Hospital Antwerp, Edegem-Antwerp, Belgium S.oralis underscoring antibiotics prior to BC collection as a major factor in BC negativity. Most antibiotics prescribed for outpatients are written for treatment of respiratory tract infections. Many of these prescriptions are necessary for curbing spread of infec- doi:10.1016/j.ijid.2010.02.1552 tion and preventing development of harmful sequelae. Less attention has been paid to the role of duration of antibiotic Successful short antibiotic treatment of childhood therapy to treat respiratory tract infections, particularly pneumonia - Myth or reality? (Invited Presentation) pneumonia in children, for the judicious use of antibiotics. 22.001 In fact, prescribing the appropriate duration of a course of antibiotic therapy is as important as eliminating prescrip- Determinants of Bacteriologic Eradication in Respiratory tions for nonbacterial illnesses in practising judicious use of Tract Infections antibiotics. M. Jacobs How long is enough and how long is too much? Thera- peutic courses need to be of sufficient duration to result in Case Western Reserve University, Cleveland, OH, USA a clinical cure to return patients as rapidly as possible to Understanding of the relationships between pharma- normal functioning and to prevent the progression of dis- cokinetic (PK) and pharmacodynamic (PD) parameters and ease and the development of dangerous sequelae. However, bacteriological and clinical outcomes of infections has unnecessarily lengthy courses of therapy may prevent the resulted in appreciation of the correlation between in vitro realization of these treatment goals by heightening the risk potency and in vivo efficacy of antimicrobial agents. PK of development of bacterial resistance and side effects and and PD principles can be applied to the development of by reducing compliance with the therapeutic regimen. In new antibacterials and optimising the formulation of exist- children, the latter is however not relevant. We investi- ing agents to help address the increasing prevalence of gated the direct impact of antibiotic exposure on resistance antibacterial resistance. Antimicrobial agents can generally at the individual level in healthy cohorts, treated with be divided into those that have time-dependent activity, azithromycin, clarithromycin, or a placebo in a randomised, such as beta-lactams, and those that have concentration- double-blind trial. Both macrolides significantly increased dependent activity, such as macrolides, lincosamides and the mean macrolide-resistant proportions of viridans strep- quinolones. For beta-lactams, the unbound serum con- tococci compared to the placebo at all time-points. Our centration of the drug exceeding the minimum inhibitory study showed that selection of resistance occurs very rapidly concentration of the causative pathogen for 40-50% of after the exposure to antibiotics, peaking in the immediate the dosing interval (40% for penicillins and 50% for post-therapy period. In conclusion, decrease of side-effects cephalosporins) is predictive of bacteriologic efficacy and could be the main benefit of shorter antibiotic treatment. can be used to determine a PK/PD breakpoint for specific dosing regimens. For concentration-dependent agents, the doi:10.1016/j.ijid.2010.02.1554 unbound serum area-under-the-curve (AUC) to MIC ratio exceeding 30 for macrolides, lincosamides and quinolones is generally predictive of bacteriologic efficacy and can be used to determine a PK/PD breakpoint for these agents. Amoxicillin and amoxicillin/clavulanate are examples of agents that have been studied and PK/PD principles applied 14th International Congress on Infectious Diseases (ICID) Abstracts e31

22.003 adverse events and lower rates of antibiotic resistance Short Treatment and the WHO Pneumonia - What are We in the community. An extensive literature search using Treating? a combination of the words ‘‘pneumonia’’, ‘‘community- acquired’’, ‘‘treatment’’, ‘‘drug’’, ‘‘antibiotic’’, short’’, Z. Bhutta ‘‘shortened’’, ‘‘day (s)’’, and ‘‘child’’ resulted in a few articles only dealing with short duration treatment of pneu- The Aga Khan University, Karachi, Pakistan monia in children, all in the developing world and most It is estimated that there are 5-9 episodes of acute respi- dealing with pneumonia defined by the WHO criteria (used ratory infections (ARI) per year / under 5 children, the vast in locations where no modern medicine can be applied). We majority of which are viral. Some 2-3% of these episodes undertook a prospective, double blind, randomized study, represent pneumonia and between 7-13% (some 11-17 mil- comparing high-dose amoxicillin (80 mg/kg) administered lion acute lower respiratory infections are severe enough to for 5 vs. 10 days in children with community-acquired alve- require hospital admission. olar pneumonia with the following inclusion criteria: 1) <5 Despite numerous advances in understanding the burden years old; 2) radiologically proven alveolar pneumonia; 3) and epidemiology of childhood respiratory pneumonia, the temperature ‘‘38.5 ◦C; 4) peripheral WBC’’ 15,000/mm3. disorder still accounts for almost 1.8 million child deaths We followed the children both clinically and with labora- annually, 98% in developing countries. It is widely stated tory findings for a month. The study will be unblinded after that in developing countries, most pneumonia is bacterial January 31st and the preliminary results will be presented. and most acute respiratory infection related deaths are due In conclusion: Paucity of data and difficulty in defining to pneumonia, however, the exact proportion of these infec- childhood pneumonia in the developed world result in confu- tions which are related to viral or bacterial infections is sion in regard to short treatment. However, the first studies unclear. Given the high burden of deaths in young children, will reveal, at least in some defined subgroups of pneu- WHO has progressively developed algorithms for the diag- monia, the efficacy and the potential use of short-course nosis and management of acute respiratory infections based treatment in childhood pneumonia. on clinical criteria of fast breathing and chest indrawing. These criteria have been used for the diagnosis and therapy doi:10.1016/j.ijid.2010.02.1556 of pneumonia in a range of settings. In recent years, the success of short course antibiotic therapy of such episodes has Antibiotic Resistance Gram-Negative (Poster Pre- opened the possibility of improving community case man- sentation) agement of such infections and reducing rates of resistance. However, a legitimate question has been raised as to the 23.001 nature of acute respiratory infections diagnosed by the WHO Clinico epidemiologic and molecular characterization of algorithms. This presentation will review the current state metallo beta lactamases (MBLs) producing nosocomial of knowledge in relation to the etiology and outcomes of res- Pseudomonas aeruginosa (PSA) piratory infections in children in developing countries and ,∗ also discuss the implications for research and programs. S. Chatterjee 1 , A. Kumar 2, K.N. Prasad 3, D. Mathai 1,A. Our findings indicate that the current criteria for defining Manoharan 1 pneumonia as suggested by WHO are too broad and proba- 1 Christian Medical College and Hospital, Vellore, Tamil bly include a host of conditions, including viral infections Nadu, India and asthma, which do not require antibiotics. A much more 2 Amrita Institute of Medical Science, Kochi, India effective and validated definition and clinical description of 3 Sanjay Gandhi Post Graduate Institute of Medical Sciences, pneumonia is needed for programmatic settings. Lucknow, India doi:10.1016/j.ijid.2010.02.1555 Background: The high prevalence of co-resistance to betalactam, aminoglycoside and quinolone against PSA has 22.004 necessitated increased use of carbapenems. MBL production Can Short Antibiotic Treatment be Widely Used in Devel- among PSA is one of the several mechanisms causing car- oped Countries bapenem resistance (CARB-R) transferable by integrons. We surveyed MBL production among PSA isolates collected via R. Dagan multicentric surveillance study. Beer Sheva University, Beer-Sheva, Israel Methods: During March-September 2009 BMPLIII received 75 consecutively collected PSA causing infections of (skin Childhood pneumonia is the most common killer of and soft tissue-48, blood and respiratory tract 11 each, children <5 years worldwide. Although in the developed and other sites, 5) from four (50-AIMS,Kochi, 21-SGPGIMS, world pneumonia does not commonly result in death, it 2-MGIMS,2-AIIMS,Delhi) Indian Medical centers. Antimicro- is an extremely common disease. Treatment is almost bial susceptibility testing by Kirby Bauer method against universally with antibiotics. However, the lack of appro- ceftazidime (CZD), cefepime(FEP), piperacillin/tazobactam priate definition of pneumonia, the difficulty in diagnosing (TZP), ticarcillin /clavulanic acid (TIM), gentamicin the pathogen and cultural differences make it extremely (GEN), amikacin(AK), ciprofloxacin(CIP), imipenem(IMP), difficult to agree on the ideal treatment. A short antibi- meropenem(MEM), aztreonam(ATM) and colistin(CL) was otic course is preferred to a longer one, since if equally done. MBL was screened by the Combined Disk Diffusion Test effective, it should be associated with lower cost, less (CDDT) method using 0.5 M EDTA (930␮g) as the inhibitor e32 14th International Congress on Infectious Diseases (ICID) Abstracts with IMP, positives (inhibition ≥7 mm) confirmed by IMP + 23.002 EDTA Etest and PCR (VIM and IMP genes). The resistance patterns of Pseudomonas aeruginosa in Results: Of the 75 PSA isolates, 12(16%) were MBL hospitals from Greece and Romania and its importance for producers. Diabetes mellitus was found to be the major risk the therapy of nosocomial infections and infection control factor in PSA infections. Overall resistance to CIP 50.7%> practices CZD 37.3% >AK 36%> FEP 34.7%. Resistance pattern among ,∗ MBL/NMBL was CZD(91.7%/23.8%), FEP(91.7%/20.6%), L.M. Junie 1 , S. kastanakis 2, M. Petrascu 1, C. Bobos¸1,A. TZP(91.7%/15.9%), TIM(100%/27%), GEN(100%/23.8), Tsouri 2, P. Karagianni 2, E. Papadomanolaki 2, G. Aleuraki 2, AK(100%/20.6%), CIP(100%/38.1%), IMP(100%/6.3%), M. Gatzima 2, I. Varthalitis 3 MEM(75%/9.5%), ATM(91.7%/38.1%). Resistance to IMP 1 University of Medicine and Pharmacy, Cluj Napoca, Roma- and MEM was 22.7% and 21.3% respectively. All isolates nia were susceptible to CL. MDR (resistant to ≥2 classes of 2 St. George General Hospital, Chania, Greece antimicrobials) was 34(45.3%).Overall 14(18.7%) were CDDT 3 Infection Control Committee, Chania, Greece positive. IMP + EDTA Etest and PCR confirmed 12 to be MBL positives. Among the MBL isolates, one was also positive Background: One of the most difficult problems in for IMP gene, which on sequencing was confirmed to be hospitals is the appearance of an increased number of Pseu- IMP 7. Sensitivity and specificity of CDDT was 100% and domonas antibiotic resistant strains. The objective of our 96.8% respectively when compared to PCR. History of prior study is to describe the resistance pattern of Pseudomonas antibiotic usage of aminoglycosides (66.7%), 3rd generation aeruginosa strains. cephalosporins (58.3%), quinolones (58.3%), carbapenems Methods: For isolating Pseudomonas aeruginosa strains, (50%), penicillins (25%), betalactam + betalactamase the usual nutritive media were used. Identification was inhibitors (8.3%) was noted for the patients with MBL made with Vitek2 system (BioMerieux). The susceptibility infection. Clinical improvement or cure with modification to the antibiotics of strains was performed by Kirby Bauer of initial antibiotics was found in 63.6% (7/11) patients with method as recommended by CLSI and Vitek2 system. Were MBL PSA. tested 229 strains isolated from urine and surgical wounds, in Cluj Napoca, Romania, and 36 strains isolated from blood samples in Chania, Greece. The majority of the strains (86.1%) were isolated from patients in wards and a percentage of 13.8 from Intensive Care Unit. Results: The strains isolated in Romania from urine showed a high resistance to betalactamins, remaining susceptible to Carbenicillin, Carbapenems, Ceftazidime and Cefepime. Over 80% of the strains, were resistant to others of third generation cephalosporins. The strains isolated from blood, presented resistance to Aztreonam (30.43%) and Ceftazidime (13%). 13% were resistant to Imipenem PCR for VIM and IMP gene in PSA and Meropenem. Pseudomonas aeruginosa isolated strains in Romania, showed resistance to Amikacin (71.4% isolated strains from urine and 29.7% from surgical wounds), Conclusion: MBL production is an important mechanism of and a low resistance to Gentamycin (18.6%), Tobramycin CARB-R among PSA. Spread should be further minimized by (25%). 29.6% were resistant to Colistin. The strains iso- using carbapenems judiciously in the treatment of PSA infec- lated in Chania, showed resistance to Gentamycin (21.4%). tions. CDDT is a useful method for screening MBL. VIM type All strains isolated from urine, were resistant to Pefloxacin of MBL was seen among all MBL positive isolates. and a high resistance was detected to Nalidixic acid (75%), Ciprofloxacin (75%) and Ofloxacin (50%). The strains isolated doi:10.1016/j.ijid.2010.02.1557 from surgical wounds, presented a resistance to quinolones, oscillating between 33.1% and 51.9%. The isolated strains from blood showed resistance to Nalidixic acid (38.5%), Pefloxacin (38.5%) and Ciprofloxacin (38.5). Conclusion: Our results could reflect the implication of some hospital multi resistant Pseudomonas aeruginosa strains in nosocomial infections. In Greece, a decline in drugs resistance of Pseudomonas strains has been noted. As a fact, it is rather encouraging, and probably we can attribute it to adherence to infection control practices and prudent chemotherapeutic agents use as proposed by Infectious Dis- eases Control Committee. The majority of the strains was detected in ward patients and owing to reduced morbidity 14th International Congress on Infectious Diseases (ICID) Abstracts e33 factors compared with patients in ICU, the reduced resis- 23.004 tance to antibiotics can be explained. Antimicrobial susceptibility profile of Pseudomonas aeruginosa strains isolated at a tertiarycare University doi:10.1016/j.ijid.2010.02.1558 Hospital (S. Orsola Hospital, Bologna, Italy) 23.003 R. Manfredi Extended spectrum ␤-lactamase production at the Komfo University of Bologna, Bologna, Italy Anokye Teaching Hospital, Kumasi, Ghana Background: The increased rate of antimicrobial resis- Y. Adu-Sarkodie tance among Gram-negative bacilli and Enterobacteriaceae School of Medical Sciences, KUMASI, Ghana is a general concern,especially in the hospital setting.A prospective microbiological monitoring including a contin- Background: In recent times enterobacteriaceae iso- ued surveillance of antimicrobial susceptibility rates of all lated at the Komfo Anokye TeachingHospital (KATH) have relevant pathogens,is ongoing at our Hospital. shown significant resistance to 2nd and 3rd generation Methods: The temporal variations of in vitro antimicro- cephalosporins. In 2006, 18-32% of all enterobacteriaceae bial sensitivity rates were registered at quarterly intervals isolated from urine and blood were resistant to the for all suitable Pseudomonas aeruginosa strains,during the cephalosporins cefuroxime, ceftriaxone, ceftazidime and year 2008.The same pathogen cultured more than once from cefotaxime. These antibiotics are the mainstay for the the same patient within one month,has been considered treatment of severe infections in the hospital. Microbial once. resistance to these antibiotics if due to the production Results: Among Pseudomonas aeruginosa isolates ␤ of Extended spectrum -lactamases (ESBL) may also indi- (494 strains tested on the whole), the best perfor- cate resistance to the fluoroquinolones, aminoglycosides mance was obtained by the old colistin (colimycin),with and other antibiotics. This limits therapeutic options for the a 100% susceptibility rate, followed by piperacillin- treatment of severe infections. We studied the extent of tazobactam (73.9-78.6.4% of tested strains),amikacin ESBL production amongst Klebsiella sp and E. Coli at KATH. (71.7-84.5% of tested strains),imipenem (69.9-79.1% Methods: ESBL production in 300 non-selected, non- of tested strains),ceftazidime (from 68.0 to 82.5% of duplicate isolates of Klebesiella sp and E.coli obtained from tested strains),tobramycin (from 63.0 to 76.4% of tested blood, urine, wounds, and sputum of both in-patients and strains).On the other hand,significantly less effective out-patients was determined by the combined disc method sensitivity profiles were shown by gentamicin (57.5% to using ceftazidime, ceftriaxone and cefpodoxime discs singly 71.3% of tested strains),ciprofloxacin (51.3-68.0% of tested and in combination with clavulanic acid. strains),aztreonam (59.5-61.2% of tested strains),ticarcillin- Results: 44% and 55% respectively of E.coli and Kleb- clavulanate (54.2-66.9%),and mezlocillin (45.3-54.2% of siella sp (57.8% K.pneumo,) were ESBL producers. ESBL tested strains).When examining temporal trends of production in the organisms was commoner in in-patients antibiotic sensitivity figures in the examinewd period (75.4%) than out-patients (24.6%), though not statistically (January-December 2008), significantly favorable changes significant (OR=1.40, 95% CI 0.79-2.46, p=0.31). In gen- were observed only for ceftazidime and ciprofloxacin (p < eral, ESBL producing organisms apart from being resistant .025). to cephalosporins were also resistant to gentamicin and Conclusion: A prospective surveillance study of antimi- ciprofloxacin. They were however susceptible to the car- crobial susceptibility rates of a major hospital-associated bapenems. organism like Pseudomonas aeruginosa is of remarkable Conclusion: The high level of ESBL production found in importance, to establish reliable guidelines of antibi- these enterobacteriaceae with the resultant microbial resis- otic treatment and prophylaxis, on local-regional basis. tance to available cephalosporins and other agents implies Piperacillin-tazobactam, amikacin,imipenem,and the same difficulties with the choice of therapeutic options for the ceftazidime still maintain a reliable role in eventual,empiric treatment of severe infections. Carbapenems are expen- regimens to be added pending microbial isolation and in vitro sive on the Ghanaian market and their use in non-severe susceptibility studies,since they remained active in nearly infections (as may be suggested by these results) may be 80% of hospital isolates of the last year 2008.Colistin main- inappropriate. Both prescribers and pharmaceutical agents tained full in vitro activity against all Pseudomonas strains will need to reflect soberly on their contribution to this sor- observed over time. An appreciable increase of sensitivity did state of affairs. We need to put an end to our practice rates to ceftazidime and ciprofloxacin was also observed of cracking nuts with sledge hammers! over the last year 2008. doi:10.1016/j.ijid.2010.02.1559 doi:10.1016/j.ijid.2010.02.1560 e34 14th International Congress on Infectious Diseases (ICID) Abstracts

23.005 anism of carbapenem resistance in the strain with positive Characterization of ertapenem resistance in Klebsiella E test—MBL. pneumoniae from Croatia doi:10.1016/j.ijid.2010.02.1561 B. Bedenic 1,∗, J. Vranes 2, Z. Bosnjak 3, A. Budimir 4,S. Kalenic 3 23.006 Changing trends in antimicrobial resistance among 1 School of Medicine, University of Zagreb, Clinical Hospital salmonella serotypes in Southern India Center Zagreb, Zagreb, Croatia 2 Zagreb Institue of Public Health ‘‘Andrija Stampar’’, S. rao 1,∗, B. Kabir 2 Zagreb, Croatia 1 3 Clinical Hospital Center Zagreb, Zagreb, Croatia kasturba Medical College & Hospital,Manipal, Karnataka, 4 School of Medicine University of Zagreb, Clinical Hospital India 2 Center Zagreb, Zagreb, Croatia Kasturba Medical College and Hospital, Madhav Nagar, Manipal, India Background: Klebsiella pneumoniae isolates with reduced susceptibility to carbapenems were recently Background: Enteric fever caused by drug resistant reported in USA, UK, Turkey and some other countries of Salmonella enterica serotype Typhi and Salmonella enter- the world. Recently eight Klebsiella pneumoniae strains ica serotype Paratyphi A has been the major public health with reduced susceptibility to carbapenems were isolates concern in the Indian Subcontinent. in four different hospitals in Croatia. The aim of the study Methods: A Retrospective analysis of antibiogram and was to determine the mechanisms of ertapenem resistance resistance pattern to Ciprofloxacin, Nalidixic acid, Ceftriax- in these strains. one Azithromicin and other routine antibiotics to Salmonella Methods: Antibiotic susceptibilities were determined by isolates from PUO cases from blood cultures during 2005- broth microdilution method according to CLSI. Transferabil- 2006 combined with a follow up during 2007-2008 represents ity of ertapenem resistance was determined by conjugation the data presented in this study. (broth mating method) using E. coli A15 R- as recip- Results: Of the 2247 from PUO cases 198 salmonella ient. Production of metallo ␤-lactamases was detected species (65 were Salmonella typhi, 132 Salmonella paraty- by double-disk synergy test and E test. B-lactamases phi A and 1 Salmonella enteritidis. Salmonella typhi and were characterized by PCR with primers specific for Salmonella paratyphi A serotypes were sensitive to Chlo- extended-spectrum ␤-lactamases, plasmid-mediated ampC ramphenicol, Ampicillin, Cotrimoxazole, and Cefriaxone ␤-lactamases, metallo ␤-lactamases of VIM and IMP series, and sensitive /intermediate to Ciprofloxacin and resistant KPC and OXA-48 ␤-lactamases. Genotyping of the strains was to Nalidixic acid (except one). MIC for Ciprofloxacin and ␮ performed by PFGE. Nalidixic acid resistance strains was 0.5/1 g/ml except for ␮ Results: All strains were resistant to ceftazidime, 3 MDR salmonella strains which had MIC value of 16 g/ml. cefotaxime, ceftriaxone, piperacillin alone and combined This was reflected on disc diffusion test as intermediate zone with tazobactam, amoxycillin/clavulanate, gentamicin and of inhibition. Retrospective blood culture analysis of 2005- ciprofloxacin. All except one strains showed resistance 2006 has shown that MDR Salmonella typhi was common to ertapenem, intermediate susceptibility or resistance to isolate then and the strains were sensitive for Ciprofloxacin ␮ meropenem and intermediate susceptibility or full suscep- (MIC being 0.125 g/ml). No antibiotic resistant Salmonella tiblity to imipenem. One strain was resistant to all three paratyphi A was isolated during this period. carbapenems. Ertapenem resistance was not transferable Conclusion: Salmonella strains with Nalidixic acid resis- by conjugation to E. coli recipient in neither of our strains. tance and reduced susceptibility and MIC to Ciprofloxacin PCR revealed the presence of blaSHV and blaCTX-M genes. have emerged as major cause of enteric fever in Indian Sub- ␮ Multiplex PCR was positive for group 1 CTX-M ␤-lactamases. continent. Nalidixic acid susceptibility (30 g disc) can be Sequencing of representative blaCTX-M genes revealed the reliably used to monitor Ciprofloxacin resistance. presence of CTX-M-15 betalactamase. The strain resistant to all three carbapenem was positive by E test for MBLs. How- doi:10.1016/j.ijid.2010.02.1562 ␤ ever, PCR was negative for VIM and IMP -lactamases. No 23.007 KPC or plasmid-mediated ampC ␤-lactamases were found. The strains were not clonally related as shown by PFGE and Molecular epidemiology of aminoglycosides resistance displayed distinct PFGE fingerprints. in Acinetobacter spp. with emergence of multidrug- Conclusion: This is the first report of carbapenem resistant strains in hospitalized patients in Iran resistant Klebsiellae in Croatia. Ertapenem resistance in R. Moniri ∗, R. Kheltabadi Farahani Klebsiella was previously reported in UK, Turkey and Israel mainly due to the production of CTX-M $-lactamases of group Kashan University of Medical Sciences, Kashan, Iran, Islamic 1 combined with porin loss (OmpK36 or OmpK35). The char- Republic of acterization of outer membrane porins needs to be done Background: Acinetobacter spp. is emerging as an impor- to clarify the mechanisms of ertapenem resistance in our tant nosocomial pathogen and is characterized by increasing strains. Further testing is necessary to determine the mech- antimicrobial resistance. Our aim was to evaluate antimicrobial susceptibility and aminoglycosides resistance genes of Acinetobacter spp. isolated from hospitalized patients. 14th International Congress on Infectious Diseases (ICID) Abstracts e35

Methods: Sixty isolates were identified as Acinetobacter antibiotic used 7 of the 8 patients prior to isolation species. The isolates were tested for antibiotic resistance by of Klebsiella pneumoniae resistant to Carbapenems. One disc diffusion method for 12 antimicrobials. The presence of patient was excluded in outcome as one patient’s sam- aphA6, aacC1 aadA1, and aadB genes were detected using ple was clinically thought to be a contaminant was not PCR. treated. 3 patients in whom resistance to carbapenem was Results: From the isolated Acinetobacter spp. the highest reported had their antibiotic was changed to Tigecycline resistance rate showed against amikacin, tobramycin, and and Polymyxin B resulting in clinical improvement. Of the ceftazidim, respectively; while isolated bacteria were more remaining 4 patients who were reported as sensitive to car- sensitive to ampicillic/subactam. More than 66% of the iso- bapenem three patients had to undergo a repeat surgery due lates were resistant to at least three classes of antibiotics, to clinical deterioration and one patient clinically died. and 27.5% of MDR strains were resistant to all seven tested Conclusion: The incidence of KPC gene at our hospi- classes of antimicrobials. The higher MDR rate presented tal was 7.5%. KPC positive isolatesare rapidly emerging in bacteria isolated from the ICU and blood samples. More pathogens. It is very important to keep this organism in mind than 60% of the MDR bacteria were resistance to amikacin, as if not treated there is a 100% probability of having a poor ceftazidim, ciprofloxacin, piperacillin/tazobactam, doxy- outcome. There is a complete cross resistance to all Car- cycline, tobramycin and levofloxacin. Also, more than bapenems containing KPC, therefore if KPC is present, the 60% of the isolates contained phosphotransferase aphA6, K pneumoniae will be resistant to all Carbapenem regard- and acetyltransferase genes aacC1, but adenylyltransferase less of the routine susceptibility testing as shown in three genes aadA1 (41.7%), and aadB (3.3%) were less prominent. isolates that are KPC positive but susceptible to Imipenem. In this study 21.7% of the strains contain three aminoglyco- Current automated systems used for susceptibility testing side resistance genes (aphA6, aacC1 and aadA1). may not accurately identify all these isolates. We must also Conclusion: The rising trend of resistance to amino- control the use of antibiotics specially PT to prevent emer- glycosides poses an alarming threat to treatment of such gence of KPC positive organisms. infections. The findings showed that clinical isolates of Acinetobacter spp. in our hospital carrying various kinds of doi:10.1016/j.ijid.2010.02.1564 aminoglycoside resistance genes. 23.009 doi:10.1016/j.ijid.2010.02.1563 In vitro activity of Tigecycline against molecularly defined Carbapenemase producing Acinetobacter baumannii 23.008 M. Hackel 1,∗, P. Higgins 2, H. Seifert 2, S. Bouchillon 1,B. Incidence of Carbapanemase Resistance Gene (KPC) Johnson 1, R. Badal 1, J. johnson 1, D. Hoban 1, S. Hawser 3, among Klebsiella pneumoniae isolates and its Clinical M. Dowzicky 4 Implications 1 ∗ International Health Management Associates, Inc., B. Yegneswaran , W. Numsuwan, D. Alcid Schaumburg, IL, USA Drexel University College of Medicine / St Peter’s University 2 Institute for Medical Microbiology, Cologne, Germany Hospital, New Brunswick, NJ, USA 3 IHMA Europe Sàrl, Epalinges, Switzerland 4 Pfizer Inc, Collegeville, PA, USA Background: Carbapenem antibiotics (Imipenem, Ertapenem, and Meropenem) idicated for infections caused Background: Acinetobacter baumannii are important by extended-spectrum {beta}-lactamase (ESBL) carrying opportunistic pathogens with increasing rates of multi- pathogens. Carbapenem resistance has been unusual in antibiotic resistance due to both intrinsic and acquired isolates of Klebsiella pneumoniae. The aim of this study mechanisms. Carbapenems are often used to treat these is to identify the prevalence of KPC positive Klebsiella infections, however carbapenem resistance is increasingly pneumoniae, and it’s clinical significance. reported, leaving few therapeutic options. This resistance Methods: All isolates of Klebsiella pneumoniae species is most often associated with acquired or intrinsic OXA- from October 1, 2007 to September 30, 2009 were tested group carbapenemase production. While A. baumannii carry for the presence of KPC gene using the modified Hodge test. the intrinsic OXA-51-like carbapenemase gene, carbapenem Medical records of patients with KPC were studied. resistance has only been associated with these genes when Results: Over the period of two-years 40,309 samples the insertion sequence ISAba1 is upstream. In this study, we were submitted for culture and sensitivity, out of which evaluated the in vitro activity of tigecycline against geneti- 7,836 were positive. Of the positives, there were 106 iso- cally defined A. baumannii from the Tigecycline Evaluation lates of K pneumoniae and 11 were ESBL positive. Of Surveillance Trial. the ESBL producing isolates, 8 carried the Carbapenem- Methods: A total 352 imipenem resistant Acinetobacter hydrolyzing ␤-lactamase. Of the eight, three isolates were baumanii from 35 countries (2004 to 2006) were evaluated. reported as being susceptible to Imipenem. Although all MICs were determined by broth microdilution and inter- the eight isolates were resistant using the Hodge test. preted according to CLSI guidelines. Carbapenemase genes Piperacillin/Tazobactam (PT) and Vancomycin were the were detected by multiplex PCR. e36 14th International Congress on Infectious Diseases (ICID) Abstracts

Results: All isolates tested in this study contained an OXA- sequence types were identiﬁed and are undergoing further 51-like gene. Additional genotypes are listed below. investigation.

N TIG MIC50 TIG MIC50 Range (mcg/ml) (mcg/ml) doi:10.1016/j.ijid.2010.02.1566

OXA-23 161 1 2 0.12-4 23.011 OXA-40 39 0.5 1 0.25-4 Emerging multi drug-resistant Acinetobacter in Iran: OXA-58 107 0.5 1 0.12-4 Study of 800 cases ISAbal-OXA-51 190 1 2 0.12-4 F. Abbasi 1, D. Yadegarynia 2,∗, M. Mardani 2, B. Frasinejad 2, T. Yaghubi 2, S. Gholamin 2 Conclusion: Tigecycline demonstrated excellent in vitro 1 Shaheed Beheshti Medical University, Tehran, Iran, Islamic activity against carbapenem resistant A. baumannii regard- Republic of less of carbapenemase type. Tigecycline’s in vitro activity 2 Shaheed Beheshti Medical University, tehran, Iran, Islamic against isolates with either intrinsic ISAba1-OXA-51 or the Republic of acquired oxacillinases (OXA-23, OXA-40 and OXA-58) sug- Background: Acinetobacter baumannii is a multi drug gests that it may be effective against resistant isolates of resistant organism associated with high morbidity and mor- this clinically important pathogen. tality. It is an emerging nosocomial pathogen in many parts of the world. The aim of the present study was to review the doi:10.1016/j.ijid.2010.02.1565 incidence of Acinetobacter in several hospitals in Tehran, 23.010 Iran and also to find out pattern of antibiotic resistance of Acinetobacter. We published primary results of this study Molecular typing of multi-drug resistant Acinetobacter when it was consisted of 100 samples. It was accepted in baumannii from London hospitals 48th Annual ICAAC/ 46th Annual IDSA congress, Oct. 2008. D. Wareham ∗, D. Bean Methods: In a retrospective study we detected 800 positive cultures of Acinetobacter from 800 patients in different Queen Mary University London, London, United Kingdom wards of several tertiary care hospitals in Tehran, Iran. Disk Background: Acinetobacter baumannnii has emerged diffusion method was used to determine the resistance of as a major nosocomial pathogen causing outbreaks of isolated Acinetobacter baumannii. Antimicrobial sensitiv- infection in the immunosuppressed and critically ill world- ity to 14 available antibiotics was analyzed. The following wide. A number of molecular typing techniques have antibiotics were tested: cefriaxone, cefotaxime, cef- been developed for use in both local surveillance and tazidime, cefepime, trimethoprim-sulfamethoxazole, gen- global epidemiological studies. We applied a recently tamicin, tobramycin, amikacin, ciprofloxacine, ofloxacine, described multi-locus sequence typing (MLST) scheme to imipenem, meropenem, piperacillin-tazobactam and tige- multi-drug resistant A. baumannii (MDRAB) recovered from cycline. London Hospitals in comparison with other molecular Results: The most frequently sites of infection were methods. wound, respiratry tract, blood stream, and urinary tract. Methods: Sixteen MDRAB were identified using multiplex The most increminated wards were burn and intensive care PCR for OXA-carbapenemases and included representatives unit with a high prevalence of wound infection, pneumo- previously assigned to the UK ‘South East’, OXA-23 (1) and nia and septicemia due to Acinetobacter. Acinetobacter was OXA-23 (2) clones. Stains were typed using pulsed field gel isolated from wound in 58.9%, tracheal discharge 9.2%, spu- electrophoresis (PFGE), randomamplified polymorphic DNA- tum in 7.1%, urine in 6.6%, blood in 5.8%, CSF in 3.4%, pleural PCR (RAPD), a multiplex PCR typing (MPT) scheme (ompA, fluid in 2%, tip of catheter (CV line) in 0.6% and brochoalve- csuE and blaOXA-51 like genes) and an A. baumannii MLST olar lavage (BAL) in 0.2%. scheme (gltA, gyrB, gdhB, recA, cpn60, gpi, rpoD). Acinetobacter baumannii showed resistance to cefri- Results: Five clearly distinguishable profiles were axone, cefotaxime, ceftazidime and cefepime more observed using PFGE and six with RAPD. MPT typing assigned than 90%. Resistance to gentamicin and trimethoprim- all but one of the strains (OXA-23 (2) representative) to sulfamethoxazole were more than 80%. Resistance to group 1. Four allelic profiles (sequence types ST) were amikacin, imipenem and ciprofloxacine were 72.7%, obtained using MLST, two of which appeared to be novel. 70.5% and 45.7% respectively. Tigecycline, piperacillin- Comparison of results revealed isolates designated ‘South tazobactam, tobramycin and ofloxacine were evaluated in East’ clone by PFGE / RAPD belonged to the previously 100 samples. Sensitivity to tobramycin and ofloxacine were described ST22 and those designated OXA-23 (1) to ST53. 28.9% and 25.3% respectively. Tigecycline and piperacillin- The allelic profile of the OXA-23 clone 2 strain was novel tazobactam were active against 100% and 74% of the strains and contained a new gyrB allele. respectively. Conclusion: Molecular techniques were comparable for Conclusion: Acinetobacter baumanii is an increasingly typing UK MDRAB. Isolates belonging to ST22, (found pre- isolated pathogen in Iran. Prevalence of carbapenem resis- viously in Italy, Portugal, Czech Republic, China, Korea tant acinetobacter is high in our study. Newer antimicrobial and Australia) and isolates belonging to ST53 (found previ- compound is needed for treatment of this infection. ously in Italy) were the most frequently types, highlighting the widespread dissemination of these clones. Two novel doi:10.1016/j.ijid.2010.02.1567 14th International Congress on Infectious Diseases (ICID) Abstracts e37

23.012 The increasing frequency of carbapenem-resistant P.aerugi- The prevalence of extended spectrum betalactamases at nosa isolates is of concern world wide. The carbapenemases a tertiary hospital in South Africa can be class A, B (metallo-ßlactamases) and D. The types of MBLs that have been described so far are, IMP, VIM, SPM, N. Mbelle GIM, SIM, with three recently reported AIM, KHM and NDM. They are typically present as integrons, often in association National health laboratory Services, Johannesburg, South with other resistance gene cassettes. The objective of this Africa study is characterization of MBl cassette-containing integron Background: The extent of extended spectrum beta lac- from P. aeruginosa in Malaysian isolates. tamase (ESBL) producing clinical isolates is now a global Methods: A total of 90 IMP-resistant clinical isolates were concern. The prevalence of ESBLs varies between species, randomly isolated from the patients admitted at Univer- geographically and with time. Delays in commencing appro- sity Malaya Medical Center (UMMC), during 2005-2008. MBL priate therapy have been shown to have an impact on producing isolates were phenotypically identified using MBL morbidity, mortality and hospital associated costs. The Etest and double disk synergy tests. Duplex PCR and PCR- availability of current South African data will provide the RFLP, were carried out to determine the presence of MBL evidence required to implement appropriate health mea- and class of integron. The gene cassette regions for the sures. class1 integrons were amplified using primer specific for the Methods: A retrospective descriptive study was per- 5CS and 3CS combining by VIM-R/IMP-R and VIM-F/IMP-F formed for the period from May 2008 to April 2009. respectively. Consecutive clinical specimens were obtained from admit- Results: Among 90 IMP-resistant isolates tested by the ted patients and patients referred from primary health care MBL Etest and double disk synergic test, 34 (37%) isolates clinics to Dr. George Mukhari tertiary hospital in Preto- were found to be MBL producers. Of these 34 MBL-positive ria, South Africa. Isolates from blood, cerebrospinal fluid, strains, PCR analysis confirmed blaIMP and blaVIM genes urine, sputum, pus and stools were processed using con- in 32 isolates (94%). In the present study, DNA sequencing ventional laboratory methods. Isolates were identified and shows that the MBL-positive genes were present as class1 susceptibility testing done on the Microscan® using the CLSI integrons. The gene cassette array of class 1 integrons con- guidelines.Demographic, clinical and laboratory data were taining MBL genes are listed as following: blaIMP-7, aacC1; evaluated. single gene cassette of blaVIM-11; aacA7 and blaVIM-2. The Results: ESBL production was identified in 454 (18%) blaIMP-4 gene was absent in the integrons of two strains of the enterobacteriaceae isolated this period. The clini- (attI; aacA7). Amplicons with lengths of 1.1 kb to 3.3 kb cal source was predominantly non-sterile sites, 386 (83%) were amplified using 5-CS and 3-CS primers for gene cas- compared to 78 (17%) from sterile sites. The majority of iso- sette regions and 4 types of PCR amplicons of gene cassette lates were from pus swabs (170) 44%, while 134 (35%) were were identified in 32 isolates with class 1 integronassociated from urine. Of the isolates identified, 271 (29%) were Kleb- MBL genes. siella pneumoniae, 89 (9%) Escherichia coli, 25 (3%) Proteus Conclusion: We confirmed that the integrons were preva- mirabilis, 25 (5%) Enterobacter cloacae, 12 (1%) Klebsiella lent and may play an important role in multidrug resistance oxytoca and the rest Enterobacter aerogenes, Morganella of P. aeruginosa. In addition, the class I was the most abun- morganii, Proteus vulgaris, Citrobacter freundii and Serra- dant type of integron in Malaysian isolates. tia marcescens. The prevalence of ESBLs in the Klebsiella pneumoniae isolates was found to be 271 (46%) and that for doi:10.1016/j.ijid.2010.02.1569 Escherichia coli 89 (12%). Conclusion: At our institution, the overall prevalence of 23.014 ESBL producing enterobacteriaceae of 18%, reaffirms the Carbapenem hydrolyzing multidrug resistant Acinetobac- global spread of ESBL producing bacteria. The presence of ter baumannii ESBLs in most of the common enterobacteriacea is consis- J. Koirala 1,∗, I. Tyagi 1, V. Sundareshan 1, S. Bergman 2,J. tent with the horizontal spread of ESBL genetic material. Lawhorn 3, C. Drake 3, C. Speil 1 Due to the significant epidemiological implications; detection and surveillance would benefit health interventions at 1 Southern Illinois University School of Medicine, Spring- our institution and the country. field, IL, USA 2 Southern Illinois University School of Pharmacy, doi:10.1016/j.ijid.2010.02.1568 Edwardsville, IL, USA 3 Memorial Medical Center, Department of Microbiology, 23.013 Springfield, IL, USA First characterization of blaIMP and blaVIM cassette- containing Novel Integron in metallo-ßlactamase produc- Background: Multidrug resistant (MDR) Acinetobacter ing Pseudomonas aeruginosa in Malaysia baumannii has emerged as a major pathogen causing healthcare-associated infections. Carbapenem susceptibil- ∗ Y. Khosravi , S.T. Tay, V. Jamuna ity in our local hospitals has declined from over 90% to less than 50% in past five years. University Of Malaya, Kuala Lumpur, Malaysia Methods: We analyzed A. baumannii isolated from vari- Background: Carbapenem play an important role in the ous patient specimens which were identified using standard treatment of infections caused by Pseudomonas aeruginosa. biochemical tests. Antibiotic susceptibility testing was e38 14th International Congress on Infectious Diseases (ICID) Abstracts done using standard disk diffusion method. Multidrug resis- role of efflux pumps in fluoroquinolone resitance was also tance was defined as resistance to 3 or more classes studied. Isolates were genotyped using PFGE and ERIC-PCR. of antibiotics including aminoglycosides, antipseudomonal Results: Six different Salmonella serovars were identi- penicillins, carbapenems, cephalosporins, and quinolones. fied, the majority being S. Agona (48%), with one of the S. MDR isolates were tested for carbapenemase production Agona isolates being unusually positive for a combination of using modified Hodge test. Phenotypic determination for TEM-1, SHV-12, OXA-1-like and DHA-1 genes. Twelve isolates metallo-beta-lactamase (MBL) production was done using (49%) were phenotypically ESBL producers, with 12, 11, 3, combined disk (imipenem + EDTA) and two different types 2 and 1 of these isolates being TEM-1, SHV-12, DHA-1, OXA- of double-disk synergy methods (imipenem + EDTA and cef- 1-like and CTX-M-15 gene postive, respectively. Four out of tazidime + EDTA). these 12 ESBL positive isolates were also resistant to flu- Results: We studied 60 non-duplicate isolates of A. bau- orquinolones with 3 out of 4 possessing double mutations mannii that were grown from patient specimens including in the gyrA gene. No mutations were detected in the gyrB blood, bone, wound, sputum, and other sources, obtained and parE genes of these 12 isolates. Inc/rep typing detected over a 12- month period in 2008-2009. Among these isolates, the presence of FIIS replicons in the majority of isolates. 65% were resistant to 3 or more classes of antibiotics meet- Phenotypic evidence for efflux pumps was detected in 4 ing criteria for MDR organisms, and 50% showed reduced isolates. Eight of the isolates were positive for integrons. susceptibility to carbapenems. Modified Hodge test was pos- Genotypic diversity was observed among the isolates, even itive in 19 (83%) of carbapenem-resistant isolates showing within isolates from the same hospital. carbapenemase production. All MDR isolates were negative Conclusion: Twelve of 23 (52.2%), a very high proportion for metallo-betalactamase (MBL) production when pheno- of non-typhoidal salmonellae from India produced ESBLs. typically tested with double-disk synergy method, using The SHV-12 ESBL is one of the most common non-CTX- imipenem + EDTA and ceftazidime + EDTA. These findings M ESBLs and is identified in many Gram-negative species, were similar when we tested with combined-disk synergy including Salmonella species. Our study confirms the role test using imipenem + EDTA. of double mutation in gyrA combined with 1 or 2 mutations Conclusion: This study confirms that majority of the in the parC and efflux mechanisms in conferring high resis- currently prevalent A. baumannii are multidrug-resistant tance to ciprofloxacin. In India, non-typhoidal salmonellae organisms, and half of them are carbapenem resistant. Car- constitute approximately 20% of the Salmonella serovars and bapenemase production appears to be the most common continued surveillance for the presence of new ESBLs and mechanism of carbapenem resistance by phenotype screen- fluoroquinolone resistances is required in India. ing method. Since these isolates were negative for MBL phenotype, production of carbapenem hydrolyzing oxacil- doi:10.1016/j.ijid.2010.02.1571 linase is the most likely mechanism of resistance. 23.016 doi:10.1016/j.ijid.2010.02.1570 First description of CTX-M extended-spectrum ␤- lactamase-producing clinical Escherichia coli strains from 23.015 Macao, China Antimicrobial resistance in non-typhoidal Salmonellae Q.H. Ye, Y. Lau ∗ B. Harish 1,∗, M. Khan 2, J. Hays 3, G. Menezes 4 Macao Polytechnic Institute, China, China 1 Jawaharlal Institute of Postgradute Medical Education & Background: Extended-spetrum ß-lactamases (ESBLs) Research (JIPMER), Pondicherry, India producing Escherichia coli (E.coli) is an emerging major 2 Erasmus MC, ROTTERDAM, Netherlands pathogen worldwide. It has the ability to hydrolyze and 3 Erasmus MC, Rotterdam, Netherlands cause resistance to various types of newer ß-lactamases 4 Jawaharlal Institute of Postgraduate Medical education antibiotics, including third generation cephalosporins and and Research (JIPMER), Pondicherry, India monobactams. Organisms that produce ESBLs remain an Background: Non-typhoidal salmonellae are among the important reason for therapy failure with cephalosporin primary causes of food-borne gastroenteritis worldwide. and have serious consequences for infection control. Those Treatment failures due to the in-vivo acquisition ESBL gene clinical microbiology laboratories detect and report ESBL- or fluoroquinolone resistance in these bacteria are well producing organism is therefore important.The objectives documented, particularly in India, though actual molec- of this study were to determine the prevalence, genotype ular information is currently lacking. In this study we and clonal relationship of extended-spectrum ␤-lactamases investigated ESBL genes, and fluoroquinolone resistance in (ESBLs) in 209 clinical Escherichia coli strains from Macao, non-typhoidal salmonellae isolated. China. Methods: 23 isolates of non-typhoidal salmonellae were Methods: Phenotypic detection was used by the standard collected. Isolates were identified biochemically and agglu- disk diffusion method, double-disk synergy test and E-test. tination, with antibiotic profiles being obtained. PCR and The genotypic characterization was detected by isoelec- sequencing were used to determine the genetic determi- tric focusing analysis (IEF). The clonal relationship between nants of antibiotic resistance. Isolates were screened for qnr the different isolates was studies by pulsedfield gel elec- gene and integrons by PCR, and plasmid analysis was per- trophoresis (PFGE) formed using PCR-based replicon typing. Crude extracts of Results: The prevalence rate of ESBLs was 30.1% accord- $-lactamase were subjected to isolelectric focussing and the ing to the Clinical and Laboratory Standards Institute. By 14th International Congress on Infectious Diseases (ICID) Abstracts e39 isoelectric focusing analysis, polymerase chain reaction and nervous, cardiovascular, respiratory, gastrointestinal and sequencing, we detected the major genotypic characteri- urogenital systems. zation of ESBLs was CTX-M-14 (76.2%). Two strains showed Methods: In the present study, some phenotyic and indistinguishable patterns by pulsed-field gel electrophore- molecular typing techniques were applied on 108 strains of sis. E. coli, 88 strains of Ps. aeruginosa and 8 strains of Serratia Conclusion: This study documented the CTX-M family as isolated from different clinical lesions in Mansoura Univer- the predominant ESBL type among Macao population. The sity Hospitals, Egypt. spread of CTX-M enzymes is concerning and deserves close Results: The distribution of antibiotic resistance among monitoring in further investigation. the isolated strains showed high incidence of resistance and imipenem was the most active antibiotic. Using the active doi:10.1016/j.ijid.2010.02.1572 pyocin typing, 72 strains of Ps. aeruginosa could be typed into 35 pyotypes. SDS-PAGE of total cell protein extracts 23.017 showed that the presence of fifteen patterns among E. coli Utilizing hospital generated antibiograms to examine strains and eleven patterns among Ps. aeruginosa strains. state trends in antibiotic resistance Using PCR technique it was found that 84% of the 50 tested strains were found to have at least one of the tested ESBLs. S. Onofrey ∗, M. Morrison, M.-Y. Lin, B. Bolstorff, A. DeMaria Also TolC and AcrA genes were present in all tested E. Massachusetts Department of Public Health, Jamaica Plain, coli except 4 strains and did not present in Ps. aerugi- MA, USA nosa except 4 strains. Plasmid profiles of 23 tested E. coli appear to be diverse. Also the prevalence of plasmids in 22 Background: Antibiograms are aggregated, hospital- tested Ps. aeruginosa strains was lower than in tested E. coli generated reports on susceptibility of bacteria of interest therefore 59.1% of tested Ps. aeruginosa strains harbored to specific antibiotics. They are utilized within hospitals plasmids. Using Pyrosequencing technique, the sequenced to assist in effective use of antibiotics. The Massachusetts region of gyrA, gyrB and ParC were able to differentiate Department of Public Health (MDPH) has been requesting between the tested strains and neighbor-joining tree was voluntary submission of antibiograms from hospitals annu- constracted to determine relatedness between the isolated ally since 1999. strains. Morover, Molecular cloning of the whole sequence of Methods: Susceptible proportions reported in antibi- bla-TEM, bla-SHV and bla-CTX-M was carried out experimen- ograms were analyzed to evaluate changes in levels of tally to study the expression of these genes and determine susceptibility over five years, while accounting for the which genes of them responsible for the resistance. effect of hospital characteristics. Trends were examined Conclusion: Molecular-based methods of typing are more for specific antibiotic and bacteria combinations as well as advantageous compared with phenotypic methods of typ- antibiotic class susceptibility patterns. Data were analyzed ing in terms of better discrimination and reproducibility. using SAS software version 9.1 (SAS Institute Inc., USA). Significant genetic variation was observed among different Results: Significant trends in antibiotic resistance strains represented by the diversity of their plasmid profiles. were seen with a strong decreasing trend in E.coli All molecular genetic methods for distinguishing organism fluoroquinolone-susceptibility and a moderate decrease in subtypes are based on differences in the DNA sequence. Klebsiella pneumoniae and Enterobacter cloacae. Specif- ically, E.coli susceptibility to ciprofloxacin decreased doi:10.1016/j.ijid.2010.02.1574 substantially over five years, and this trend was more pronounced in specific regions of the state. Other hospital 23.019 characteristics such as bed count and hospital type did not Extended spectrum beta-lactamases in Escherichia coli appear to have a significant association with antibiotic resis- and Klebsiella spp. from Eastern Romania tance trends. ,∗ Conclusion: Antibiograms may serve as useful tools in E. Miftode 1 , O. Dorneanu 2, D. Leca 3, A. Teodor 4,A. examining regional antibiotic resistance trends. Trends iden- Badescu 5, G. Juganariu 5, A. Vita 5, C. Dorobat 5 tified may be used to inform further studies and pinpoint 1 University of Medicine and Pharmacy - Hospital of Infec- areas of concern for hospitals. tious Diseases, Iasi, Romania 2 Univ Medicine and Pharmacy Iasi, Iasi, Romania doi:10.1016/j.ijid.2010.02.1573 3 University of Medicine and Pharmacy, Iasi, Romania 23.018 4 Univ of Medicine and Pharmacy, Iasi, Romania 5 Univ Medicine and Pharmacy, Iasi, Romania A Comparative study on gram-negative bacterial infections in Mansoura University Hospitals, Egypt Background: The emergence and dissemination of ESBL are problems of major importance for the population health; W. El-Naggar, R. Ibrahim, E. Habib ∗, S. Gerorge, E. Abd- ESBLs represent a first example of factor that contribute Elmagid to the global crisis concerning the treatment of Klebsiella Faculty of Pharmacy, Mansoura, Egypt pneumoniae and Escherichia coli against which the third generation cephalosporins are not efective anymore. Background: Gram negative bacteria are responsible for Methods: Clinically isolates of E. coli (n= 642) and numerous infectious diseases. These diseases can occur in Klebsiella (n=92) were collected from patients with dif- and harm any part of the body, the skin, eyes and the ferent types of infections (sepsis, urinary tract infections, e40 14th International Congress on Infectious Diseases (ICID) Abstracts etc), hospitalyzed between september 08 and septem- occurred among carbapenemase producers. The expert sys- ber 09 in a Hospital of Infectious Diseses from Eastern tem showed sensitivity (SN) of 76% and specificity (SP) of 87% Romania. Double disc synergy test using cefotaxime and for carbapenemase detection, when confronted to the geno- amoxicillin/clavulanic acid discs was used to screen ESBL type, with the greatest SN for KPCs (82%) and the lower for producers and these strains were subsequently subjected to MBLs (25%). The recognition of suspected carbapenemase confirmatory Etest. producers could be increased with the combined used of Results: E. coli resistance to cefotaxime, ceftazidime, IPM and MEM with modified cut-off points of >=2.0 mg/L and cefoxitin, ciprofloxacin and imipenem was found to be 40, >=1.0 mg/L, respectively (SN 97%, SP 90%). 29, 6, 30 and 1% respectively. Klebsiella resistance to cefo- Conclusion: VITEK2 may be suitable in clinical labora- taxime, ceftazidime, cefoxitin, ciprofloxacin and imipenem tories for Class A carbapenemase detection, but should was 70, 57, 22, 41 and 4% respectively. % of ESBL produc- be accompanied with modifications in the cut-off used for ers E. coli was 15% (97 strains) and Klebsiella was 38% (35). screening of suspected carbapenemase producers to ensure All the ESBL producing strains were susceptible in 100% to their proper detection. imipenem and meropenem. Conclusion: Carbapenems remain the most active agents doi:10.1016/j.ijid.2010.02.1576 against Gram-negative isolates, including ESBL producers strain of E. coli and Klebsiella spp. isolated from community- 23.021 acquired and nosocomial infections from Eastern Romania. Emergence of multidrugresistant gram negative bacilli and enterococci from rectal swabs of newborn and their doi:10.1016/j.ijid.2010.02.1575 mothers from Central India ,∗ 23.020 S. Chitnis 1, V. Chitnis 2 , D. Chitnis 1 Can we rely on automated VITEK2 system the detection 1 Choithram Hospital and research center, Indore, India of KPC and other class A carbapenemase producers enter- 2 Medical University of Americas, St James Parish, Saint obacteriaceae? Kitts and Nevis ∗ F. Pasteran , C. lucero, R. soloaga, A. Corso Background: Newborn babies acquire gut flora mainly from mother and surrounding. We had observed in the faecal Instituto Nacional de Enfermedades Infecciosas ‘‘Dr. C. Mal- samples of newborns prevalence, colonization of multidrug brán’’, Buenos Aires, Argentina resistant, ESBL pandrug resistant gram negative bacteria, Background: Class A carbapenemases have become more vancomycin resistant enterococci as a new threat in the prevalent within Enterobacteriaceae. Proficient methods newborn admitted in hospital.The influx of these bacteria are needed for their early detection in clinical micro- into hospitals has major implications for infection—control biology laboratories in any attempt aimed for targeting and empirical treatment strategies. optimal antimicrobial therapy and controlling their spread. Methods: A total of 140 samples of faeces from neonates Automated systems, as VITEK2, are increasingly used for and mothers admitted in general maternity ward and ICU routine susceptibility testing to decrease the in-laboratory of two hospital in central India were examined within turnaround time. However, the performance of VITEK2 for 24-48 hours for presence of ESBL, pandrug resistant gram the whole class A carbapenemase family detection has never negative bacilli, and vancomycin resistant been assessed before. Objective: to determine the perfor- enterococci. Antibiotic susceptibility test were per- mance of VITEK2 for carbapenemase detection compared formed using Kirby-Bauer disc diffusion method and results with both, CLSI agar dilution MIC and the genotype obtained were interpreted according to CLSI. Van A and ESBL gene by molecular methods. was confirmed using E test, PCR and RT PCR. Methods: Methods: we designed a panel composed by Results: 1. A total of 48 E.coli,49Klebsiella,21Pseu- diverse bacterial genera with distinct carbapenem suscep- domonas and 52 Entercocci isolates were obtained. The tibility patterns composed by 37 carbapenemase producers percentage of multidrug resistant E.coli, Klebsiella, Pseu- and 34 nonproducers (n): KPCs (17) Sme (10), NMC-A/IMI domonas and enterococci was 78.79, 66.67, 58.8 and 91.18% (2), GES (4), VIM/IMP (4) and CTX-M (12), AmpCs (12), respectively. For gram negative bacilli % resistance for chlo- combined mechanisms and others (10), respectively. The ramphenicol (47%), cabapenem 58.9% and ampicillin (74.3%) resistance mechanisms of the strains were assessed by aminoglycosides (70.9%), quinolones (65.8%) and cefopara- PCR/DNA sequencing. Each isolate was tested with the zone+ sulbactum (58.1%). piperacillin+tazobactum (69.2%) VITEK2 using the AST-N082 cards specifically designed for cotrimoxazole (47%) cephalosporin (71.1%).The prevalence South American countries (which included only imipenem of ESBL gene (TEM and SHV) among E.coli and Klebsiella -IPM- and meropenem -MEM-), according to the manufac- was 100% and 75% respectively. The pandrug resistant was turer’s instructions and by CLSI agar dilution MICs for both 18.15% among E.coli and 20.4% among Klebsiella and 1.5% carbapenems. Discrepant results were resolved by retesting among Pseudomonas Of 52 enterococci, 47.06%. of them the isolates. were vancomycin resistant strain and harboured van A gene. Results: Overall categorical interpretations with VITEK2 Enterococci were showing a high level resistance to amino- showed a 72% and 79% of agreement with reference MICs glycosides (82.35%), ampicillin (82.35%), chloramphenicol for IPM and MEM, respectively. Very major (VM), major (MA) (38.24%), teicoplanin (44.12%) and linezolid (8.82%). and minor (MI) errors were: IPM, VM 3%, MA 11% and MI 13%; Conclusion: We report high rates of colonization with MEM, VM 4%, MA 6% and MI 11%. Most of the errors (>80%) ESBL and pandrug resistant gram negative organism and 14th International Congress on Infectious Diseases (ICID) Abstracts e41 vancomycin resistant enterococci among faecal samples case-control study should be conducted to validate these from newborn admitted in ICU, maternity ward with in 24- findings. 48 hours from two hospitals in central India. The colonization is mainly due to antibiotic usage by the mother as well as doi:10.1016/j.ijid.2010.02.1578 newborn in ICU. Antibiotics used were cefotaxime, gentamicin amikacin and ciprofloxacin. It poses a great threat to 23.023 infection control measures and complicates the selection of Multidrug resistant and sensitive strains of Pseudomonas empirical treatment. aeruginosa: Establishing clonal relationship by Pulsed Field Gel Electrophoresis and in vitro antibiotic synergy doi:10.1016/j.ijid.2010.02.1577 testing by E test ,∗ 23.022 S.F.A. Mohd Nawi 1 , R. Karunakaran 2, K.-L. Thong 3, M.Y. Yusof 2, J. Vadivelu 2 Patients with hematological malignancies who are prescribed quinolone prophylaxis postchemotherapy in a 1 Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia hospital with high gram-negative quinolone resistance are 2 Department of Medical Microbiology, Faculty of Medicine, at a higher risk for febrile neutropenia University of Malaya, Kuala Lumpur, Malaysia 3 ,∗ Institute of Biological Sciences, Laboratory of Biomedi- E. Ng 1, Y.X. Liew 2, Y. Ding 1, L.P. Koh 1, J. Jin 1, L.Y. Hsu 1 cal Science and Molecular Microbiology, Faculty of Science, 1 National University Health System, Singapore, Singapore University of Malaya, Kuala Lumpur, Malaysia 2 Singapore General Hospital, Singapore, Singapore Background: The emergence of multidrug resistant Background: Febrile neutropenia (FN) remains a major Pseudomonas aeruginosa (MDRPA) as one of the leading noso- cause of morbidity and mortality in patients receiving comial pathogens imposes a serious health threat due to chemotherapy. Major prophylactic strategies include gran- limited antibiotic options. In this study, a sample of clon- ulocyte colony stimulating factor and antibiotics, the most ally distinct MDRPA and sensitive strains of Pseudomonas widely used of which are quinolones. While quinolone pro- aeruginosa (SSPA) were tested against various antibiotics phylaxis has been shown to be effective in areas where combinations to establish synergistic activity against these fluoroquinolone resistance is low, this same efficacy has strains. not been proven in areas where resistance is high. We Methods: A total of 39 retrospectively collected MDRPA reviewed the efficacy of quinolone prophylaxis in prevent- strains isolated over three years with a particular antibi- ing FN in patients with leukemia and lymphoma undergoing ogram (sensitive to colistin but resistant to ceftazidime, chemotherapy at our institute - a tertiary academic medical cefepime, cefoperazone, cefoperazone/sulbactam, center where quinolone resistance among aerobic gram- ciprofloxacin, imipenem, meropenem, piperacillin, negative bacilli (GNB) exceed 40%. piperacillin-tazobactam, gentamicin, netilmicin, with Methods: A retrospective chart review was performed on varying susceptibility to amikacin) and 19 SSPA collected all patients with acute leukemia and lymphoma who under- prospectively were genotyped using Spe1 DNA macrorestric- went chemotherapy and were at high risk (>5%) of FN at our tion analysis and pulsed-field gel electrophoresis (PFGE). institute between 1 October 2008 and 30 September 2009. The strains were from different patients from various sites Demographic and clinical characteristics for each episode of (blood, tissue, fluid, catheter tip, bronchiol alveolar lavage chemotherapy were collected, with the main outcome being (BAL), urine, sputum, swab, tracheal secretion and nasal presence/absence of FN. Generalized estimating equation swab). Clonal relatedness was determined at ≥85% level of (GEE) models were used to analyze the data to adjust for similarity and grouped into different clusters. A representa- serial autocorrelation due to repeat measurements of both tive strain from each cluster was tested against 10 different outcome and covariates for each patient. paired combinations of various antimicrobials (␤-lactams, Results: There were a total of 510 chemotherapy quinolone, aminoglycoside, tigecycline, rifampicin and episodes from 119 patients within the study period, with colistin) to establish synergistic activity against these median number of chemotherapy episodes being 3. Demo- strains using the investigational E test fixed ratio method. graphic and clinical characteristics - including disease stage Results: There were 46 distinct clones out of a total of 58 - were similar between patients on and off quinolone MDRPA and SSPA resolved by PFGE from which 10 clonally dis- prophylaxis. Among all patients, those on quinolone prophy- tinct strains (8 MDRPA and 2 SSPA strains) were selected for laxis were at significantly higher risk for both FN (OR:5.4; synergy testing. The antibiotic combination which most fre- 95%CI:3.1-9.4; p < 0.01) and FN with bacteremia (OR:5.3; quently demonstrated synergy was cefepime with amikacin 95%CI:2.7-10.6; p < 0.01). Subgroup analysis for patients (4/10 strains). Other synergistic combinations were aztre- with acute myeloid leukemia and lymphoma showed simi- onam with either ceftazidime or cefepime, and meropenem lar higher risk of FN for patients with quinolone prophylaxis with ciprofloxacin (3/10 strains respectively), ceftazidime (OR:7.1; 95%CI:2.2-23.0; p < 0.01 and OR:3.8; 95%CI:1.7-8.7; with either ciprofloxacin or amikacin (2/10 strains respec- p < 0.01 respectively). All GNB isolated in these patients tively) and imipenem with ciprofloxacin (1/10 strains). The were resistant to quinolones. combination of ceftazidime with amikacin was antagonis- Conclusion: In a hospital with high quinolone resis- tic in 1/10 strains. The other antibiotics combinations were tance rates, quinolone prophylaxis failed to protect patients either additive or indifferent. with hematological malignancies from developing FN as Conclusion: PFGE was a useful and discriminative molec- well as FN associated with bacteremia. A prospective ular subtyping tool to establish clonal relatedness among e42 14th International Congress on Infectious Diseases (ICID) Abstracts strains. Results of antimicrobial synergy testing indicate that is to describe emergency of polymyxins resistance during although certain combinations may act synergistically, it was therapy. still strain dependent. These preliminary findings require Methods: A 30 years old male patient with bilioma after further confirmation with testing of a larger number of iso- liver transplantation had eighteen successive cultures isolates. This study was funded by the University of Malaya lates of E. aerogenes (Ea)from blood and peritoneum fluid Research Grant F vote: FS242/2008B recovered during thirty days hospitalization. Identification was done by VitekTM (Biomerieux) and antimicrobial suscep- doi:10.1016/j.ijid.2010.02.1579 tibility test were done by disk-diffusion (DD) and EtestTM (AB Biodisk) according to CLSI. Polymixins agar dilution was also 23.024 performed. All isolates were submitted to pulsed field gel KPC Antibiogram in a large teaching Brazilian Hospital electrophoresis analysis. Results: In the third day of hospitalization the first blood J. Almeida 1, A.P. Cury 2, M. Maffucci 2, H. Caiaffa 2, J.A. culture was positive for Ea susceptible to carbapenens. MIC Duarte 2, F. Rossi 3,∗ for polymyxin B was 1 mg/L and for colistin 0,5 mg/L. DD 1 University of São Paulo, São Paulo, São Paulo, Brazil showed 14 mm of zone inhibition for colistin. After six days 2 University of São Paulo, São Paulo, Brazil of meropenem therapy Eaisolates became resistant to car- 3 HOSPITAL DAS CLINICAS, SAO PAULO, NA, Brazil bapenens with MIC higher than 32 mg/L. Colistin therapy was initiated until patient’s death. The eight initials iso- Background: Describe susceptibility profile of KPC Kleb- lates recovered before colistin treatment had MIC less than siella pneumoniae producers recovered in a teaching 2 ␮g/ml for polymyxins and eight Ea isolates recovered after hospital from São Paulo. this period had MIC above 12 ␮g/ml for polymyxins. The four- Methods: We analyzed 27 isolates of KPC, one per teenth isolate, one day before the patient’s death, had MIC patient, from July 2008 to April 2009. Identification was per- of 64 mg/L for polymyxin B and colistin, DD inhibition zone TM formed by GNI650 Cards Vitek (Biomerieux, Marcy l’Etoile, for colistin was 7 mm. Correlation between DD and MIC above France); susceptibility test was performed by disk diffusion 8!g/ml for polymyxins was seen with disk inhibition zones and the Hodge Test was done according to CLSI-M100S19 inferior than 13 mm. All Ea belonged to the same clone. recommendations. blaKPC detection was done by PCR with Conclusion: CRE is a therapeutically and epidemiological previously described primers and Pulsed Field Gel Elec- challenge in every hospital. Colistin is one of the therapeu- trophoresis (PFGE) was also performed. Minimal Inhibitory tically options but resistance may emerge during treatment Concentration (MIC) for polymyxin B, tigecycline and car- and its in vitro activity is not routinely recommended by TM bapenens was performed by Etest (Biomerieux, Marcy CLSI. l’Etoile, France). Results: KPC antibiogram showed multiple resistance as doi:10.1016/j.ijid.2010.02.1581 expected: 100% to ertapenem, 81,4% to meropenem, 77,7% to imipenem, 93,6% to amikacin; 82,5% to gentamicin, 89% 23.026 to cefepime and ceftazidime and 100% to ciprofloxacin, sul- Outbreak of (OXA-66 carbapenemase) multidrug-resistant phametoxazol/trimetropim, piperacillin/tazobactam and to Acinetobacter baumannii in a Spanish tertiary-care hos- aztreonam. MIC 50/90 were 2 mg/l and 3 mg/l to tigecyclin, pital: Epidemiology and study of patient movements and 2 mg/l and 48 mg/l to polymyxin B. PFGE showed that ∗ 89% belonged to the same molecular profile. F. Gonzalez , E. Culebras, J. Head, M. Gomez, G. Morales, Conclusion: KPC isolates showed very few therapeutically J. Picazo options being tygecyclin the most active drug among those Hospital Clinico San Carlos, Madrid, Spain isolates. In our institution treatment with polymyxin B alone has to be carefully monitored until MIC is available. The Background: Acinetobacter baumannii is an increasingly same molecular profile emphasizes the horizontal spreading common nosocomial pathogen. Carbapenems have been of these multiresistant bacteria. the agents of choice for severe Acinetobacter infections. We describe an outbreak of multidrug-resistant (MDR) A. doi:10.1016/j.ijid.2010.02.1580 baumannii that produced OXA-66 carbapenemase and was resistant to imipenem. We also analyze the relationship 23.025 between the spread of this strain and patients’ movements Decreased susceptibility to polymyxins emerging during within the hospital. treatment for carbapenem-resistant Enterobacter aero- Methods: Thirty-one isolates of A. baumannii with very genes infection similar susceptibility patterns from 15 patients, recovered in a 2 months period, were studied. We analyzed 8 more J. Almeida 1, H. Caiaffa 1, A.P. Cury 1, G.D. Almeida 1, D.O. isolates recovered during the following year. ERIC-PCR and Garcia 2, M.N. Burattini 1, F. Rossi 1,∗ RAPD genotyping methods were used to define clusters of 1 University of São Paulo, São Paulo, Brazil clonally related isolates. PFGE was used to confirm the 2 Instituto Adolfo Lutz, São Paulo, Brazil results and to check the maintenance of the epidemic strain over the following year. Patterns of possible transmission Background: Emergence of carbapenem resistant enter- were analyzed by recording patient movements within the obacteriaceae (CRE) is worrisome and polymyxins are hospitals. Antibiotic susceptibility testing to 28 agents was possible therapeutic options. The objective of this article performed by microdilution and by E-test. The isolates were 14th International Congress on Infectious Diseases (ICID) Abstracts e43 screened by PCR analysis with primers specific for 6 car- Results: The main evaluation took place in May — August bapenemase genes. Amplification products were sequenced 2009. Each of the completed levels was evaluated for sta- to determine the gene present. tistical significance of knowledge change of the LOs. As Results: Twelve of the 15 patients studied were hospi- many questions were correct before and after the game, the talizated at the ICU. The most frequent sites of isolation statistically significant improved responses were measured were the respiratory tract (16) and the blood (11). With the (using McNemar’s test), for the following questions: ‘‘if you exception of colistin (0% resistance) there were no antibi- cannot see a microbe it is not there’’, ‘‘most coughs and otics with good activity against these isolates. Of the other colds get better without medicine’’ and in particular ‘‘we antibiotics tested, tigecycline showed the best activity with use good microbes to make things like bread and yogurt’’. an MIC90 value of 2 mg/L. The genotypic study revealed There was a trend towards improved knowledge however in that the same strain was responsible for all the infections. other questions did not reach statistic significance All the isolates harboured the bla-OXA-51—like gene and the Conclusion: The study demonstrated that computer 6 of them chosen to sequence the gene were identical and games can teach children about hygiene and antibiotics in 100% homologous with the bla-OXA-66 gene. PCR showed an enjoyable way. Further study is needed to evaluate an that the insertion sequence ISAba1 was present upstream of impact on behaviour change the oxacillinase gene in all the isolates. Conclusion: a) Molecular typing revealed that the out- doi:10.1016/j.ijid.2010.02.1583 break detected in our hospital was due to a single A. 23.028 baumannii clonal group. b) The epidemic strain of A. baumannii produces an OXA-66-ISAba1 carbapenem-hydrolyzing Antimicrobial utilization and susceptibility patterns of a oxacillinase. c) Even though the outbreak was controlled, sentinel group of bacterial isolates prior and subsequent and the number of isolates decreased significantly, the clone to the introduction of Ertapenem to the hospital formu- responsible of the outbreak persisted at the hospital during lary the following year. J. Araujo 1,∗, C. Rodrguez-Osorio 1, E. Criollo-Mora 1,A. Ramos-Hinojosa 1, A. Macías Hernandez 2, A. Ponce-de- doi:10.1016/j.ijid.2010.02.1582 Leon 1, J. Sifuentes-Osornio 1 23.027 1 INSTITUTO NACIONAL DE CIENCIAS MEDICAS Y NUTRICION Online games teaching children hygiene and antibiotic SALVADOR ZUBIRAN, TLALPAN, Mexico 2 resistance: Evaluation of the e-Bug games National Institute of Medical Sciences, Mexico City, Mexico Background: It has been suggested that after the intro- D. Farrell 1, P. Kostkova 1,∗, J. Weinberg 1, D. Lecky 2,C. duction of ertapenem into hospital use, the amount of other McNulty 2 carbapenems and the rate of resistance to other antimi- 1 City University, London, United Kingdom crobials decreases. We conducted a retrospective study to 2 Health Protection Agency, Gloucester, United Kingdom evaluate these outcomes. Methods: We studied 48 months (two 24 month-periods) Background: e-Bug is a EC-funded antibiotic, hygiene before (PRE) and after (POST) the introduction of ertapenem teaching resource aiming to reinforces an awareness of in August 2004. Antibiotic use was determined using the microbes, respiratory hygiene and prudent antibiotics use standard defined daily dose (DDD) per 1000 patient/days. among junior and senior school children across Europe. e- Antimicrobial susceptibility testing to Escherichia coli, Bug junior web games were developed for children age 9-12 Pseudomonas aeruginosa, Klebsiella pneumoniae and Acine- years. The e-Bug junior game has a number of ‘‘levels’’ tobater baumanii was performed with the Vitek automated teaching the given set of learning outcomes (LOs). Player, system. We used chi-square for trend to compare rates of shrunken inside human body, interacts with good and bad resistance and changes in antimicrobial use. cartoon microbes (Fig 1) as well as antibiotics and viruses. Results: In the PRE-period, we analyzed 4072 E. Teaching the LOs is implemented through interaction with coli, 677 P. aeruginosa, 571 K. pneumoniae, and 67 A. microbes (making yogurt (Fig 3), finishing course of antibi- baumanii isolates; in the POST 4648, 884, 559, and otics (Fig 2). Knowledge is tested seamlessly before and after 109, respectively; antibiotic consumption was as follows: each level in a Game Show style similar to the game ‘‘Do you PRE-period: meropenem 89.9 DDD/1000/patients/days, want to be a Millionaire?’’ antipseudomonal cephalosporins 90.9, and ceftriaxone Methods: Evaluation was primarily conducted in the UK 195.65; POST period: 75.3, 103.58, and 184.77, respec- and online demonstrating statistically significant knowledge tively. The rate of antimicrobial susceptibility was: E. coli,to gain of the learning outcomes. This was complemented meropenem in PRE-period 99.6% and in POST-period 98.05%, by focus groups and observational studies with 29 pupils to ceftazidime 88.67% and 84.75% (p < 0.000), respectively; taking part (and fully completing the pre and post question- to P.aeruginosa, meropenem 67.41% and 61.74% (p = 0.004), naire) from three schools. Before playing the game, only 4 respectively, ceftazidime 63.74% and 62.12% (p = 0.3388), pupils ‘‘agreed’’ that fungi were microbes while after play- respectively, and piperacillin/tazobactam 69.17% and ing 18. Smaller improvements were seen in other questions 67.21%(p = 0.15), respectively; K. pneumoniae, meropenem including: ‘‘We use microbes to make things like bread and 100% and 98.7% (p < 0.05), respectively, and ceftazidime, yogurt’’ (11 correct before, 23 correct after) and ‘‘Soap can 86.60% and 90.29% (p = 0.018); A. baumanii, meropenem be used to wash away bad bugs’’ (20 before vs 24 after) 95.2% and 79.09% (p = 0.08), respectively, and ceftazidime 76.14% and 58.88% (p = 0.12), respectively. e44 14th International Congress on Infectious Diseases (ICID) Abstracts

Conclusion: Our data show that after the inclusion of Conclusion: Carbapenem-resistant A. baumannii infec- ertapenem, the use of other carbapenems and ceftriaxone tions were associated with severe morbidity, requiring significantly decreased, however the use of antipseu- prolonged hospitalization and ICU admissions, and also domonal cephalosporins significantly increased; of note, resulted in increased mortality. there was a slight decrease in the susceptibility to carbapenems and broad-spectrum cephalosporins during the doi:10.1016/j.ijid.2010.02.1585 POST-period, which could be attributed to the intensive use of both, ceftriaxone and antipseudomonal cephalosporins. Arboviruses (Poster Presentation) doi:10.1016/j.ijid.2010.02.1584 24.001 Doxycycline modify the cytokine storm in patients with 23.029 dengue and dengue hemorrhagic fever Clinical characterization of patients with carbapenem- 1,∗ 2 resistant versus carbapenemsusceptible Acinetobacter J. Zavala Castro , T. Fredeking baumannii infections 1 Universidad Autonoma de Yucatan, Merida, Yucatán, Mex- I. Tyagi ∗, J. Koirala ico 2 Antibody Systems Inc., Hurst, TX, USA Southern Illinois University School of Medicine, Springfield, IL, USA Background: Dengue virus infection is an acute febrile disease caused by a virus of the genus Flavivirus, family Background: Steady rise in carbapenem resistance in Flaviridae. Usually is a mild self-limiting acute illness, but Acinetobacter baumannii has become a major challenge for may evolve to a hemorrhagic form characterized by plasma clinicians. The objective of this study is to characterize leakage and hemorrhagic manifestations. The treatment of clinical features of infections secondary to carbapenem- both forms has been limited to the management of the signs resistant organisms compared to carbapenemsusceptible and symptoms, and sometimes a retroviral treatment has organisms. been used. The cytokine cascade has a crucial role in the Methods: We conducted a retrospective analysis of data pathogenesis of dengue (DF) and dengue hemorrhagic fever for 39 patients from two tertiary care medical centers (DHF), and the presence of the Th1 and Th2 cytokines are who had positive cultures for A. baumannii. Collected responsible to cross-regulate the disease from a mild illness data included clinical presentations, underlying illnesses, (DF; Th1-type response), to a severe illness (DHF; Th2-type treatment course, clinical outcome, microbiological data response). Recently, doxycycline was show to inhibit the and other laboratory data. Statistical comparisons were cytokine storm caused by Staphylococcal exotoxins, specifi- done between patients infected with carbapenem-resistant cally the cytokines involved in the Th2-type response. In this (CRAB) and carbapenem-susceptible (CSAB) isolates using work, we use the doxycycline and tetracycline treatment in Fisher’s exact test and Student’s T-test. Multidrug resistance patients with dengue and dengue hemorrhagic fever,in order (MDR) was defined as resistance to more than two classes of to regulate the Th1 and Th2 cytokines. antibiotics generally active against A. baumannii. Methods: Thirty patients were included in the work. Results: Total 17 (44%) patients had carbapenem- The patients were divided in groups of 5 each: DF, DF+ resistant (CRAB) and 24 (62%) had multidrug resistant (MDR) doxycycline, DF+ tetracycline, DHF,DHF+ doxycycline, DHF+ A. baumannii. Mean age (53 ± 5.7 years) and male predom- tetracycline. The doxycycline groups were treated with inance (70%) were comparable in both groups. Predisposing oral doxycycline 200 mg/day/7 days, the tetracycline groups factors included diabetes mellitus (15), pressure ulcers (12), were treated with oral tetracycline 1.5 g/day/7 days. The malignancy (8), paraplegia (7), burn (5), peripheral vascu- patients were bleeding in days 0, 3 and 7. Serum concen- lar disease (5), and chronic renal failure (5). Majority of the trations of IL-6, IL-1␤, IL-1ra, TNF-␣, and sTNF-R1 were infections involved wound (13) and bone (10) followed by determined by ELISA. Clinical laboratory were performed sputum (8), urine (5) and bloodstream (3). Mean duration for with each bleeding, and a clinical control of signs and symp- first positive A. baumannii cultures after admission to the toms were carry out every day. hospital was 6.6 (±3.4) days. Patients infected with CRAB Results: Doxycycline groups shows the higher immune- had significantly higher rates of respiratory or other organ regulation of cytokines IL-6, IL-1␤, and TNF-␣, with an failures (47% vs. 14%, p < 0.05), and were more frequently increase in the levels of IL-1ra and sTNF-R1, followed by admitted to the intensive care unit (53% vs. 18%, p < 0.05), the tetracycline groups which presents an slightly higher compared to the patients with CSAB. Patients with CRAB regulation than the control group without treatment. The were also more likely to be admitted for prolonged dura- improvement of the patients was better in the doxycycline tions in the hospital (mean = 31.5 vs. 8.5 days, p < 0.01) and groups, with a faster remission of the symptoms than the in the intensive care unit (mean = 25.9 vs. 1.2 days, p < 0.05). other groups. Mortality was significantly higher among patients with CRAB Conclusion: The use of doxycycline in the treatment of compared to those with CSAB (29% vs. 4.5%, p < 0.01). A. dengue and dengue hemorrhagic fever patients could regu- baumannii infections were treated for an average duration late the cytokine cascade and improve the recovery of the of 24 (±7) days. Antibiotics used for treatment included patients with dengue and dengue hemorrhagic fever. carbapenems, ampicillin-sulbactam, tigecycline, aminoglycosides, colistin and polymyxin B. doi:10.1016/j.ijid.2010.02.1586 14th International Congress on Infectious Diseases (ICID) Abstracts e45

24.002 tive analysis was performed on 197 patients in whom serum Field hospital for fluid intake: The solution for the dengue antigen-capture ELISA was carried out. The diagno- decrease mortality in dengue fever sis of dengue was made based on dengue IgM positivity and the presence of classic clinical features of dengue fever. ∗ D. Borghi , M.D. Canetti, W. Braz, L. Cortes, R.C. Vascon- Results: A total of 75 patients were identified to have cellos dengue fever. The overall sensitivity of dengue antigen- capture ELISA was 64% (48/75). Sensitivity was 81.5% when Military Fire Corps, Rio de Janeiro, Brazil testing was carried out on serum samples taken during Day Background: December 2007, some cases of dengue hem- 1 to 4 of fever, 59.4% during Day 5-6 and 42.9% during Day 7- orrhagic fever were diagnosed in clildren in Rio de Janeiro, 8. In patients who did not have dengue fever, the specificity Brazil. Along the following months, the has ravaged the was 100%. state, infecting more than 150,000 people with 232 sus- Conclusion: The results suggest that the dengue antigen- pected deaths. 42% of fatal cases were in children. The capture ELISA is most useful in the diagnosis of dengue fever deaths showed us that the plasma leakage and shock are within the first 4 days of fever. more common than hemorrhagic phenomena. In many cases, the presence of pleural, pericardial and peritoneal effu- doi:10.1016/j.ijid.2010.02.1588 sions were associated with a severe disease. The emergency rooms in the state were not capableto absorb the extra 24.004 demand and causing the collapse of the healthcare system. Specific point mutations in the envelope protein of The last outbreak in Rio de Janeiro was happen in 2002 with Tick-borne encephalitis virus enhance non-viraemic the serotype 3 and now the serotype2e3hasbeen reported. transmission efficiency in a tick vector Methods: On February 2008, a hundred of new dengue M. Khasnatinov 1,∗, K. Ustanikova 2, T.V. Frolova 3, V.V. cases were being reported/ hour, so the health depart- Pogodina 3, N.G. Bochkova 3, L.S. Levina 3, M. Slovak 4,M. ment of Rio the Janeiro State, the Mylitary Fire Corps and Kazimirova 4, M. Labuda 4, B. Klempa 2, E. Eleckova 2, E.A. the Armed Forces assembled 7 field hospitals to support Gould 5, T.S. Gritsun 6 the emergency rooms, working with more 1000 health care providers. The average field hospital was equipped with 1 SC FHHR SD RAMS, Irkutsk, Russian Federation an electronic blood cell counting machine, 30 beds for 2 Institute of Virology, Slovak Academy of Sciences, hydratation and 1 advanced ambulance. This intervention Bratislava, Slovakia was based in the cocept of disaster medicine. The patients 3 Chumakov Institute of Poliomyelitis and Viral Encephali- were triaged in the hospitals, had their blood taken for tides RAMS, Moscow, Russian Federation diagnosis, kept in observation and hydratated. The caes 4 Institute of Zoology, Slovak Academy of Sciences, with deterioration were admitted to the hospital and if the Bratislava, Slovakia patient got better, he was sent home. 5 Centre for Ecology and Hydrology Oxford, NERC, Oxford, Results: The intravenous fluid administration during 12 United Kingdom hour observation period was associated with a decreased 6 The University of Reading, Reading, United Kingdom risk for the death and complications. On April, 29,000 cases were treated in the field hospitals and less than 2% of the Background: Tick-borne encephalitis virus (TBEV) is patients were admitted to the emergency hospitals. transmitted to humans by Ixodid ticks causing >10,000 cases Conclusion: The Field hospitals were a practical solution of disease annually. The risk of human infection relates to to reduce the mortality and morbility in this outbreak. the efficiency of virus transmission between infected and uninfected ticks. Here we identify specific mutations in the viral envelope protein that affect transmission efficiency of doi:10.1016/j.ijid.2010.02.1587 TBEV between ticks. 24.003 Methods: The genomes of 4 field isolates of TBEV defi- Utility of dengue antigen-capture ELISA in the diagnosis cient in haemagglutination, were sequenced and recreated of dengue Fever in the real world by site-directed mutagenesis, in a TBEV infectious clone. They were then compared with the wild-type infectious ∗ S. Kalimuddin , H.N. Leong, X.L. Bai, S.H. Lim, K.P. Chan clone in mice, porcine kidney PS cells and adult and nymphal I. ricinus ticks. Singapore General Hospital, Singapore, Singapore Results: Sequence analysis revealed unique amino acid Background: Dengue fever is an endemic and potentially substitutions D67G, E122G or D277A in the envelope glyco- fatal viral infection threatening more than 2.5 million peo- protein. Each mutation resulted in an increase of net charge ple in over 100 regions around the world - hence the need for and hydrophobicity on the virion surface. When introduced timely and accurate diagnosis using an easy and affordable individually into the TBEV infectious clone (IC), each sub- assay. stitution inhibited haemagglutination and reduced mouse Methods: In our study, the use of a commercial dengue neuroinvasiveness from 65% to 15-30%. Antibody produc- antigen-capture ELISA (PLATELIA DENGUE NS1 AG by Bio- tion in infected mice was 1.5-3 times lower for IC-E122G Rad) was evaluated to demonstrate its usefulness in and IC-D277A suggesting lower levels of viraemia and/or diagnosing acute dengue viral infection in an acute tertiary deficient immune stimulation induced by these viruses. All centre in Singapore. Our country is endemic for dengue fever mutants demonstrated delayed growth in PS cells during the with more than 7000 cases reported in 2008. Retrospec- first 24hpi; however, mutant IC-D67G exhibited significantly e46 14th International Congress on Infectious Diseases (ICID) Abstracts better growth characteristics than IC-E122G and IC-D277A. Methods: Treated and mock-treated female Syrian golden The reproduction of IC-E122G and IC-D277A in fasting ticks implanted with telemetry units measuring temperature and was similar to that of control HA positive virus whereas activity, were utilized to test the antiviral effects of the the titres of IC-D67G were significantly lower (2.5-3 vs. 1-2 compound named BAT-V1. The animals were followed for log10PFU/ml, respectively). In feeding ticks, the titre of IC- 14 days post-challenge. Clinical signs of disease were mon- E122G increased approximately 1000-fold and IC-D277A and itored. Temperatures and acitivty levels were recorded by IC-D67G - approximately 300-fold, whereas for control virus telemetry. Clinical chemistry, hematology, and coagulation the increase was about 10-fold. Non-viraemic transmission parameters were measured and viral titers in the tissues and efficiency from infected to uninfected ticks was increased blood were analyzed. by each individual substitution in nymphal I. ricinus (Figure Results: We demonstrate that PIRV infection in Syrian 1). golden hamsters leads to morbidity, fever, lethargy, hemorrhagic fever manifestations, viremia, and replication in select tissues and results in 100% mortality within 8 days after challenge. Treating hamsters with BAT-V1 prior to challenge significantly protected the animals from death, which is important because survival of hamsters infected with PIRV has not previously been reported. Abnormal temperatures, hematology, clinical chemistry, and coagulation parameters associated with PIRV infection in hamsters all rebounded to normal levels in the treated animals. Lower viremia and inhibition of viral replication in select tissues were also observed in treated animals when compared to mock-treated animals. Conclusion: Results from this study demonstrate a BSL- 3 arenaviral hemorrhagic fever animal model that can be utilized to test and screen multiple antivirals in a time Figure 1 Tick-to-tick transmission rate (clear bars) is efficient and cost effective manner. Additionally, the data expressed as the proportion of infected I.ricinus nymphs. demonstrate pre-exposure protective efficacy of an antiviral Black triangles show the average virus titres in individu- against PIRV-induced hemorrhagic fever in the Syrian golden ally infected recipient nymphs as determined by plaque hamster model. assay. Conclusion: We hypothesize that the mechanism doi:10.1016/j.ijid.2010.02.1590 of adaptation of TBEV to its host utilizes the shift of 24.006 charge/hydrophobicity at several critical aminoacid residues exposed on the virion surface. This shift results in Characterization of a novel neutralizing monoclonal different biological consequences depending on the local- antibody that recognizes the fusion loop of Flavivirus isation of certain aminoacid residue. The results provide envelope protein valuable information concerning the maintenance in nature Y. Deng 1,G.Ji2, Y. Kang 2, T. Jiang 1, J. Dai 2, E. Qin 1,Y. and the emergence of pathogenic variants of TBEV. ,∗ Guo 2, C. Qin 1 doi:10.1016/j.ijid.2010.02.1589 1 Beijing Institute of Microbiology and Epidemiology, Bei- jing, China 24.005 2 International Joint Cancer Institute, Second Military Med- A pre-exposure prophylactic for arenaviral hemorrhagic ical University, Shanghai, China fever in the pirital virus-Syrian golden hamster model Background: Dengue, West Nile and yellow fever viruses E. Vela ∗, R. Stammen, J. Garver, S. Sarrazine are major human pathogens that belong to the Flavivirus genus, and cause large epidemics and deaths worldwide. Battelle, Columbus, OH, USA Given the lack of approved antiviral treatment, recombi- Background: Arenaviral infections in humans have the nant monoclonal antibodies (MAbs) have been verified as capacity to lead to hemorrhagic fever and may be fatal. candidate for the treatment of flavivirus infections. Supportive care and ribavirin remain the only options for Methods: A panel of MAbs against dengue 2 virus was arenaviral infections in humans; however, treatment is often produced according to the standard procedure. Indirect ineffective because of the time frame before the disease is immunofluorescence assay and ELISA were performed to recognized. Pirital virus (PIRV) is a New World arenavirus identify the cross-reactivity against flaviviruses. In vitro that was isolated from the cotton rat (Sigmodon alstoni)in andin vivo experiments were performed to analyze the neu- the Municipality of Guanarito, Portuguesa State, Venezuela tralizing and protection profiles of a selected MAb against in 1994. This virus is not associated with any form of disease dengue and other flavivirus. Epitope mapping and in vitro in humans and can be studied in a biosafety level 3 (BSL- binding inhibition assays were further carried out to charac- 3) laboratory environment; therefore, the development of terize this specific MAb. a small animal model system is ideal for testing and/or Results: Plaque reduction neutralization test demon- screening of vaccines and therapeutics against arenavirus strated that MAb 2A10G6 was active to neutralize dengue hemorrhagic fever. 1-4, yellow fever and West Nile viruses. In vivo protection 14th International Congress on Infectious Diseases (ICID) Abstracts e47 experiments showed that mAb 2A10G6 protected sucking will be used to determine the specificity and sensitivity of mice from lethal dengue 1-4 viruses challenge in a dose- the ELISA for diagnostic purposes. dependent manner. Thus, we have established a novel flavivirus cross-reactive neutralizing mAb 2A10G6. Phage- doi:10.1016/j.ijid.2010.02.1592 displayed random peptide library mapped the epitope of mAb 2A10G6 to a common antigenic site within the highly 24.008 conserved N-terminal fusion loop peptide of flavivirus enve- Preparation of antigenically active recombinant yellow lope protein. Functional assays confirmed that mAb 2A10G6 fever viral envelope domain III protein bind with the fusion peptide and blocks infection primarily S. Smouse 1,∗, F.J. Burt 2 at a step after viral attachment. Conclusion: Together, these experiments define the char- 1 University of the Free State, Bloemfontein, Free State, acteristics of a novel flavivirus cross-reactive neutralizing South Africa MAb 2A10G6 and make it a suitable candidate for human- 2 UNIVERSITY OF THE FREE STATE, 9324, ZA, South Africa ization into a therapeutic antibody to treat severe flavivirus infections in human. Background: Yellow fever virus belongs to the genus Fla- vivirus, of the family Flaviviridae. It is a mosquito-borne virus endemic in tropical regions of Africa and South Amer- doi:10.1016/j.ijid.2010.02.1591 ica. Although an effective vaccine is available, the virus 24.007 remains a major public health threat, particularly in Africa Gene optimization for expression of Crimean-Congo where vaccination is limited by poverty, civil wars and the haemorrhagic fever viral nucleoprotein inaccessibility of rural areas prone to outbreaks. It is a reemerging pathogen with case-fatality rates that can exceed ,∗ R. Samudzi 1 , F.J. Burt 2 50%. The diagnosis of infection and testing of the immune status of vaccinees require reagents that are prepared in 1 University of the Free State, Bloemfontein, Free State, biosafety level 3 and 4 facilities. The viral envelope pro- South Africa tein plays an important role in eliciting antibodies and hence 2 UNIVERSITY OF THE FREE STATE, 9324, ZA, South Africa serves as an ideal diagnostic and research tool for the detec- Background: Crimean-Congo haemorrhagic fever (CCHF) tion of antibodies. The aim of the study was to compare virus causes a severe and often fatal infection. The virus has various bacterial expression systems for the preparation of the propensity to cause nosocomial infections and hence a a recombinant yellow fever viral envelope protein for the rapid and sensitive diagnosis is important for isolation of the detection of antibodies against yellow fever in vaccinated patient for protection of health care workers and implemen- individuals. tation of supportive therapy. Current serological diagnostic Methods: The domain III region of the envelope (EDIII) assays are based on enzyme linked immunosorbent assays gene was amplified with primers identified using sequence (ELISA) or immunofluorescence (IF) tests using inactivated data retrieved from GenBank. The EDIII gene was cloned virus which necessitates biosafety level (BSL) 4 facilities for into three different E.coli bacterial expression systems for preparation of reagents. The aim of the study was to pre- comparison of protein yield, solubility and suitablity in an pare a safe recombinant nucleoprotein (NP) and determine ELISA. Proteins were all expressed with an N+ terminal His its suitability for detection of antibody responses in survivors tag for purification. A direct ELISA was developed in which of CCHF infection. To facilitate protein expression the gene the plates were coated with antigen and reacted with serum encoding the nucleoprotein was optimized for E.coli usage. samples from vaccinees. Methods: The CCHF nucleoprotein gene coding sequence Results: Each antigen was evaluated using serum samples was submitted to GenScript (USA). OptimumGene software collected from vaccinees and serological cross reactivity was used to optimize codon usage, GC content, elimi- of the antigen against heterologous flaviviral antibody was nate polyadenylation sites and modify cis-acting sites. The determined using convalescent serum samples from patients optimized gene was synthesized and the nucleoprotein with known flaviviral infections, such as West Nile. Protein expressed in an E.coli bacterial expression system with yields varied significantly between the different expression a His tag for purification. CCHF antibody positive human systems with higher yields and increased solubility obtained sera were tested in an ELISA using the recombinant NP from expression at lower temperatures. Higher reactivity antigen. was associated with homologous antibody. Results: A direct ELISA was developed in which plates Conclusion: Preliminary results suggest that bacterially were coated with the recombinant NP antigen and reacted expressed recombinant EDIII protein is antigenically active with convalescent human sera from confirmed CCHF and potentially useful for detecting antibodies against yel- patients. The antigen expressed from the optimized NP gene low fever virus. was found to detect IgG antibodies against CCHF virus. Conclusion: Recombinant proteins have been shown to doi:10.1016/j.ijid.2010.02.1593 be safe, cost effective reagents that can be prepared for biohazardous pathogens without the requirements of BSL 4 facilities. Optimization of the CCHF N gene was essential for high expression of soluble NP. The protein expressed was shown to react against antibodies in convalescent CCHF patients. A panel of serum samples from confirmed patients e48 14th International Congress on Infectious Diseases (ICID) Abstracts

24.009 24.010 Development of a recombinant antigen and multiplex PCR A novel cell encapsulation mode for delivery of thera- for differentiation of tick-borne and mosquito-borne fla- peutic antibodies against West Nile Virus infections that viviruses maintains steady plasma antibody levels throughout therapy L. Mathengtheng ∗, F.J. Burt A.J.S. Chua 1,∗, E.M. Brandtner 2, J.A. Dangerfield 2,B. UNIVERSITY OF THE FREE STATE, 9324, ZA, South Africa Salmons 2, W.H. Gunzburg 2, M.L. Ng 1 Background: Crimean Congo haemorrhagic fever (CCHF) 1 National University of Singapore, Singapore, Singapore virus is widely distributed in Africa. Though cases of sus- 2 SGaustria, Singapore, Singapore pected CCHF infections are routinely investigated, less than 10% are confirmed. A proportion are usually Rickettsia spp. Background: West Nile virus (WNV) is currently endemic infections but a large number remain undiagnosed. This in various parts of all five continents in the world. Being warrants investigation of other tick-borne pathogens such a member of the Japanese encephalitis virus subgenus, as flaviviruses. Although the presence of mosquito-borne WNV can cause potentially fatal neuro-invasive diseases flaviviruses in southern Africa is known, that of tickborne such as encephalitis and meningitis. Unfortunately, to date, flaviviruses was suggested by serological evidence in cat- no vaccine or antiviral therapy has yet been approved. tle but not confirmed. Ixodes ticks are the known principal One antiviral strategy in development involves the pas- vectors of tick-borne flaviviruses and are endemic in south- sive administration of neutralizing antibodies. As with ern Africa. The domain III of the flavivirus envelope protein most immuno-therapies, plasma antibody levels diminish was reported to differentiate between the highly cross- between treatments. This is especially detrimental in fla- reactive tick- and mosquito-borne flaviviruses. Our aim was vivirus immuno-therapies as sub-neutralizing concentrations to prepare a noncross reactive representative tick-borne of antibodies can instead enhance infection. Here, we recombinant antigen that will differentiate between anti- report a proof-of-concept for a novel mode of delivery bodies against the tick- and mosquito-borne members, and using encapsulation of hybridoma cells producing therapeu- to develop a nested multiplex PCR that can be used for tic antibodies which enables the maintenance of a steady differentiation. Langat virus, a tick-borne flavivirus, was level of antibody in the plasma, thus preventing any possible selected as representative for preparation of a recombinant antibody-dependent enhancement (ADE). antigen because it can be handled in a BSL 2 laboratory. Methods: Recombinant domain III of the envelope glyco- Methods: The domain III region of the envelope protein protein (rE-DIII) of WNV was cloned, expressed in bacteria, (EDIII) of Langat virus was amplified by PCR and cloned and purified. It was then inoculated into balb/c female mice into a pQE-80L expression vector. The recombinant protein and splenocytes harvested to generate hybridomas. Limit- was expressed in a bacterial expression system, purified ing dilution was subsequently performed and producers of in Nickel-charged columns and characterized using Western antibody specific to WNV were selected. Following which, blot. The protein was evaluated in an ELISA for cross- the selected hybridomas were encapsulated in polymers reactivity with mosquito-borne flaviviruses. For the nested of sodium cellulose sulfate. Viability of the encapsulated multiplex PCR, primers that amplify conserved regions of hybridoma clones, their ability to continuously secrete anti- flaviviruses and CCHF were identified. bodies, and most importantly, whether antibodies can be Results: The assay was nested to increase sensitivity released from the capsules were then characterized. and detected the viral nucleic acid of 10 known fla- Results: Pilot batches of hybridomas remained viable and viviruses and CCHF virus. A 13kDa EDIII recombinant protein divided beyond 100 days postencapsulation. Moreover, the was expressed and purified. The antigen was able to dif- encapsulated hybridoma cells and their progeny were able ferentiate between antibodies directed against tickand to continuously secrete WNV-specific antibodies, and the mosquito-borne flaviviruses and also showed clear cut-offs secreted antibodies could be released from the capsules. when tested against known positive antibodies directed Conclusion: Our preliminary results showed that encap- against louping ill, tick-borne encephalitis and West Nile sulation of cells producing therapeutic antibodies can viruses. indeed be a potential solution to improving treatment out- Conclusion: The recombinant antigen is an important tool comes for immunotherapies. This is especially essential for the differentiation of flaviviral groups and will be used for immunotherapies against flavivirus infections so as to to screen human and cattle sera for antibody against tick- minimize any potential ADE side-effect. However, the appli- borne flavivirus. Similarly the multiplex PCR will be a useful cation of this technology for the treatment of infectious tool for screening acute serum samples and ticks. diseases is still at its infancy and we are currently in the midst of further optimizing and characterizing this technol- doi:10.1016/j.ijid.2010.02.1594 ogy.

doi:10.1016/j.ijid.2010.02.1595 14th International Congress on Infectious Diseases (ICID) Abstracts e49

24.011 role of C protein in the pathogenesis of arthropod-borne Association of tumor necrosis factor-alpha gene promoter flaviviruses is poorly understood. Examination of whether regions polymorphism in Japanese encephalitis patients flavivirus C protein can associate with cellular proteins and contribute to viral pathogenesis would define the platform ,∗ S.K. Pujhari 1, R.K. Ratho 2 , S. Prabhakar 1, B. Mishra 1,M. towards the development of new anti-virals against fla- sharma 1, M. Modi 1 vivirus infection. Methods: Yeast-two-hybrid screening of brain library 1 Postgraduate Institute of Medical Education and Research, was employed to identify the host interacting partners of 160012, UT, India WNV/DENV C protein. Co-immunoprecipitation and muta- 2 Postgraduate Institute of medical Education and Research, genesis studies were used to delineate the interacting 160012, India domains of host and C proteins. We used a combination of Background: More than three billion populations are liv- lentivirus-mediated gene knock-down/over-expression anal- ing under the threat of Japanese encephalitis in the south yses, real-time RTPCR, co-immunoprecipitation, Western East Asian countries including India. The pathogenesis of this blotting, densitometry, pull-down, proteasome activity and disease is not clearly understood, and is possibly attributed competition assays to unveil the biological significance of to the genomic variation in virus as well the host genetic identified host-C protein association. make up. The present study focused to determine the role Results: This study identified human Sec3 exocyst protein of -238G/A, -857C/T and -863C/A polymorphism of tumor (hSec3p) as a novel interacting partner of WNV/ DENV C pro- necrosis factor-alpha (TNF-a), gene promoter polymorphism tein. Mutagenesis studies showed that SH2 domain-binding in Japanese encephalitis patients as a part of host role in motif of hSec3p binds to the first 15 amino acids of C protein. disease severity and pathogenesis. We reported that hSec3p can modulate virus production Methods: Twenty encephalitis cases (PCR/IgM positive) by affecting viral RNA transcription and translation through 16 JE IgM positive fever cases with out encephalitis were the sequestration of elongation factor 1 alpha (EF1␣). We considered as subject group I and II respectively, and from A also demonstrated that flavivirus C protein degrades hSec3p 46 healthy individuals were taken as controls. The genomic through proteasome-mediated pathway. DNA was extracted from whole blood/clotted blood. TNF-a Conclusion: This study highlighted for the first time that promoter polymorphism was performed by PCR restriction hSec3p functions as a new transcriptional and translational fragment length polymorphism. The statistical analysis was repressor of flavivirus replication. Our study also demon- performed by X2 using GraphPad software. strated that flavivirus C protein plays an important role Results: The genotype frequencies of C/C at -863 are 90% in nullifying the antiviral checkpoints imposed by hSec3p and 93.75% in subject group I and II respectively and 47.83% and allowing the virus to establish a microenvironment that in controls. The distribution AA in subject group I and II facilitates successful replication and infection. Understand- are 10% and 6.25% respectively and 32.61% in control, in ing the molecular mechanism of flavivirus C protein and fever and in encephalitis patients. Where as distribution of hSec3p interaction, besides revealing the new cellular func- C/A was found only in controls (19.56%). Significantly higher tions of hSec3p, could possibly pave the way towards the frequency of distribution was observed in JE encephalitis development of potential hSec3p-derived antiviral agent (Subject group I) and fever cases (Subject group II) as com- against flaviviruses. pared to that of healthy controls (X2 10.522, p = 0.005, X2 10.77, p = =< 0.005). The frequency of C/C at-857 are in doi:10.1016/j.ijid.2010.02.1597 the range of 65.22 to 75%, of C/T are 15% to 32.6%, where as the frequency distributions of G/G at —238 position are 24.013 in the range of 87.5% to 100% and of G/A 6.25% to 12.5% Effect of dengue virus infection on the host signal trans- There was no difference observed in the subjects and control duction pathways groups. M.K. Chong, A.J.S. Chua ∗, M.L.M. Ng Conclusion: With the available TNF-a promoter variations data analysis reveals that position -863promoter likely to National University of Singapore, Singapore, Singapore play a substantial role in severity of Japanese encephalitis viral infection. Background: Dengue virus (DENV) is a single, positive- stranded RNA virus from the family Flaviviridae. Dengue infection is a medically important infectious disease affect- doi:10.1016/j.ijid.2010.02.1596 ing many tropical and subtropical countries. To date, vaccine 24.012 and anti-viral drugs for DENV infection is still not avail- A novel antagonistic relationship between human Sec3 able. This is mainly due to the incomplete understanding of exocyst and flavivirus capsid protein the pathogenesis and the underlying molecular mechanism involved during infection. This project aims to study the ∗ B. Raghavan, K.L. Yeo , M.L. Ng virus-host interplay by investigating the signal transduction pathways that are activated during DENV infection. National University of Singapore, Singapore, Singapore Methods: RT2 Profiler PCR array from SABiosciences was Background: The Flaviviridae family comprises several employed to screen for the pathways that were affected medically important pathogens such as West Nile virus (WNV) during DENV infection on Human Embryonic Kidney (HEK)- and Dengue virus (DENV). Flavivirus capsid (C) protein is a 293 cells. A panel of 84 genes from 18 biological pathways key structural component of virus particles. However, the were analyzed and quantified simultaneously. The HEK293 e50 14th International Congress on Infectious Diseases (ICID) Abstracts cells were infected with DENV at multiplicity of infection of each phase was mandatory since each phase has complete 1 and the total RNA were extracted after 12hr,24hr,and 48hr opposite management strategies. post infection (p.i.). The RNA of infected cells and mock Results: Evidences were forwaded from retrospective infected cells were reverse-transcribed into cDNA which analysis and management of 9 fatalities of DHF, and suc- were then served as templates for real-time polymerase cessfully managed patient with DHF grade IV who was chain reaction in a 96-well plate containing predispensed complicated with Hypotension ascitis, bilateral pleural effu- gene specific primer sets. The gene expression profiling of sion mild pericardial effusion and acute liver failure. DENV-infected cells were compared to that of mock-infected Conclusion: These comparison of dilemmas of identifying cells. the phases and complications and maintenance of critical Results: The PCR array data showed that there was no fluid balance will be discussed in this paper. This will also significant change in the gene expression profile of infected prove the importance of early involvement of the intensive cells at 12hr p.i. as compared to mock infected cells. Never- care for the management of patients with DHF with severe theless, the number of activated genes increased from 24hr leakage. p.i. to 48hr p.i. Among 18 signal transduction pathways, the most affected pathways are NF␬B, CREB, Jak-Stat, phos- doi:10.1016/j.ijid.2010.02.1599 pholipase C, insulin and low density lipoprotein pathways. Besides, there are also novel genes identified to be activated 24.015 in this study. All the activated genes were analyzed and an Japanese encephalitis virus and neuronal cell interaction: interactome map was generated. It provides a better under- a study on cellular receptor and gene expression profile standing of the virus-host interplay during different stages S. Das, R. Vasanthapuram of DENV infection. Conclusion: PCR array allows fast and convenient anal- National Institute of Mental Health and Neurosciences ysis of many gene expression profiles simultaneously for (NIMHANS), 560029, India different samples. Therefore, the comparison of the gene expression profiles of all four different DENV serotypes can Background: Japanese encephalitis virus (JEV) is a be carried out to study the similarities and differences in mosquito borne flavivirus responsible for acute encephali- virus-host interaction. tis in humans. Very little information is available on the cellular receptor for JEV as well as changes in host gene expression following JEV infection in the CNS. Consequently, doi:10.1016/j.ijid.2010.02.1598 the present study was undertaken to (i) identify the cellular 24.014 proteins involved in JEV entry and (ii) to study JEV mediated Jumping over the sharp edge of dengue shock syndrome alteration in cellular gene expression. Methods: A ‘Virus Overlay Protein Blot Assay (VOPBA) was V. Pinto used to identify cell membrane protein on mouse neuroblas- toma cells (Neuro2a) interacting with JEV. The identity of Faculty of Medicine, University of Peradeniya., Kandy, Sri the interacting protein was established using MALDI TOF. A Lanka series of experiments including‘infection inhibition assay’, Background: Dengue is a mosquito-borne viral infection and flowcytometric analysis further confirmed the identity which sometimes can lead to a potentially lethal compli- of the protein. Additionally, using the bioinformatic tool - cation called Dengue Hemorrhagic Fever (DHF) and dengue FTDOCK, protein-protein interaction was studied. shock syndrome (DSS). In severe cases, the patient may Total RNA extracted from JEV infected Neuro2a cells was rapidly go into a critical state of shock and die within subjected to microarray analysis to study alteration in gene 12 to 24 hours. Major pathophysiological hallmark of DHF expression profiles. Standard assays for apoptosis (TUNEL is an increasing vascular permeability leading to leakage and Real-time PCR) were used to validate the microarray of plasma and hypovolaemic shock. Also the haematologi- results. cal abnormalities, leucopenia, thrombocytopenia, immune Results: Heat shock protein 70 (Hsp70) was identified as complex formation, vasculopathy, thrombopathy myocardi- the receptor for JEV on Neuro2a cells based on the following tis and Disseminated Intravascular Coagulopathy (DIC) with observations (i) surface expression of Hsp70 on Neuro2a cells massive bleeding contribute to shock and fatal outcome. (ii) reduction in virus infectivity using anti-Hsp70 antibodies, They also can complicate with pericardial and pleural effu- co-immunoprecipitation results demonstrating JEV -Hsp70 sions, ascitis and Liver failure. interaction and delineating the residues in the interacting Methods: With the available data of case studies with pockets using bioinformatic tools. 11 mortalities and 3 successfully managed cases two phases Microarray analysis revealed upregulation of 660 genes of fluid derangement were identified in severe DHF. Namely and downregulation of 949 genes in JEV infected Neuro2a leaking phase and auto transfusion phase which can lead cells. A large number of differentially expressed genes to more complex situations like pulmonary oedema. Both were found to be involved in apoptosis, oncogenesis, cel- phases were very difficult to diagnose as well as to manage lular metabolism, neurodegeneration and immunological since the situations can complicate with internal bleeding functions. Upregulation of pro-apoptotic genes (p53, VEGF, and myocarditis. Serveral protocols had been forwaded and Gadd45) and downregulation of anti-apoptotic gene (bcl-2) the aggressive management according to the protocols is were observed. TUNEL assay and DNA fragmentation fol- proved to be effective. Though these protocols were not lowed by conventional and real time PCR further confirmed addressing the different phases, a clear identification of apoptosis in JEV infected Neuro2a cells. 14th International Congress on Infectious Diseases (ICID) Abstracts e51

Conclusion: In conclusion, this study for the first time this assay suitable for routine screening of blood donations identified Hsp70 as the receptor for JEV on Neuro2a cells. and organ transplantations. Further, this study illustrated that apoptosis is one of the mechanisms of JEV induced damage of infected neuronal doi:10.1016/j.ijid.2010.02.1601 cells. 24.017 doi:10.1016/j.ijid.2010.02.1600 Wild yellow fever cases in Sao Paulo state, Brazil, 2009 ,∗ 24.016 M. Mascheretti 1 , A. Ribeiro 1, C. Tengan 1, H.K. Sato 1, P. Opromolla 1, A. Suzuki 2, R. Brasil 2, C. Fortaleza 3,F. Chikungunya virus (CHIKV) infection: Analytical perfor- Chudk 4, M.S. Carli 4, R. Albernaz 1, R. Souza 2 mance of real-time NASBA assay 1 ,∗ Centro de Vigilância Epidemiológica CVE/CCD/Secretaria G. Rossini 1 , F. Cavrini 2, P. Gaibani 3, A. Pierro 4, M.P. de Estado de Saúde de São Paulo, Sao Paulo, Brazil Landini 5, V. Sambri 6 2 Instituto Adolfo Lutz CCD/ Secretaria de Estado da Saúde 1 Centro Riferimento Regionale Emergenze Microbiologiche de São Paulo, Sao Paulo, Brazil (CRREM), Bologna, Italy 3 Faculdade de Medicina de Botucatu, Universidade Estadual 2 S. Orsola-Malpighi Hospital, BOLOGNA, Italy Paulista, Botucatu, Brazil 3 S.Orsola-Malpighi Hospital, Section of Microbiology, 4 Grupo de Vigilância Epidemiológica de Botucatu and BOLOGNA, Italy Itapeva CVE/CCD/Secretaria de Estado da Saúde de São 4 S.Orsola-Malpighi, Bologna, Italy Paulo, Sao Paulo, Brazil 5 S.Orsola-Malpighi Hospital, section of Microbiology, Background: Yellow fever (YF) is an arboviral disease BOLOGNA, Italy caused by a virus from Flaviviridae family and genus 6 University of Bologna, Bologna, Italy Flavivirus endemic in tropical regions of America and Background: Chikungunya virus (CHIKV), an alphavirus Africa. Transmission occurs after mosquito bite, Aedes and belonging to the Togaviridae family, is transmitted to human Haemogogus. Urban YF was eradicated in Brazil in 1942, by several species of mosquitoes, with Aedes Aegypti and A. sporadic wild transmission has been maintained in Amazon Albopictus being the two main vectors. The virus is endemic area. Two laboratoryconfirmed cases were reported in 2000 in Africa, India, South-East Asia and recently in southern- and two cases in 2008 in Sao Paulo state suggesting a re- Europe and is responsible for an acute infection of abrupt emergence after 50 years. onset characterized by high fever, asthenia, headache, Methods: Descriptive study of YF cases in Sao Paulo state, rash, myalgia and a painful polyarthralgia. Occurrence of Brazil in 2009. CHIKV asymptomatic infections, whose epidemiological con- Results: From February to April 28 confirmed cases of YF sistency is still to be assessed, leaves hypothesize spread were reported including 11 deaths, case fatality rate 39,2%. of infection by blood transfusion or by tissue or organ 18 were male (64,3%), the mean age was 29 years old (range transplantation and highlights the need for highly sensitive 8 days to 52 years old). Four cases occurred in children under CHIKV-specific tests. Objective of this study is to analyze the 16 years old (8 and 12 days; 14 and 15 years old). New- analytical performance of real-time nucleic acid sequence- borns mother’s YF onset symptoms started two to five days based amplification (RT-NASBA). before delivery suggesting perinatal transmission. Symptoms Methods: The analytical sensitivity of the assay was vali- varied from mild to severe disease, 75% (21/28) of the dated with a panel of blood donor plasma samples spiked cases were hospitalized. Most common symptoms were fever with 10-fold serial dilutions of CHIKV, previously quanti- (25/26), headache (15/19), jaundice (5/20), abdominal pain fied by TCID50 assay, with viral titers ranging from 105 to (16/25), vomit (9/18) and hemorrhage (12/27). Aspartate 1 TCID50/mL. 10 replicates for each viral concentration aminotransferase mean was 4,772UL (range 32—28,900UL; were analyzed. Following RNA extraction, all samples were reference value 40,00UL), missing data in 6 cases. Direct amplified by RTNASBA and for each virus concentration, the bilirrubine mean was 2,82 mg/dL (range 0,20—21,50 mg/dL; detection rate (n.positives/n.total) was evaluated. Finally reference value 1,5 mg/dL), missing data in 7 cases. Four the analytical sensitivity of the NASBA assay has been com- cases had renal failure. All cases were laboratory-confirmed: pared with realtime PCR based methods (RT-PCR). YF IgM antigen-capture ELISA (24/26), blood or tissue virus Results: RT-NASBA assay has an amplification rate of 100% isolation (5/15), blood or tissue RT-PCR (14/16), immunohis- for plasma samples spiked with CHIKV titers >1 TCID50/mL. tochemistry (5/13). Human transmission was associated with RT-NASBA has higher analytical sensibility than RT-PCR, leisure and work activities in rural areas of Sarutaia, Piraju, which in turn has an amplification rate of 100% for viral Buri, Avare and Tejupa municipalities. All cases occurred concentrations > 20 TCID50/mL. among unvaccinated person. Mass vaccination campaigns Conclusion: The results of this study document a good were implemented in 50 cities with more than 1 million analytical sensitivity of the RTNASBA assay, even higher if doses (vaccination coverage was 87%). Five fatal cases of YF compared with RT-PCR methods. Thus, this assay can be used vaccine-associated viscerotropic disease were reported dur- as routine laboratory test for diagnosis of CHIKV infection in ing February to October 2009. Other epidemiological control plasma samples. Furthermore, the high sensibility of the test measures were adopted including entomologic assessments and shortness of turnaround time to obtain the results, make and monkey deaths surveillance investigation. e52 14th International Congress on Infectious Diseases (ICID) Abstracts

gram positive coccus and enterobacteriaceae like gram negative rod (57% vs.27%). Conclusion: We conclude that polymicrobial bacteremia is an important entity especially in hospital acquired setting. We were able to predict mortality, prognosis or determination of contamination from the gram stain result of blood culture.

doi:10.1016/j.ijid.2010.02.1603 25.002 Infective endocarditis after dental surgery Conclusion: The early identification of YF transmission re-emergence in Sao Paulo state was important to establish V. Krcmery 1,∗, A. Demitrovicova 1, E. Kalavsky 1, P. Kisac 1, effective public health intervention to prevent and control M. Karvaj 2, F. Bauer 2, R. Kovac 2, P. Mlkvy 2 future outbreaks. 1 St. Elizabeth University College of Health and Social Sci- ences, Bratislava, Slovakia doi:10.1016/j.ijid.2010.02.1602 2 Slovak Medical University, Bratislava, Slovakia Clinical Bacterial Infections (Poster Presentation) Background: Dental surgery is one of the major risk factor for occurrence of infective endocarditis, mainly in 25.001 patients with pre-existing cardiac disorders (prior cardiac Clinical significance of polymicrobial bacteremial as surgery, rheumatic heart diseases, prosthetic valve, congen- determined by the pattern of gram stain ital vitium cordis, previous endocarditis etc.). Methods: Within 606 cases in our national database, 52 M. Norizuki ∗, S. Yamamoto, N. Hosokawa (8.6%) patients with infective endocarditis occurred within Kameda Medical Center, Kamogawa, Japan 7 days after dental surgery (teeth extraction 40 — 76.9%, periodontal abscess 3 — 5.8%, caries debridement 3 - 5.8% Background: Polymicrobial bacteremia has been associ- and other dental procedures 6 —11.5%). Ten (19.2%) of them ated in higher mortality in past studies. The objective of were breakthrough — occurred despite of antibiotic prophy- this study was to investigate etiology, source of infection laxis with amoxycillin (3 — 5.8%) roxithromycin (6 — 11.5%) and mortality. or clindamycin (1 — 1.9%). Methods: We retrospectively reviewed microbiological Results: Comparing risk factors of 52 patients with infec- result of blood cultures in 865-bed tertiary hospital in Japan tive endocarditis after dental surgery and entire group of 606 during the past 22-months ends 31 September 2009. In- patients, neoplasia (9.2% vs. 0%; p < 0.04), prosthetic valve hospital mortality, 28-day mortality, follow up period, site (19.9% vs. 3.8%; p < 0.05), hearth failure (15.5% vs. 1.9%; of infection, past medical history, gram stain result of blood p < 0.02) and patients cured only with antibiotics (57.4% vs. culture (gram positive cluster, gram positive chain, enter- 42.3%; p < 0.04) were less frequently among patients with obacteriaceae like gram negative rod, non-fermenting gram endocarditis after dental surgery. Vice — versa vitium cordis negative rod (e.g. P.aeruginosa), gram positive rod and congenital heart (3.3% vs. 15.4%; p < 0.01), right side (2.5% fungi) and organisms were collected. vs. 9.6%; p < 0.01) and patients cured with antibiotics and Results: Ten-thousand eight hundred thirty-eight blood surgery (42.6% vs. 57.7%; p < 0.04) were more frequently cultures were taken and 16.3% (n = 1,771) were positive. Sev- observed among infective endocarditis after dental surgery. enteen cases of polymicrobial bacteremia were excluded Mortality was insignificantly lower (15% vs 9.6%; NS) in because of contamination. There were fifty-one (2.9% patients with infective endocarditis after dental surgery. of positive blood culture) episodes of polymicrobial bac- Conclusion: Surprisingly, viridans streptococci (5.8%), teremia. Four patients were excluded because of admission and previous cardiac surgery (5.8%) were not signifi- at the end of investigation. Sixty percent of patients were cantly associated with infective endocarditis after dental male and the average age was 72.7 years. Although over surgery as expected. Viridans streptococci, Staphylococcus all hospital mortality was 42.3%(n = 20), 28-day mortality aureus and HACEK group were replaced by gramnegative was 21%(n = 10). The three leading sources of infection were bacteria (P < 0.004) (Escherichia coli, Enterobacter spp., billiary tract infection (49%), urinary tract infection (15%) Pseudomonas aeuginosa) in ethiology of infective endocardi- and neutropenic fever (11%). There were 24 cases of hospi- tis after dental surgery. tal acquired infection and 23 cases of community acquired infection. Hospital acquired polymicrobial bacteremia had doi:10.1016/j.ijid.2010.02.1604 higher mortality than community acquired (63% vs.22%). Enterococcus species (18%), E.Coli (17%) and Klebsiella (15%) were common pathogens cultured. The hospital mortality was different in combination of organisms. Three or four organisms were higher mortality than two organisms (57% vs. 36%). The combination of gram positive coccus and non- fermenting gram negative rod were higher mortality than 14th International Congress on Infectious Diseases (ICID) Abstracts e53

25.003 gens of Streptococcus mutans (MS), main pathogen of the Efficacy of serum semi-quantitative procalcitonin mea- dental caries, but little is known about the ontogeny of the surement kit PCT-Q for bacteremia mucosal immune system in the first day of life especially in preterm newborn (below 37 weeks of gestation). Thus, we ∗ T. Kodama , H. Wakatake, M. Yanai, S. Fujitani compared the levels and specificity of SIgA to MS and others species enrolled with initial infection in fullterm (FT) and St. Marianna University School of Medicine, Kawasaki-City, preterm (PT) early in life. Japan Methods: Stimulate saliva from 160 children, with 0 day Background: Serum procalcitonin (PCT) concentration of life, were enrolled in this study. Salivary IgA and IgM levels has been used as a specific biomarker for diagnosis and were determined by ELISA. Subsets of 24 fullterm (FT) and severity of the bacterial infections. Although data of quanti- 24 Preterm (PT) children showing similar salivary IgA lev- tative PCT concentration for bacterial infections have been els were paired and matched for gender, racial background, accumulated, clinical implications for semi-quantitative breastfeeding. SIgA antibody reactivity to MS, Streptococcus PCT concentration have not been well defined. Thus, we sanguinis (SSA), Streptococcus mitis (SMI) and Streptococcus report the clinical utility of PCT-Q especially for cases with gordonii (SGO) Ags was determined in Western blot assays. bacteremia. Results: Levels of SIgA were statistically different (Whit- Methods: PCT-Q concentration was measured in those ney test, p<0.05) between groups and in FT were 2.5 who were suspected bacterial infections among all patients times higher than PT children. Fifty and 37.5% of PT and who were evaluated in our Emergency Department from FT respectively not show any response to antigens of the September 2007 to March 2008. PCT-Q concentra- microorganisms tested. Significant diversity was observed tion was divided into four classes (<0.5, > = 0.5, > = 2.0, in IgA antibody response patterns to Ags. The number and > = 10.0ng/mL) and above 0.5ng/mL that was the cut-off intensity of reactive bands was higher in FT than PT children value were defined as bacterial infections. We compared for all antigens tested. Some antigens were more frequently the results of PCT-Q with quantitative PCT concentra- detected in salivas, such as: 165KDa of SGO, 172 KDa of SSA, tion, white blood cells (WBC) and C-reactive protein (CRP). 202 KDa of SMI, 185 and 160 KDa of MS. Responses to 165KDa The results of blood culture of all recruited patients were of SGO were unique among those antigens that presented collected and the results of PCT-Q positive for bac- different in their pattern of recognition between FT and PT teremia were also analyzed. Furthermore we compared (Chi-square, p<0.02). the rates of detection of Methicillin-resistant Staphylococ- Conclusion: The data indicate that salivary IgA responses cus aureus (MRSA) in this period with that of previous one to Ags can occur in the first day of life and children PT year. show a diminished response of SIgA to SSA, SMI, SM and Results: A total of 291 patients among all 16,700 patients SGO Ags which may be due to lower concentrations of IgA were evaluated. The concentration between PCT-Q and (FAPESP:07/57346-5; 07/50807-7). quantitative PCT were almost concordant. Discordance between PCT-Q concentration and WBC was observed, doi:10.1016/j.ijid.2010.02.1606 while significant correlation between PCT-Q concentration and CRP concentration was obtained. The sensitivity and 25.005 specificity of PCT-Q among patients with bacteremia was Infectious complications of venomous snakebite: 2 cases 72.1% and 64.4%, respectively. The rate of detection of MRSA from Eastern Nepal fell from 6.5% (50/766) to 3.8% (29/773). S.K. Sharma ∗, S. Shrestha, B. Badhu, C.S. Agrawal, B. Conclusion: PCT-Q is useful for diagnosing severe bacte- Khanal rial infections including bacteremia. PCT-Q could be useful to restrain from the emergence of bacterial resistant strains BP Koirala Institute of Health Sciences, Dharan, Nepal by decreasing unnecessary antimicrobial usage. Background: Venomous snakebite is a common and deadly disease throughout the tropics, but there are few reports of doi:10.1016/j.ijid.2010.02.1605 infections associated with snake envenomation in Asia.We 25.004 describe two patients with distinct infectious syndromes fol- Salivary IgA responses in newborn against pathogen of oral lowing venomous snakebites in Eastern Nepal. cavity. Influence of prematurity in this response Methods: Two case reports. Results: Case 1: Endopthalmitis and necrotizing fasci- ∗ R.D. Nogueira , M.L.T. Sesso, M.C.L. Borges, L.R. Roberti, itis. A 21 year old female victim of snake bite (common V.P.L. Ferriani cobra) to the foot presented within 30 minutes and received 24 ampoules of antivenom (Bharat Serum, India) over University of Sao Paulo - Faculty of Medicine of Ribeirao 2 days. After 18 hrs she developed dusky, ascending Preto, Ribeirao Preto, SP, Brazil wound discoloration associated with (pain, blisters, fevers, Background: Analysis of the mucosal immune system and leukocytosis). Necrotizing fasciitis was diagnosed and represents an interesting way to understand the microbial treated with antibiotics and surgical debridement. On hos- colonization in early life, particularly the response of SIgA pital day 2nd, the patient developed right eye pain and (Secretory IgA) present in saliva because it represents the blindness. Analysis of vitreous humor aspirate revealed gram first line of defense. Previous study showed in children with negative bacilli, and intravenous and ocular antibiotics were 6 months of age, high complexity of SIgA response to anti- administered; aspirate cultures revealed growth of Serratia e54 14th International Congress on Infectious Diseases (ICID) Abstracts marcescens. The patient was discharged after 21 days, with aureus in 27.3% (n = 3), and Acinetobacter species in 9.1% moderate foot dysfunction and total eye blindness. (n=1). Case 2: Local soft tissue infection with Enterococcus. Conclusion: Clinical spectrum of IE in our study was dif- A 62 years old alcoholic male presented within 1 hour after ferent from the west.Majority of patients being young, RHD snakebite to the right hand from an unknown species. He still being the common underlying heart disease. However had applied two tourniquets (to right forearm and arm) that microbiological pattern was similar to western studies, i.e. were loosened in the emergency ward. He developed mild staphylococcus aureus being the commonest isolate. So, we local swelling and neurological symptoms (ptosis, opthalmo- need a large study to know the real epidemiological, micro- plegia) within two hours of the bite, and received 200 ml biological pattern of IE in our country. of antivenom (Bharat serum, India) over 2 hours. (Although the neurologic symptoms resolved) the patient subsequently doi:10.1016/j.ijid.2010.02.1608 developed fevers and the hand swelling increased over 2 days. The wound developed gangrene and purulence 25.007 over requiring surgical debridement. Wound cultures grew The relation of the contraction period and the bacteria of Enterococcus species, and he received gentamicin, metron- the otorrhea of chronic otitis media idazole, and vanomycin. He was discharged on day 18th with M. Shinogami ∗, H. Iwamura, W. Nakanishi, C. Yamada moderate loss of hand functions. Conclusion: Snakebite-associated infection in the trop- Tokyo Metropolitan Hospital, Tokyo, Japan ics can manifest variously, with local, regional and remote effects on injured tissues. More studies are warranted for Background: Chronic otitis media [COM] is an infectious this important complication of envenomation. disease to need treatment of the antibiotics many times for a long time. It is often that COM suffers from treatment because the appearance frequency of resistant bacteria or doi:10.1016/j.ijid.2010.02.1607 fungus increases. Aim of our study is to clarify cause bacteria 25.006 of the otorrhea of COM and what kind of patient resistant Clinicomicrobiological profile of infective endocarditis in bacteria increase with. a tertiary care centre of Nepal Methods: 103 patients aged 2 years to 79 years [median age 53.2 years] who complained otorrhea with COM were M. Ghimire enrolled in a study at the Tokyo Metropolitan Police Hospital during September from 2007 to 2009. Diagnosis was made BPKIHS, Dharan, Nepal by otolaryngologists, the otorrhea was collected. The per- Background: Infective endocarditis is a common problem foration of ear drum to last for more than three months and data regarding its clinical and microbiological pattern was defined as COM. Antibiotic treatment within one month from developing countries are sparse. We studied clinical was excluded. The relation of the contraction period and features and the microbiological pathogens in patients with numbers, kind, sensitivity of bacteria was examined. Infective Endocarditis. Results: The patients who had illness under 1 year were Methods: A hospital based, cross sectional descriptive 47 people, for 1 -20 years were 29, for more than 20 years study was carried out over a period of 1 year. were 27. In total, 85 of 103 patients had positive culture. Results: A total of 54 patients with history of fever and Staphylococcus aureus was found in 37[43%]. Pseudomonas underlying heart disease were evaluated for IE. Out of them aeruginosa was found in 23 [27%]. Candida or Aspergillus 11 patients (20.4%) had Dukes definite IE. Fever was present was found in 11 [13%]. Streptococcus pneumonia was found in 100% cases (n = 11) as it was the inclusion criteria of in 2. In the 27 patients who had illness for more than 20 the study, followed by SOB 81.8% (n = 9), anorexia 81.8% years, Pseudomonas aeruginosa was found in 10, Candida or (n = 9), malaise 63.6% (n = 7), cough 54.4% (n = 6), palpita- Aspergillus was found in 9, MRSA was found in 2, and Serratia tion 45.5% (n = 5), swelling of body 45.5% (n = 5), myalgia marcescens was found in 2. 36.4% (n = 4). Past history of RHD was present in 18.2% (n = 2) Conclusion: In this study, the cause bacteria of otorrhea and only 18.2% (n = 2) of patients were in penicillin prophy- of the COM found that obviously it was different from that of laxis. No patients had undergone any dental procedure in the acute otitis media. Specially, it found that the bacteria last 2 weeks prior to the presentation. One patient (9.1%) in such case as the Pseudomonas aeruginosa and MRSA that was intravenous drug abuser and 36.7% (n = 4) of patients it had a difficulty in the treatment increased as much as the were smoker. History of antibiotic therapy prior to the pre- year which COM took increased, and fungus which treatment sentation was present in 36.7% (n = 4) patients. None of the by the antibiotic was invalid to had identification given, too. patients had a history of prior IE. Pallor was the most com- We have to do treatment by the antibiotic carefully until mon sign 63.6% (n = 7), followed by edema 54.5% (n = 6), cause bacteria have identification given by a bacteriological icterus 36.4% (n = 4). Embolic events seen in 18.2% (n = 2). examination about the otorrhea of the COM. Dental caries and focal neurological deficit were seen in 9.1% (n = 1) each. Peripheral signs in IE were not seen in doi:10.1016/j.ijid.2010.02.1609 any of the cases. Petechial hemorrhage in 18.2% (n = 2) patients. Anemia (Hb < 10gm %) in 36.4% (n = 4) cases, leu- cocytosis and microscopic haematuria in 72.3% (n = 8) and 27.3% (n = 3), respectively. Blood culture positivity was seen in 36.4% .The most common pathogens were Staphylococcus 14th International Congress on Infectious Diseases (ICID) Abstracts e55

25.008 this could partially explain the higher failure rates found in Bone and joint infections in elderly and young adults the elderly as compared with young adults. patients: Comparison of clinical features and outcomes (1991-2007) doi:10.1016/j.ijid.2010.02.1610 F. Nacinovich 1, C.A. Pensotti 2,∗, C. Vizzotti 3, P. Fernandez 25.009 Oses 3, A. Ferraris 4, P. Luchetti 3, M. Marin 3, A. Sucari 3,J. Prosthetic joint infections: A multidisciplinary approach Thierer 5, C. Di Stéfano 6, D. Stamboulian 7 (1992-2008) 1 FUNCEI and ICBA, Ciudad Autonoma de Buenos Aires, C.A. Pensotti 1,∗, F. Nacinovich 2, P. Fernandez Oses 3,J. Argentina Thierer 4, A. Ferraris 5, C. Vizzotti 3, C. Di Stéfano 6,D. 2 FUNCEI and Clinica Privada Monte Grande, Ciudad Stamboulian 7 Autonoma de Buenos Aires, Argentina 1 3 FUNCEI, Ciudad Autonoma de Buenos Aires, Argentina FUNCEI and Clinica Privada Monte Grande, Ciudad 4 FUNCEI, Ciudad Autónoma de Buenos Aires, Argentina Autonoma de Buenos Aires, Argentina 2 5 ICBA, Ciudad Autonoma de Buenos Aires, Argentina FUNCEI and ICBA, Ciudad Autonoma de Buenos Aires, 6 FUNCEI, Ciudad Autonoma de Buenos Aires, Argentina Argentina 3 7 Clinical Director of FUNCEI, Ciudad Autonoma de Buenos FUNCEI, Ciudad Autonoma de Buenos Aires, Argentina 4 Aires, Argentina ICBA, Ciudad Autonoma de Buenos Aires, Argentina 5 FUNCEI, Ciudad Autónoma de Buenos Aires, Argentina Background: The effect of age on the presentation and 6 FUNCEI, Ciudad Autonoma de Buenos Aires, Argentina outcome of BJI is unclear. Available data is mostly based on 7 Clinical Director of FUNCEI, Ciudad Autonoma de Buenos the analyses of mixed populations. Aires, Argentina The objective was to evaluate the clinical and microbiological features and outcomes of BJI in young adults vs. Background: The management of prosthetic joint infec- older patients. tions (PJI) requires combined medical treatment and Methods: We carried out a retrospective cohort study surgery. The one or two-stage exchange arthroplasty (EA) comparing 341 episodes (ep) of BJI in elderly pts (>65 yo) or resection arthroplasty (RA) are the conventional surgical vs. 336 ep in a younger (>16 yo and < 50 yo). approach suggested. Results: From 1/91 to 11/07 we registered 908 ep: 341 The objectiv was to analyze the clinical and microbio- (37.5%) were > 65 yo (47.2% male; mean age 73.5, r:65-103) logical features and the outcome of PJI treated with the and 336 (37%) < 50 yo (72.1% male; mean age 32.4, r: 16-50). conventional surgery approach. Mean follow-up was 36.7 months (r: 1-168). Methods: We performed a retrospective cohort study of Comparison between elder vs. younger patients ep.: PJI episodes (ep.) treated with EA or RA. The medical and a) Type of infection: osteomyelitis (OM) 25.5% vs. surgical approach were not previously standardized, but 36.6% (p < 0,001), septic arthritis (SA) 2.9% vs. 11.9% individualized according to the patient and the treating (p = 0.0018), implantassociated infections (IAI) 64.8% vs. team. Statistical analysis: we used the Stata 10, applying 43.2% (p < 0,001); b) Location: upper extremities 10.1% the Chi 2 test. Difference was considered statistically sig- vs. 14.6% (p = 0.037), lower extremities 75.6% vs. 69.6% nificantat p< = 0.05. (p = 0.079), spine 4.7% vs. 9.5% (p = 0.014), sternum OM 7.3% Results: From 01/92 to 05/08, 309/1026 ep. (30.1%) in vs. 0.6% (p < 0.001); c) Source of infection: hematogenous, our database were PJI; 129/309 ep. (41.7%) were treated ± contiguity and post-trauma (p = NS), post-surgical 70.2% vs. with EA or RA. Mean age 68,2 11,4; 58.1% female. Late PJI 59% (p = 0.002); d) Comorbidities 75% vs. 19% (p < 0.001); 75.6%, 21.3% early, 3.1% IO. c) clinical picture: pain and phlogosis (p = NS), fever 16.4% Location: hip 61.7%, knee 32.8%, shoulder 3.9%, elbow vs. 36% (p < 0,001), fistula 29% vs. 37.2% (p = 0.023), puru- 1.6%. lent discharge 34% vs. 41.4% (p = 0.048), sed. rate > 50 mm/h Source of infection: postoperative 93,6%. 41.6% vs. 28.6% (p < 0.001); e) Microbiology: gramposi- Clinical features: pain 72.1%, flogosis 33.3%, sinus tract tive cocci (p = NS), gramnegative bacilli 16.4% vs. 8.6% 22.5%, purulent discharge 21.7%, fever 14.0%. Sed rate (p = 0.0022), polymicrobial 19.1% vs. 13.1% (p < 0,001), neg- >50 mm/h: 66.3%. ative cultures 5% vs. 1.9% (p = 0.0012); f) Surgical treatment: Microbiology: 57.6% grampositive cocci (S. aureus 35.2%, 75.4% vs. 63.7% (p = 0.0057); f) Outcome: cure/improvement CoNS 13.6%, other 9.2%), 10.4% gramnegative bacilli (P. 79.2% vs. 83% (p = NS), failure 5.3% vs. 2.4% (p = 0.049), aeruginosa 8% Enterobacteriaceae 4%); polimicrobial 24%, relapse 12.6% vs. 10.4% (p = NS). fungi 1.6%, anaerobic bacteria 0.8%, culture negative 5.6%. Conclusion: In our experience, BJI affect most often Antibiotic therapy: TI: 20 weeks (median; IR 12-26); oral upper extremities (OM and SA) and spine (OM) in male young 50%, switch to oral therapy 37.5%, parenteral only 12.5%.TS adults. Post surgical IAI in lower extremities and sternum in 28,9% ep; median 24 weeks (IR 11-37). show higher compromise in older female and the clinical Surgical treatment: two-stages EA 50.4%, one-stage EA picture is often more insidious than in young adults. Nor- 13.9%, AR 35.7%. mal sed. rate does not exclude the presence of BJI in both Follow up: 27 months (median; IR 16-50). groups. Gramnegative bacilli and polymicrobial infections Outcome: cure/ improvement: 109 (87.2%), relapse 9 are more common in elderly. Surgical treatment is imple- (7.2%), failure 3 (2.4%), not evaluable (3.2%). mented most frecuently in the elderly; however due to a In the univariate analysis, only PJI treated with two- more conservative approach is usually implemented in IAI, stages EA had a better outcome (p = 0.04). e56 14th International Congress on Infectious Diseases (ICID) Abstracts

Conclusion: The management of PJI should be individual- 25.011 ized according to the patient characteristics and evaluated A comparison of infective endocarditis related Seque- with a team (orthopedic surgeons and infectologist). This lae incidence among population- based, multicenter, and is the key in determining the functional status of the pros- hospital-based cohorts: Data trom a systematic review for thesis, in order to define the surgery strategy. Two-stages the global burden of disease project EA is the method that achieves better control of infection. ,∗ There were no significant differences in the outcome with A. Bin Abdulhak 1 , M. George 2, L.M. Baddour 3,E. the others variables studied. Patricia 4, V. Chu 5, M. Ezzati 6, B. Hoen 7, I.M. Tleyjeh 8 1 King Fahd Medical City, Riyadh, Saudi Arabia doi:10.1016/j.ijid.2010.02.1611 2 pepsico, gerogia, GA, USA 25.010 3 MAYO CLINIC COLLEGE OF MEDICINE, ROCHESTER, MN, USA 4 Mayo clinic, Rochester, MN, USA Cerebrospinal meningitis outbreak in Kano state, Nigeria 5 Duke university, North carolina, NC, USA O. Biya 1,∗, O. Alabi 2, G. Tolough 1 6 harvard, Boston, MA, USA 7 University, Paris, Paris, France 1 Nigerian Field Epidemiology and Laboratory Training Pro- 8 KING FAHD MEDICAL CITY, RIYADH, Saudi Arabia gram, Abuja, Nigeria 2 Nigeria Federal Ministry of Agriculture, Abuja, Nigeria Background: Referral bias has been shown to influence infective endocarditis (IE) epidemiology in a previous study Background: Neisseria meningitides (Nm) is the lead- comparing IE patients from Olmsted county, Minnesota and ing cause of epidemic Cerebrospinal meningitis (CSM). Kano those referred to Myao clinic from other hospitals. Due to State in northern Nigeria is located within the ‘African scarce data from population based studies in many coun- meningitic belt’ and has reported frequent CSM outbreaks tries, less representative IE patient populations may be in the past. In March 2009, a suspected outbreak of CSM needed to estimate the burden of this disease. We aimed to was reported from Kano. We conducted an investigation to compare the incidence of IE related sequelae among pub- describe the magnitude of the outbreak and institute public lished pouplation- based, multicenter, and hospital-based health control measures. cohorts. Methods: We reviewed patient hospital records, inter- Methods: We conducted a systematic review of viewed healthcare workers and hospitalized cases. A total puplished studies,surveys,and other data sources in of 60 hospitalized cases chosen systematically in one of the order to assess the global epidemiology of IE and reporting Local Government Areas (LGAs) were interviewed related disabling sequelae. A simplified model was with a structured questionnaire. We collected Cerebrospinal used and it included cure, valve surgery,stroke, and fluid (CSF) specimens from suspected cases from the first death. Electronic databases searched included MID- 15-20 suspected cases from each LGA. A suspected case of LINE,EMBASE,LILACS,koreaMED,AMED,EXTRAMED,scopus CSM was defined as any person aged two years and above and web of scinence.To estimate IE sequela and mor- with sudden onset of fever (>38oC axillary) and any one tality,data from population based studies were used of these signs: neck stiffness, altered consciousness, and preferentially whenever availabe for a given country other meningeal signs. A confirmed case was defined as a followed by multicenter cohorts and then hospital series. suspected case with laboratory confirmation. We analyzed We copmare the incidence of IE related sequelae among data with Epi info version 3.3.2 and Microsoft excel office published population- based, multicenter, and hospital 2003. based cohorts. Results: A total of 1036 suspected cases were reported Results: Data were from 40 countries and 2 interna- with 30 deaths, a case fatality rate of 2.9%. The overall tional collaborations. we identified 121 cohorts, 21 were attack rate was 10.0 per 100,000 persons but varied over population-based, 21 were muticenter, and 79 were hospital the weeks and by LGA. Majority of the cases were aged 2- based. The incidence on IE related sequelae did not differ { } 15 years 812 (78.4%) . The age-specific attack rate for age significantly among the different cohorts (table). group 2-15 years was 19.6 per 100,000 persons. Of 60 cases interviewed, only 3 (5.0%) had received CSM vaccination Population based Studies Valve Stroke Mortality within previous 3 years. Out of 124 CSF samples analyzed, replacement (%) (%) 69 (55.6%) tested positive for Nm serogroup ‘A’ (Nm A). (%) The recommended drugs for case management in meningitis Mean(Standard Deviation) 25(13) 7(13) 25(10) outbreaks — oily chloramphenicol and ceftriaxone were not Median (Range) 21(44) 15(32) 21(35) available. Multicenter Cohorts Conclusion: Nm A was the cause of the CSM outbreak Mean(Standard Deviation) 38(16) 14(19) 20(8.8) that affected mostly age group 2-15 years in Kano. The Median(Range) 43(47) 15(29) 18(37) authorities should conduct a reactive vaccination campaign Hospital Cohorts targeting this age group and procure adequate drugs for Mean(Standard Deviation) 28(16) 16(21) 23(25) effective case management. Medican(Range) 26(63) 12(42) 23(57) Conclusion: In this systematic review of IE studies, the doi:10.1016/j.ijid.2010.02.1612 incidence of IE related sequelae did not differ significantly among different types of sampled populations. Due to the paucity of population-based data from many countries, hos- 14th International Congress on Infectious Diseases (ICID) Abstracts e57 pital based series could be used as an alternative source to risk factors(GBD) has not included specific assessment of estimate the global burden of IE. the burden of IE and its sequelea. We aimed to describe the methdology for a comprehensive assessment of IE bur- doi:10.1016/j.ijid.2010.02.1613 den trends in 21 world regions for 1990-2005 as part of the current GBD 2005 effort. 25.012 Methods: A systematic review of published studies, sur- The impact of a microbial sealant to reduce surgical site veys,and other data sources is being conducted in order infection reduction in cardiac surgery to assess the global epidemiology of IE and related disabling sequelae. Cases of IE were defined according to the P. Dohmen 1,∗, T. Christ 1, J. linneweber 2, W. Konertz 1 Duke, modified Duke, Steckelberg,Von Reyn and modified 1 Charite Hospital, Medical University Berlin, Berlin, Von Reyn. A simplified model was used for the system- Germany atic review and it included cure,valve surgery,stroke, and 2 Charite Hospital, Medical University Berlin, Berlin, death.Electronic databases included. Germany MEDLINE,EMBASE,LILACK, KoreaMED, AMED, EXTRAMED, scopus and web of science.Only population based studies Background: Surgical site infection (SSI) do have a serious were used to estimte the incidence. impact on patients undergoing cardiac surgery. This study Results: We identified 121 studies: 21 population- was performed to prove if additional preoperative care by based,21 multicenter studies, and 79 hospital cohorts. using a microbial sealant can reduce surgical site infection. Data originated from 40 countries and 2 international Methods: To improve preoperative surgical care two collaborations. Only 18 population based studies reported groups of patients were identified during thes same period on the incidence of IE/100,000 in 9 countries.Australia(3), of time. Between January and August 2007, a control France (2.2,3), Denmark(2.4,2.7),Italy (3.6), Nether- group (n = 718), receiving standard institutional preopera- lands(1.5,9.6), Sweden(0.39,6.2), Tunisia(5.5), UK(1.6,2.3), tive preparation and between January and August 2008,the USA(1.7,3.8,4.2,4.95,11.6). Valve replacement was per- InteguSeal group (n = 780) who received additionally a micro- formed on 30%(mean) and 29%(median) of IE cases.Stroke bial sealant prior to sternotomy. Both groups were evaluated occured in 15%(mean)and 14%(median).Mortality occured by patients characteristics and a pre-operative risk scores. in 23%(mean) and 21%(median) of cases. Bias secondary End-point of this study was freedom from SSI. to incomplete data, non representative populations, and Results: Follow up was 100% completed. The values of missing data for national or regional populations remain the pre-operative risk score of the control group and the important challenge. Specific strategies to address this lim- InteguSeal group was significantly different in both groups, itation are ongoing and include (1) translating non-English ± ± respectively 9.7. 1.5 and 10.1 1.8 (p = 0.001). studies (2) searching the gray literature; and (3) contacting The clinical end-point, however showed a highly signif- IE experts in world regions with limited or no data. icant decrease of SSI in the InteguSeal group 1.4% (n = 11) Conclusion: A comprehensive and systematic assessment compared with the control group 4.3% (n = 31), (p < 0.003) of the global burden and trends in IE mortality and disability althrough they were at higher risk for SSI. using a rigorous methodology is being conducted. IE is a rel- Conclusion: Thus, the pre-operative risk score for atively uncommon disease but is associated with significant patients of the InteguSeal group was significant higher com- morbidity and mortality. Completion of this effort will add pared to the control group, there was a highly significant substantively to the summary estimates of cardiovascular reduction of surgical site infections seen. mortality and disability. doi:10.1016/j.ijid.2010.02.1614 doi:10.1016/j.ijid.2010.02.1615 25.013 25.014 The global burden of infective endocarditis: Methodol- Psoas abscess in Korea: Etiology, clinical features, treat- ogy for a systematic review to assess disease burden and ment and outcome trends in 21 world regions for 1990-2005 M.W. Kang ∗, Y.J. Kim, K.-W. Hong, S.I. Kim, Y.R. Kim I.M. Tleyjeh 1,∗, M. George 2, A. Bin Abdulhak 3, E. Patricia 4, V. Chu 5, M. Ezzati 6, B. Hoen 7, L.M. Baddour 8 The catholic University of Korea, Seoul, Korea, Republic of 1 KING FAHD MEDICAL CITY, RIYADH, Saudi Arabia Background: Abscess of the psoas muscle is a rare dis- 2 pepsico, gerogia, GA, USA ease. Because of nonspecific presentation, it is difficult to 3 King Fahd Medical City, Riyadh, Saudi Arabia diagnosis. There is a wide spectrum in etiology, time to diag- 4 Mayo clinic, Rochester, MN, USA nosis, and therapeutic options. This study is to describe the 5 Duke university, North carolina, NC, USA etiology, clinical features, treatment, and outcome of psoas 6 harvard, Boston, MA, USA abscess from multicenter in Korea. 7 University, Paris, Paris, France Methods: We retrospectively reviewed the medical 8 MAYO CLINIC COLLEGE OF MEDICINE, ROCHESTER, MN, USA records of patients with psoas muscle abscess who were admitted to three university hospitals in Korea over 10 years. Background: Infective endocarditis(IE) is an important Results: A total of 87 patients (46 male, 41 female) were contributor to mortality and morbidity worldwide. However, included in this study. The mean age was 56.3 ± 18.5 years previous work in the global burden of diseases, injuries,and old. The mean duration of hospitalization was 31.9 ± 24.37 e58 14th International Congress on Infectious Diseases (ICID) Abstracts days, time from admission to diagnosis was 13.6 ± 82.9 days. 0.84, p < 0.001) and 0.73 (CI 95% 0.67- 0.79, p < 0.001) for Fourteen cases as ‘‘secondary’’ abscess, and pyelonephri- 28-days mortality and ICU-admission, respectively. tis (7/14, 50%) were most frequent etiology. Positive blood Conclusion: CURB-65 score showed a good discrimination culture were obtained in 25% (27/81) and the causative capacity for ICU-admission and 28 days-mortality in CAP in pathogens were S. aureus (17/27, 62.8%), E.coli (4/27, Uruguay and could be used for early identification of patients 14.8%), Coagulase negative staphylococci (3/27, 11.1%), with high mortality and requiring ICU-admission in Uruguay. K. pneumoniae (2/27, 7.4%) and Candida species (1/27, 3.7%). Among 49 patients who were cultivated from abscess doi:10.1016/j.ijid.2010.02.1617 material, 41 microorganisms were grown in 34 patients (35/49, 71.4%) and the most frequent organisms were S. 25.016 aureus (17/35, 41.5%) E. coli (6/35, 114.6%), K. pneumoniae Encrusted Pyelitis: A kidney stone disease of infectious (5/35, 12.2%). Forty patients(45.9%) underwent surgical origin debridement, 11 percutaneous drainage, 4 aspiration, and M. Lodigiani ∗, C. Ottone, V. Bellesi, D. Cera, S. Rojas, A. 31 patients were received only antibiotic treatment. The Celentano, S. Ripoll overall mortality was 10% (n = 9). Comparison of treatment options showed mortality was not significant different Hospital de Emergencias Dr Clemente Alvarez, Rosario, between patients for only antibiotics and for antibiotics plus Argentina invasive procedure (12.9% (4/31) vs 8.9% (5/56), p = 0.55). Conclusion: The etiology of psoas abscess can vary with Background: Encrusted Pyelitis is a rare stone disease each countries. In Korea, ‘‘primary’’ psoas abscess was more related to group D2 Corynebacterium. prevalent than ‘‘secondary’’ psoas abscess, and S.aureus It was first described in 1993 by Aguado- Morales et-al was the most prevalent organism. The causative organisms in transplanted patients and later in patients with native can be identified by abscess culture in most cases. High index kidney having predisposing factors which were underlying of suspicion is important to early diagnosis. urologic disease and/or urologic manipulation, debilitating disease, hospitalization, and prolonged antibiotic therapies. Methods: A 31- year-old female with a history of repeated doi:10.1016/j.ijid.2010.02.1616 urinary tract infection who required a left nephrectomy was 25.015 studied. She was admitted in our service because of persis- Mortality and ICU-admission in community-acquired pneu- tent symptoms of pyelonephritis with no growth of bacteria monia: CURB-65 score validation in Uruguay on urine culture, and the presence of obstructive acute renal failure. ,∗ H. Albornoz 1 , D. Goleniuk 2 Ultrasound of the kidney detected hyperechogenic material in the pelvis. Mild dilation of right ureter with a 4 mm 1 Hospital Departamental de Rivera and Cooperativa de Asis- diameter stone in distal urether. tencia Medica de Rivera-FEMI, Montevideo, Uruguay Abdominal CT: right kidney with abnormal morphology 2 Hospital Departamental de Rivera, Cooperativa de Asis- and loss of cortico-medular differentiation. Hyperdense tencia Medica de Rivera-FEMI and Cooperativa Medica de lesions with coraliform lithiasic aspect. Rivera, Rivera, Uruguay A percutaneous nephrostomy was performed. Background: Community-acquired Pneumonia (CAP) is A coraliform stone was seen and the presence of still an important health problem with high mortality. Early Corynebacterium Urealyticum in the urine culture and cul- identification of patients with severe CAP should improve ture of the stone was detected. Treatment with vancomicine the results. CURB-65 score of the British Throracic Society was completed for 21 days. is one of the simplest predictor’s score of mortality and Results: Encrusted Pyelitis is characterized by accumu- intensive care unit admission (ICU). Objetive: to validate the lation of struvite crystals in ulceronecrotic lesions of an CURB-65 score in CAP patients admitted to three community inflamed and infected chorion of the urinary tract. It’s hospitals in Rivera, Uruguay. related to the colonization with C. Urealyticum, aerobic Methods: A prospective cohort of CAP patients admitted gram positive bacilli, non sporulated, with frequently groups between 1st May 2005 and 30th April 2007 was included and with a V shape, positive catalasa, negative nitrate, posi- followed up until one year of hospital discharge. Area under tive ureasa. C. Urealyticum is a common hast of skin and the ROC and specificity and sensibility were estimated for mucosa, particularly in genital area which, in presence of CURB-65 score for 28 days-mortality and ICU-admission. predisposing conditions, colonizes the urinary tract causing Results: 495 patients (63 ± 19 years, male 53.9%) were infection. The clinical manifestations are a triad of pyuria- included. 28-days mortality and ICUadmission were 20.8% hematuria, alkaline urine and presence of struvite crystals. (102/491) and 19.9% (98/492), respectively. 28-days mor- The growth of C. Urealyticum in urine samples increases tality in patients with CURB-65 0, 1, 2, 3 and 4-5 was 4 when a selective culture is used and the period of incubation (6/150), 14.2 (30/211), 43.6 (41/94), 67.7 (21/31) and 80% is of 48 hours. C. Urealyticum is generally resistant to B- (4/5), respectively (p < 0.001). ICU admission in patients lactamic and amuinoglucosides and sensible to vancomicine with CURB-65 0, 1, 2, 3 and 4-5 was 8 (12/150), 15 (32/213), and teicoplamine; with variable sensibility to quinolones, 29.5 (28/95), 74.2 (23/31) and 100% (3/3), respectively erithromicin, rifampicin and tetracycline. (p < 0.001). Area under the ROC was 0.79 (CI 95% 0.74 — 14th International Congress on Infectious Diseases (ICID) Abstracts e59

Conclusion: It is the purpose of this work to study 25.018 this case because of its low incidence in not transplanted Infective endocarditis in children: Analysis of cases admit- patients. ted to a cardiac surgery referral hospital from January 2006 to July 2009 doi:10.1016/j.ijid.2010.02.1618 L.A. Pereira 1, G.Q. Lopes 2, M.R.G. Vasques 1, P.R. 25.017 Travancas 3, W. Paiva 3, L.C. Simões 3, G.I.D. Ferraiuoli 1,M. ,∗ Distant infection and the risk of Prosthetic Joint Infection D.S. Santos 1, C. Lamas 1 (PJI): A case control study 1 Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil G. Tsaras ∗, D.R. Osmon, A.D. Hanssen, L.M. Baddour, D.G. 2 Associação Fluminense de Ensino, Duque de Caxias, Brazil Greene, W.S. Harmsen, J.N. Mandrekar, J.M. Steckelberg, 3 Insituto Nacional de Cardiologia, Rio de Janeiro, Brazil W.R. Wilson, E.F. Berbari Background: Paediatric infective endocarditis(PIE) is MAYO CLINIC COLLEGE OF MEDICINE, ROCHESTER, MN, USA overall not a common disease, and there are few recent series describing this condition in developing countries. We Background: The risk of prosthetic joint infection (PJI) describe our local experience and identify risk factors for associated with prior distant organ infection has not been acquisition of PIE. assessed. Methods: This is a prospective study, using the ICE case Methods: We performed a single-center, case-control report form (CRF). Cases were defined by the modified Duke study between December 2001 and May 2006 in a 2000 criteria. Data extracted from these CRFs were analysed on bed tertiary care hospital in Rochester, Minnesota. Cases Microsoft ExcelR. Means were expressed ±standard devia- were patients hospitalized with total hip or knee arthro- tion. Chi-square values were calculated in Statcalc (EpiInfo) plasty infection. Controls were patients with a total hip Results: Twenty six children were included; they were arthroplasty (THA) or total knee arthroplasty (TKA) hospi- divided into 2 groups: A (age < 1 year) and B (age ≥ 1 year). talized within the same time period without a prosthetic Group A (gpA) had 5 children (4 male, M, 1 female, F), mean joint infection. Controls were frequency matched to cases age 41 ± 46 days. Group B (gpB) had 21 children (14 M, 7F), by prosthesis location. Data regarding demographic features with mean age 12,1 ± 4,4 years. Congenital heart disease and potential risk factors related to the development of a was present in 15/26 (58%), 5 in gA, 10 in gB. Rheumatic PJI were collected. Logistic regression was used to assess heart disease was present in 7/21(33%) of gp B. Diagnosis the association of variables with the odds of infection. of PIE was definite in 21/26 (81%; 2 gpA,19 gpB). Mitral, Results: There were 339 cases and 339 controls. tricuspid, aortic and mitroaortic valves were affected in 164/339(48.4%) cases had a THA and 175/339(51.6%) had similar proportions. Acute clinical presentation was present a TKA. The two most common organisms responsible for in 20/26 cases (81%; 5 gpA,15 gpB); and subacute in 6 (6 PJI were Staphylococcus coagulase negative and S. aureus, gB). Hospital acquisition of infection was present in 11/26 encountered in 101/339(30%) and 95/339(28%) of cases (42%; 5/5 gpA e 6/21 do gpB). Causative microorganisms are respectively. 111/339(32.7%) of cases and 62/339(18.3%) shown in Figure 1 and clinical features in figure 2. Intra- of controls had a distant organ infection in the preceding venous (IV) access was a predisposing procedure in 12/26 two years prior to the development of PJI (adjusted odds (46%) patients (5 gA e 7 gB). Recent (same admission) cardiac ratio, 2.18 [95% CI 1.46 - 3.26]; p-value < 0.0001). The two surgery was present in 11/26 (42%; 5 gpA e 6 gpB). Transtho- most common distant infections were Urinary Tract Infec- racic echocardiograms showed major criteria in 25/26(96%). tion (33/339 cases and 22/339 controls) and Respiratory Complications were emboli (2 gA, 9 gB), persistently positive Infection(31/339 cases and 23/339 controls). Blood stream blood cultures (1 gA,4 gB), central nervous system events (8 infection within two years preceding the development of PJI gB) and cardiac failure (1 gpA,8 gpB). Mortality was 4/5 (80%) occured in 14/339 cases and none in controls. in gpA and 9/21(43%) in gpB. Conclusion: Prior distant organ infection is independently Conclusion: Children less than 1 year old had acute pre- associated with an increased risk of PJI. Patients with an sentation, hospital acquired infection and high mortality arthroplasty and a distant organ infection should be evalu- more often, when compared to older children. Previous IV ated and treated promptly. access and cardiac surgery were frequently seen in this group as predisposition to infection. doi:10.1016/j.ijid.2010.02.1619 doi:10.1016/j.ijid.2010.02.1620 25.019 Anaerobic bacteria as etiological agents of intraabdominal infections from a Costa Rican hospital C. Quesada-Gómez ∗, E. Rodríguez-Cavallini, M.D.M. Gamboa-Coronado University of Costa Rica, San José, Costa Rica Background: Intraabdominal infections (IAI) are serious life-threatening conditions that endanger patient’s life e60 14th International Congress on Infectious Diseases (ICID) Abstracts and are caused usually by the indigenous intestinal flora. of anaerobic bacteria is helpful, not just in Costa Rican The study of the anaerobic bacteria involved in the IAI hospitals, but in those of the Latin American region. contributes for a better treatment; nevertheless, it is performed by few laboratories in Costa Rica as well as other doi:10.1016/j.ijid.2010.02.1621 Latin American countries. Methods: Two hundred thirty one intraabdominal samples 25.020 were studied by anaerobic bacteria. Samples were taken by Blood culture negative infective endocarditis (IE). Clin- medical staff and sent, under anaerobic conditions, to the ical features, long- term outcome and comparison with Anaerobic Bacteriology Research Laboratory of the Univer- positive blood culture IE sity of Costa Rica. From the San Juan de Dios Hospital, Costa F. Nacinovich 1,∗, E. Perez Carrega 1, M. Trivi 1, J. Thierer 2, Rica (for nine years: 1999 to 2008). D. Navia 1, F. Piccinini 1, M. Marin 3, A. Sucari 3, P. Fernandez Once there, each one was inoculated into prereduced 3 4 ◦ Oses , D. Stamboulian media and incubated for 48 h at 35 C. After this, each sample was streaked in blood agar supplemented with vitamin K 1 ICBA, Buenos Aires, Argentina and hemin in order to isolate characteristic colonies. These 2 Blanco Encalada 1543, Ciudad Autonoma de Buenos Aires, were identified using Gram staining, physical colonial char- Argentina acteristics, and hemolysis. For definitive identification the 3 FUNCEI, Ciudad Autonoma de Buenos Aires, Argentina RapID 32A® (bioMérieux) system was used. 4 FUNCEI; Clinical Director, Ciudad Autonoma de Buenos Results: A total of 265 anaerobic isolates were obtained Aires, Argentina from 129 positive samples (56%): 71% of the strains were Gram positive and 29% Gram negative; 2 isolates per sample. Background: Blood-culture negative infective endocardi- Bacteroides was the genus most frequently isolated (22%), tis (BCNIE) is a challenge for clinicians, due in part to the followed by Eggerthella and Clostridium (16 and 15%), The difficult diagnosis and the appropriate choice of antibiotic species of B. fragilis group were the most frequent (more treatment. details in the table)Anaerobic bacteria as etiological agents Methods: To evaluate clinical findings and long-term out- of intraabdominal infections from a Costa Rican hospital come of patients (pts) with BCNIE vs pts with positive blood (1999 — 2008) cultures IE (BCPIE) we analize a prospective observational registry of consecutive definitive episodes (ep) of IE according to modified Duke criteria admitted at the institution. Patients follow up was made by patient visits and/or phone calls. The outcome (relapse and reinfection) was evaluated by Kaplan Mayer method. Results: From August 1998 through December 2006, 177 ep. of IE in 169 patients were included. One hundred and thirty four (75,7%) were definitive IE; 32 (23,8%) were BCNIE. Median age 67 y/o (range=16-87); male 25 (78,2%). Previ- ous antibiotic therapy was used in 14/32 ep (43,75%). NVIE 12/32, PVIE 11/32 (5 early) and 9 intracardiac devices. Aor- tic valve 15, Mitral valve 6, Tricuspid valve 1 and both aortic and mitral valve 1. Clinical picture: fever 25 (78%), sepsis 5 (15,6%), new regurgitation heart murmur 9 (28%). Compli- cations were found in 18/32 patients (56,2%): heart failure 11 (61%), embolic events 6 (75%; 4 were in CNS). Surgery: 24/32 (75%); 13/24 had a positive valve culture or valve PCR. In-hospital mortality: 4/32 (12.5%; 2/24 with surgery). Long- term follow up lasted 1034 days (range 67-3492) and there were 4 relapses (16,5%). The overall mortality was 46,4% (13/28); 8/13 died patients had previous surgery (61,5%). Compared with pts with BCPIE, it was noted that pts with BCNIE more frequently have intracardiac devices (prosthetic valves and pacemakers), surgical treatment and a double rate of mortality in the long-term follow up group. The other variables did not show a statistically significant difference. Conclusion: BCNIE represents a challenge in the clinical practice. It is noteworthy that half of cases had previous antimicrobial therapy; this observation must conscious us about antibiotic use, especially in those patients with intracardiac devices. The mortality and complications makes Conclusion: Knowledge of the etiological agents involved necessary a lasting and rigorous follow up of pts with BCNIE. contributes to the therapeutic success in IAI; so the study doi:10.1016/j.ijid.2010.02.1622 14th International Congress on Infectious Diseases (ICID) Abstracts e61

25.021 Foodborne Diseases and Outbreaks (Poster Presen- Treatment of Chronic Osteomyelitis (COM): Rwanda expe- tation) rience of in situ sterile Plaster of Paris (POP) pellets 26.001 containing antibiotics Shiga-toxin producing Escherichia coli in fresh milk from ,∗ I. Nyaruhirira 1 , E. Nsengiyumva 2 small-holder dairy farms in Kaduna, Nigeria 1 National University of Rwanda, Kigali, Rwanda N.E. Waziri 1,∗, J.U. Umoh 2, H.M. Kazeem 2, I. Ajogi 2 2 Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda 1 National Veterinary Research, Institute, Plateau State, Background: COM constitutes a serious public health bur- Plateau, Nigeria den in developing countries. Diagnosis of acute OM is often 2 Ahmadu Bello University, Zaria, Zaria, NG, Nigeria missed in primary care and patients are referred at a late stage of COM in referral hospitals, thus requiring heavy, long Background: Untreated milk is a good source of trans- and costly treatment. Treatment in many developing coun- mission of human and animal disease causing agents. In tries is not standardized and patients’ outcomes are often Nigeria, milking of cows is generally done using unhygienic poor. procedures and pastuerization of milk is rarely done. Shiga Methods: From June 2000 to March 2001, 67 patients toxin-producing Escheriachia coli are foodborne pathogens diagnosed with COM at the University Teaching Hospital of associated with hemorrhagic colitis and hymolytic-uremic Kigali, Rwanda were placed into two treatment groups: syndrome. We conducted a study to determine hygienic Group 1 (34 patients) received ‘‘classic treatment,’’ practices during milking, assess the microbial quality and sequestrectomy, surgical toilet, and closing of the wound presence of E.coli in fresh milk from samllholder dairy farms over sucking drains. Patients also received I.V. antibiotics in Kaduna. until the wound healed and then received wide spectrum Methods: We used a multistage cluster sampling to select oral antibiotics until normalization of the ESR. forty farms from three senetorial districts in Kaduna State. Group 2 (33 patients) were also treated by sequestrec- Fifteen milk samples collected from each farm were ana- tomy, surgical toilet, and closing of the wound over sucking lyzed for total plate (TPC), and coliform counts (CC), and drains. The latest was given 24 hours I.V. antibiotics as presence of E. coli. The E. coli isolates were analyzed for prophylaxis, received in situ sterile POP pellets containing the presence of virulent genes by polymerase chain reac- fusidic acid plus oxacillin or amoxicillin. All patients were tion. Data on variables that describe the milking facilities discharged when the wound was closed and fistula dried. and hygienic practices during milking were obtained. The Patients were followed post-operatively after 20 months. mean TPC and CC were normalized by a logarithm base ten Results: Of all patients, 37% were referred by a health transformation and used as dependent variables. Indepen- professional, 21% had selfmedicated, and 42% were first dent sample t-test and one way analysis of variance were treated by a traditional practitioner. used to check associations. The majority of cases were misdiagnosed as acute Fig. 1 PCR amplifications from the E. coli isolates. osteomyelitis (Group 1, n=22; Group 2, n=27). Aureus Staphylococcus was the most frequent germ(Group 1, n=22; Group 2, n=22): 39% were oxacillin resistant; 5% were fusidic acid resistant; none were vancomycin resistant. Hospital stay was significantly (p=.0008) longer for Group 1 (32 days) compared to Group 2 (18 days) patients. Wound healing was significantly (p=.0017) longer for Results: Thirty eight (98%) farms milked cows by hand Group 1 (48 days) compared to Group 2 (36 days) patients. and had TPC and CC of 5.5±0.17 and 3.46±11. In the 23 At 20-month follow-up, treatment failures and infection (57.5%) farms that washed the cows’ udders before milk- recurrence was significantly (p=.0017) higher for Group 1 ing, TPC and CC were 5.39±0.09 and 3.38±0.15, while in (n=15) compared to Group 2 (n=6). farms that did not wash, TPC and CC were 5.65±0.15 and Excellent results (wound healing and fistula dried) were 3.51±0.08 (p<0.05). TPC and CC of farms that never exam- obtained in 58% of Group 1 patients compared to 87% of ined the udders before milking, 5.61±0.18 and 3.47±0.10, Group 2 patients. and those that always examined the udders, 5.30±0.12 and Conclusion: In situ sterile POP pellets containing antibi- 3.46±0.11, were statistically significant (P<0.05). Four (40%) otics is an effective and cost-efficient alternative treatment of the E. coli isolates were positive for Stx2d genes. for COM and is suitable for resource poor healthcare set- Fig. 2 PCR amplifications from the E. coli isolates tings. doi:10.1016/j.ijid.2010.02.1623 e62 14th International Congress on Infectious Diseases (ICID) Abstracts

Conclusion: All farms had microorganisms in excess of 26.003 tolerable levels due to unhygienic practices. Presence of Burden of illness for food-borne Salmonella: a cohort virulent Stx2d producing E. coli has a serious public health study in an agricultural community in Yucatan, Mexico implication as milk is sometimes consumed without pasteur- ,∗ ization. Farmers were educated on hygienic practices during M.B. Zaidi 1 , F.D. Campos 1, F. Martinez 1, F. Gutierrez 1,M. milking and importance of milk pasteurization. Measures Leon 1, A. Polanco 1, T. Estrada-Garcia 2, J.J. Calva 3 aimed at reducing milk contamination especially during 1 Hospital General O’Horan, Merida, Yucatan, Mexico milking should be enforced in all dairy farms. 2 Centro de Investigacion y Estudios Avanzados del IPN, Mex- ico City, Mexico doi:10.1016/j.ijid.2010.02.1624 3 Instituto Nacional de Ciencias Medicas y Nutricion 26.002 ‘‘Salvador Zubiran’’, Mexico City, Mexico Investigation and control of a meningitis outbreak in Background: There is a great need for conducting Birbhum-Murshidabad border of West Bengal, India, March community-based integrated food-chain surveillance in 2009 highly endemic settings to assess the impact of Salmonella infections on human health. G. Roy Methods: A 15-month cohort study was conducted in NIE, ICMR, Chennai, India, 700060, West Bengal, India Buctzotz, a small, well nourished, agricultural community in Yucatan, Mexico. Twice-weekly household visits for surveil- Background: Sudden onset of high fever, severe lance of diarrheal disease, collection of stool samples and headache, nausea and convulsion, followed by unconscious- health education were performed in 126 infants less than 3 ness, struck in nine villages of both banks of river Brahmani years of age and 120 adults over 74 years. Ten samples each in Birbhum-Murshidabad border of West Bengal, India, from of foodanimal intestines, raw retail meat, and ready-to-eat 19.03.2009 to 25.03.2009 causing panic after eight deaths. food and beverages were tested weekly. Salmonella isolates We along with Rapid Response Team investigated the out- were serotyped, and tested for antimicrobial susceptibility break to determine the cause and worked for containment. and PFGE according to standard methods. Methods: We defined the case, confirmed the outbreak Results: Salmonella contamination rates in chicken, and line listed by house to house visit; arranged hospi- swine and cattle intestine and raw retail meat were 20% and talization, laboratory investigation and treatment of case- 27%; 82% and 69%; and 74% and 75%, respectively. Salmonella patients; examined, treated and monitored contacts; under- was also recovered from 5% of cooked pork, 4% of cooked took hygienic, disinfective and environmental measures chicken and 4% of fresh fruit beverages. The annual inci- involving community; strengthened immunization, health- dence of diarrhea of any etiology was 2.1 episodes/infant education and advocacy. and 0.7 episodes/elder. Incidence of Salmonella-associated Results: Attack Rate (AR) of two villages of Nalhati II diarrhea was 21 episodes/100 infants and 13 episodes/100 block of district Birbhum and western part of Brahmani was elders. Asymptomatic carriage was detected in 18% of 2.21 with higher incidence among male and 16-49 years age household members. None of the cohort subjects suffered group with hospitalization of 27 cases. Case fatality Rate dehydration or required hospitalization. The distribution (CFR) was 6.45. AR of seven villages of Nabagram and Khar- of Salmonella serotypes in humans closely correlated with gram blocks of Murshidabad district and eastern part of those isolated from animals and foods. PFGE analysis of the Brahmani was 3.60 with higher incidence among male and two top serotypes, Agona and Meleagridis, and two virulent 16-49 years age group with hospitalization of 116 cases. CFR serotypes, Enteritidis and Typhimurium, showed that many was 1.90. These areas are riverine low lands with marshy human isolates were indistinguishable or closely related to paddy fields full of culex and other mosquitoes; several animal isolates. In the few household clusters detected, the water bodies where migratory birds used to come; scattered infant was symptomatic and older family members were bushes and trees with bat population; congested unhygienic usually diarrhea-free. Overall, 3.5% of isolates were resis- hutments with backyard poultry and pig rearing by a section. tant to ceftriaxone, 17.7% to nalidixic acid, and 0% to Poverty, lack of awareness and poor nutritional status were ciprofloxacin; 5.6% were resistant to ampicillin, chloram- common. Frequent migration for better livelihood through phenicol and trimethoprimsulphamethoxazole. masonry and other labouring works is rampant. Blood slides, Conclusion: In highly endemic settings, multiple clones of culture, IgM, virology; urine and CSF examinations were per- Salmonella circulate in the food chain and are continuously formed. CSF suggested Pneumococcal meningitidis. transmitted to humans of all ages. Constant exposure results Conclusion: It was a fatal bacterial meningitis outbreak in sporadic symptomatic infections at the extremes of age which was controlled by prompt treatment and public health and asymptomatic infections at other ages. Future preven- intervention. Improvement of personal hygiene, nutritional tive interventions should focus on health education aimed status, housing and environment and persistent advocacy at reducing household transmission, and on the rational use and surveillance are recommended to prevent future out- of antimicrobials in food animal production. break. doi:10.1016/j.ijid.2010.02.1626 doi:10.1016/j.ijid.2010.02.1625 14th International Congress on Infectious Diseases (ICID) Abstracts e63

26.004 what viruses are circulating among human living in the area. Laboratory investigation for clonality of a foodborne out- We conducted environmental sampling in Metro Manila, the break due to Vibrio parahaemolyticus in Singapore, 2009 capital of the Philippines, and Bulacan, the area with a fifth of population of Metro Manila, to detect enteric viruses. ,∗ M.-V. La 1 , S. Zulaina 1, R. Jureen 2, R. Lin 2 Methods: From March, April and August 2009 water samples were collected from 14 sites of river running in Metro 1 National Public Health Laboratory, Singapore, Singapore Manila and Bulacan region. Water was concentrated by Poly 2 National University Hospital, Singapore, Singapore ethylene glycol precipitation method. We performed real Background: We report a laboratory investigation of a time PCR and conventional PCR to detect virus that can gastroenteritis outbreak caused by Vibrio parahaemolyticus cause water borne disease. All positive samples by conven- following the consumption of the local salad dish ‘‘Indian tional PCR underwent sequence analysis and phylogenic tree rojak’’ from a popular hawker stall in Singapore in April were constructed. 2009. The total number of involved cases was 154, with 48 Results: By both real time PCR and conventional PCR, cases hospitalized and 2 dead. The National Public Health almost all water samples were positive for viruses, including Laboratory collaborated with the investigation of collected enteroviruses(100%), adenovirus(64.3%), rotavirus(85.7%), isolates of V. parahaemolyticus to determine genetic relat- hepatitis A virus (HAV) (100%), astrovirus(42.9%) and edness of these isolates. noroviruses(87.5%) in these areas. Detected rotavirus Methods: Repetitive extragenic palindromic PCR (REP- belonging to G serotype 1 and this is identical to the virus PCR), PCR for the thermostable direct hemolysin gene (tdh) detected in China Detected hepatitis A virus is belonging to and the tdh-related hemolysin gene (trh) as well as serotyp- genotype IA. The viral titers of samples in April, enterovirus, ing were performed on all isolates from suspected outbreak hepatitis A virus, norovirus G1, and rotavirus were higher cases and some unrelated control strains. The REP-PCR fin- than that of August. gerprint was generated with the Agilent® Bioanalyzer using Conclusion: The result of our study substantially showed DNA 1000 LabChip® kit, and then analyzed with Bionumerics that seasonality of the rotavirus in the environment agreed software. with that of human rotavirus infection in the Philippines. Results: REP-PCR profiles obtained from 15 of 16 inves- In addition, our study suggested that other enteric viruses tigated isolates were identical. REPPCR typing appeared would spread in dry season in the Philippines. We believe to be as discriminatory as pulse-field gel electrophoresis focusing on the aspect may improve water quality as well as in this outbreak investigation. All above outbreak isolates prevention of enteric viral diseases in the Philippines. were positive for tdh, negative for trh and had serotype O4:K55.Conclusion: REP-PCR in this setting was a rapid and doi:10.1016/j.ijid.2010.02.1628 useful molecular typing method for the laboratory evaluation of genetic and epidemiological relationships among V. 26.006 parahaemolyticus strains. Detection of human enteric viruses in shellfish, vegetables, waters and environmental samples: a preliminary doi:10.1016/j.ijid.2010.02.1627 study ,∗ 26.005 V. Cannella 1 , G. Purpari 1, A. Ferrari 2, A. Migliazzo 1,P.Di Marco 1, A. Guercio 1 Detection waterborne diseases associated viruses in the river water Metro Manila and Bulacan, the Philippines 1 Istituto Zooprofilattico Sperimentale della Sicilia, ,∗ Palermo, Italy, Italy T. Imagawa 1 , A. Suzuki 1, M. Saito 2, Y. Masago 3,C. 2 Istituto Zooprofilattico Sperimentale del Piemonte,Liguria Okumura 3, S. Lupisan 4, R. Olveda 4, T. Omura 3,H. e Valle D’Aosta, Genoa, IT, Italy Oshitani 1 Background: Human enteric viruses contaminations of 1 Tohoku University Graduate School of Medicine, Sendai, foods destined for human use, as shellfish, vegetables and Japan waters, are considered a Public Health problem. Many 2 Research Center for Emerging and Re-emerging Infections, epidemiological studies show that Adenoviruses, HAV (Hep- Manila, Philippines atitis A Virus) and Norovirus gastrointestinal infections are 3 Tohoku University, Sendai, Japan increasing in industrialized countries. These viruses are 4 Research Institute for Tropical Medicine, Manila, Philip- largely excreted in feces and show a high resistance in the pines environment. Environment pollution can occur in many man- Background: Untreated groundwater is responsible for ners. However one of the major source is represented by the about half of the waterborne disease. Inadequate water dis- personal hygiene of food-handlers and consumers. Moreover, tribution system in that may not be able to provide clean filter-feeder organisms such as mussels are bio-accumulators water, and use river water for the living are two main cause of viruses in waters. Thus, undercooked shellfish consump- of water borne disease in developing countries. In addition, tion involves sanitary risk. Irrigation and fertilization of viruses causing diarrhea are stable in environmental water fields with sewage may externally contaminate vegetables and serve as threat to humans In the Philippines, about and fruits. In order to warrant an high level of food safety, 10,000 children died of severe diarrhea annually and data European Commission, introduced the concept of ‘‘HACCP’’ for viruses in the environment is not enough. So, detection (Hazard Analysis and Critical Control Points). This rule (EC of those viruses from river water is important as it indicates 178/2002) provides for bacteria quantitative limits and ana- e64 14th International Congress on Infectious Diseases (ICID) Abstracts lytical methods only. Viral detection methods and limits rate {204[8.6%] 2,373} was recorded in nine LGAs. The over- are being studied. Recently, the Environmental Protection all attack rate was {2,373 [163.8] 1,447,725} per 100,000 Agency has included Adenovirus into the ‘‘Contamination persons but varies over week and by LGAs. Majority of Candidate List’’ among the microorganisms to monitor to the cases were aged 2-30 years {1,681 [71%] 2,373}. The warrant foods and environment health. Aim of this study is attack rate among 2-30 years was {1,681[187.3] 897,580} to improve knowledge about Adenovirus, Norovirus and HAV per 100,000 populations. Of the 22 stools samples analyzed diffusion in shellfishes, vegetables, waters and environmen- {15 [68.2%] 22} were positive for vibrio cholerae sero-group tal swabs samples. 01, Ogawa. Methods: Specimens were collected from food- Conclusion: Vibrio Cholerae Serogroup 01, Ogawa was the production centers, hospitals, military and school canteens cause of the outbreak that affected mostly age 2-30 years from January 2008 to October 2009. They were tested with high attack rate and Case Fatality Rate. Active case through biomolecular methods (Nested RT-PCR, Nested PCR management, health education, environmental sanitation and sequencing) and virus isolation in cell lines (A549 and and decontimation of wells were mounted. FrhK-4). Results: 19 samples of a total of 270 tested, resulted doi:10.1016/j.ijid.2010.02.1630 positives by Nested PCR for Adenovirus and 4 of them were positive also for virus isolation in A549 cell lines. Only one 26.008 mussel sample was positive through Nested RT-PCR for HAV Phenotypical profile against antibiotics of Lactobacillus and negative by virus isolation into FrhK4. Sequence analysis sp isolated from artisanal cheeses confirmed the results and showed the presence of Aden- G. Rozos 1, A. Vatopoulos 2, X. Voidarou 3, D. Vassos 3,A. ovirus serotype 2 and 41. Alexopoulos 4, S. Plessas 4, E. Bezirtzoglou 4,∗ Conclusion: These results support the hypothesis that Adenovirus serotypes 2 and 41 are the most frequent con- 1 Cyclades Prefecture, Syros, Greece taminants and their role as indicators of viral environmental 2 National School of Public Health, Laboratory of Microbiol- contaminations. ogy, Athens, Greece 3 Arta Prefecture, Arta, Greece doi:10.1016/j.ijid.2010.02.1629 4 Democritus University of Thrace, Greece, Orestiada, Greece 26.007 Gastroenteritis outbreak investigation in Adamawa State Background: ‘‘Kopanisti’’ and ‘‘Tyrovolia’’ are tradi- Nigeria, 2009 tional artisanal cheeses produced in Mykonos island, Greece, from raw unpasteurized milk of cows and ewes. Their ,∗ M. Adamu Kida 1 , S.A. Idris 2 organoleptic properties are exquisite and they are considered to be of high nutritional value. Our aim was to identify 1 Nigerian Field Eppidemiology and Laboratory Training pro- the lactobacilli composing the fermenting microflora of gram,ABU Zaria, Abuja, Nigeria these cheeses and to evaluate their susceptibility against 2 Ahmadu Bello University, Zaria, Nigeria commonly used antibiotics. Background: In developing countries Vibrio cholerae Methods: Isolation and identification of the strains was is the leading cause of rapidly, progressive, large-scale performed by selective culture in MRS agar and by utiliza- outbreak of gastroenteritis. The transmission is mainly tion of the API 50 test respectively. Phenotypical resistance faeco-oral associated with poor sanitation. Adamawa State was assayed by the broth microdilution method, curves is among Nigerian States that have reported frequent gas- were plotted against M.I.C s and deviation from the Gaus- troenteritis in the past. In August, 2009 a suspected outbreak sian distribution (‘‘wild type’’ and ‘‘not wild type’’ strains) was reported in the State following floods in the northern was assessed. Bimodal curves indicating separate subpop- parts. Over 2,000 people displaced and many of them with ulation to the right end of the distributions, ‘‘hills’’, no access to clean drinking water. We conducted an outbreak ‘‘valleys’’ and ‘‘tails’’ were the criteria of assessment. The investigations to confirm, the outbreak, described the mag- antimicrobial agents in test represented all possible modes nitude in view to instituted public health control measures. of pharmacological action and were the following: peni- Methods: The nine reporting Local Gogernment Areas cillin G, streptomycin, sulbactam/ampicillin, ampicillin, (LGAs) were indentified. we reviewed patient’s hospital vancomycin, teicoplanin, erythromycin, clindamycin, oxyte- records, interviewed patients and health care workers, we tracycline, chloramphenicol, gentamicin, metronidazole, conducted active case search in the communities and col- trimethoprim, fusidic acid and quinopristin/dalfopristin. lected stools specimens from the suspected cases from Results: Lactobacillus dominating the microflora of these reporting LGAs. Suspected case is defined as person of any cheeses belongs to the following fifteen species: L aci- age with profuse, effortless watery diarrhea with three or dophilus (9.77%), L brevis (4.89%), L curvatus (3.16%),L more stolls in 24 hours residing in the affected areas of helveticus (7.47%), L plantarum (13, 5%), L parapalantarum Adamawa State. A confirmed case is any suspected case (10.34%), L paracasei (8.33%), L reuteri (3.74%), L johnsonii with laboratory confirmation (presence of Vibrio cholerae (2.01%), L delbrueckii subsp lactis (7.18%), L delbrueckii in the stools). Data analysis was performed and cases were subsp bulgaricus (6.32%), L gasseri (2.58%), L fermentum mapped. (6.03%), L rhamnosus (4.6%), and L pentosus (10.5%). Results: From 29th July to 10th October, 2009 a total Tentative ECOFF values are also proposed, often differ- of 2,373 cases with 204 deaths were reported, case fatality ent than those proposed by SCAN and NCCLS. All species had 14th International Congress on Infectious Diseases (ICID) Abstracts e65 resistant strains to at least one antimicrobial. MIC 50 and MIC the establishment of an active Federal Emergency Prepared- 90 as well as microbiological breakpoints clearly are species ness and Response (EPR) committee and the decision by all dependent. A multiresistance antibiotic profile was effec- States to preposition vaccines and drugs independent of the tive for most bacterial strains, and pronounced resistance Federal Government. profiles were observed for the commonly used antibiotics. Our results strongly suggest resistant patterns to the Lac- doi:10.1016/j.ijid.2010.02.1632 tobacillus genus which could be either intrinsic (against vancomycin, trimethoprim and metronidazole) or acquired 26.010 (against penicillin, oxytetracycline and erythromycin). How- Risk factors for repeated cholera outbreak in Arua munic- ever, some strains with MIC close to the breakpoint values ipal council, north-western Uganda can be attributed to natural variation within the species. M. Andrawa 1,∗, P. Anguzu 2, A. Anguaku 2, C. Nalwadda 1,O. Conclusion: As antibiotic resistance is a growing problem, Namusisi 3, R. Tweheyo 4 an holistic approach strategy based on animal, plant and food control should be capable to stop its spread. 1 Makerere University School of Public Health, Kampala, Uganda doi:10.1016/j.ijid.2010.02.1631 2 Arua District Local Government, Arua, Uganda 3 African Field Epidemiology Network, kampala, Uganda 26.009 4 Makerere University School of Public Health, Kampala, An outbreak of Cerebrospinal meningitis in Jigawa state Kampala, Uganda Nigeria 2009 Background: Cholera outbreaks have occurred annually in ∗ M.O. Akhimien , H. Akpan H. Arua district especially in the Municipal Council (AMC) since 2005 with an average case-fatality rate (CFR) of 2.1%. The Nigerian Field Epidemiology and Laboratory Training Pro- study objective was to establish the risk factors for repeated gram, Abuja, Ab, Nigeria cholera outbreak in AMC with a view of designing appropri- Background: Cerebrospinal Meningitis (CSM) is a fatal ated strategies for preventing future cholera outbreaks. infection with high morbidity and mortality. Jigawa State Methods: Unmatched case control study was conducted with a population of 5 million people lies within the nation’s in July 2009. Cases were defined as individuals who had meningitis belt. We conducted a descriptive study of the lived in the Municipality for at least two years and had outbreak. symptoms of cholera, while controls were persons that lived Methods: Health workers as well as cases were inter- in the neighbourhood of a case, but did not have symp- viewed. Hospital records, laboratory and CSM surveillance toms of cholera. Case definitions of the Epidemiology and data in the state were reviewed. Surveillance division, Ministry of Health Uganda were used Results: There were community mobilization/advocacies as eligibility criterion for cases. A total of 23 cases and 46 and health staff sensitization/motivations as part of pre- controls were interviewed using a semi structured question- epidemic preparation. The index case a 13 years old male naire and analysis done using EPI INFO 2008 version 3.5.1. presented in the clinic on the 23/12/08. The cases increased Univariate and bivariate analysis was done. Odds ratios and from 12 and one death in epidemiologic week one to 1,238 95% confidence intervals were used to determine association cases and 43 deaths in week 13. The most affected age group and statistical significance at p<0.05. was5—15years (>65%). A reactive vaccination was carried Results: Factors identified for repeated outbreak of out at 11 of the 26 affected LGAs targeting age group 2-30 cholera in AMC included: being younger than 25years years at week 15. Of the 113 cerebrospinal fluid samples of age (OR = 4.3, CI = 1.29 — 14.21); having no post pri- taken 84 was positive for Neisseria meningitides type A, two mary education (OR = 5.6, CI = 1.46 — 21.50); having source for Haemophilus influenza and others were negative. Case of information on cholera from IEC materials (OR = 0.84, fatality rate (CFR) was dependent on the area. The epidemic CI = 0.11 — 0.85); not covering latrine after use (OR = 6.48, ended in the state with 8,616 cases, 306 deaths, CFR of 3.6 CI = 2.11 — 19.90); using un protected water source and an attack rate of 181.9. The CSM surveillance was 100% (OR = 5.65, CI = 1.66 — 19.99) and drinking untreated water timely and 87% complete. (OR = 5.34, CI = 1.78 — 16.01). Conclusion: The State ran out of prepositioned Conclusion: Risk factors for repeated cholera outbreak drugs/vaccine as the epidemic was propagating faster were: being younger than 25years; having no post primary than the control measures. Supplies were delayed from the education; not covering latrine after use; using unprotected Federal level due to delay in resource mobilization. Pockets water source and drinking untreated water, while having of vaccination were done at those LGAs that had crossed source of information on cholera from IEC materials was pro- the alert threshold and schools that were experiencing tective. The findings emphasised the importance of personal outbreaks through the assistance of medicine san frontiers. hygiene, communal sanitation and being knowledgeable and Most cases had lived in overcrowded rooms and had not educated. been vaccinated in the last five years. The laboratories ran out of supplies. doi:10.1016/j.ijid.2010.02.1633 Unequal distribution of qualified personnel led to the varied CFR observed in various part of the state and this was further complicated by erratic drugs supplies to the hospitals. The recommendations from this investigation led to e66 14th International Congress on Infectious Diseases (ICID) Abstracts

26.011 26.012 Top health concerns in rural Honduras following the intro- E.coli infectious complicated with HUS in Georgia duction of clay water filters E. vashakidze 1,∗, T. megrelishvili 1, E. Pachkoria 1,P. R. Hemrajani 1,∗, B. Morehouse 2, K. Elam 1, D. Markley 1, L.F. Imnadze 2, S. canava 3, L. Tevzadze 3, M. Lashkarashvili 4 Stevens 1, G. Bearman 3, M.P. Stevens 1 1 tbilisi state medicine university, tbilisi, Georgia 1 Virginia Commonwealth University, Richmond, Va, USA 2 National Center for Disease Control and Public Health, 2 Virginia Commonwealth University, Richmond, VA, USA Tbilisi, Georgia 3 Richmond, VA, USA 3 National Center for Disease Control and Public Health, tbilisi, Georgia Background: Access to clean water is a major health issue 4 National Center for Disease Control and Public Health, for many living in rural Honduras. In June 2008, clay water tbilisi, Georgia filters were distributed to individual homes in La Hicaca, a rural mountain community in the Yoro area of Honduras. In Background: Infectious diarrhea with its morbidity is the June 2009, a needs assessment survey was administered to main issue of Georgian population and at the same time residents in this area. it is the multifactor problem (climato-geographic, social- Methods: In June 2009, a needs assessment survey was economic, etiological). Noticeable increasing rate of E.coli administered in La Hicaca and other communities in the infectious, (including EHECEnterohemorrhagic E.coli, 0124, Yoro area that collected data on demographics, water source 0111, and et al.) has been revealed in etiological structure and principle health concerns. One question asked, ‘‘What of infectious diarrheas in recent years. During this period are the three biggest health care problems that you worry some sporadic cases of hemorrhagic colitis have been regis- about? (Check all that apply)’’ There were 15 options in tered, and among the patients of different ages they were the areas of water sanitation, nutrition, education, mater- complicated with HUS syndrome that indicates to possible nal/child health, access to doctors and medicine and specific circulation of E.coli. 0157. disease concerns. Survey respondents in La Hicaca who used Methods: Since 2009. 07- up to2009. 09 18 cases of E.coli clay water filters and all other respondents were compared complicated with HUS syndrome have been registered. Most regarding their principle health concerns. Respondents were patients were rural residents (14 - 78%), only 4 (22%) were excluded if they filtered their water but did not live in La urban. 8(44%) patients were children, 10 (55%) were adults. Hicaca or if they did not respond to the question regarding Among male and female patients HUS complication rate was health concerns. equal. All the patients associated the onset of the disease Results: Of 101 completed surveys, 12 survey respondents with the ingesting of unwashed and raw fruits or vegeta- from La Hicaca used clay water filters and 70 respondents bles. Hemorrhagic colitis dynamics in clinical estimation of from the Yoro area did not. For the respondents who did cases revealed development of hemolytic anemia, throm- not use filtered water, water sanitation (48.6%) and nutri- bocytopenia, and renal failure which were confirmed by tion (42.9%) were the principle health concerns. For the clinical-laboratory findings. La Hicaca residents who utilized water filters, access to Results: The onset of disease was acute: low grade fever healthcare in terms of distance (41.7%) and overall cost of (37,5-37,8 (C), severe diffuse pain in abdomen accompanied healthcare (50%) were the principle concerns. with cramps, frequent bowel movement with loose, watery Conclusion: When comparing the primary health concerns stool 5-6 times a day. On the 2-3rd days of disease condi- of rural Hondurans in La Hicaca who utilize clay water filters tion was worsened by increasing of intoxication and frequent to those who use a different water purification method, the bowel movement with bloody stool about 10-15-20 times a principle health concerns differ. Water sanitation and nutri- day. Acute renal failure developed in 11(61%) patients, in tion were the principle concerns for those who do not use spite of adequate treatment with infusion of crioplasma and filtered water, and access to healthcare in terms of distance polyionic solutions 9(50%) patients required haemodialysis in and cost were the concerns for those respondents who uti- specialized department. Severe Thrombohemorrhagic syn- lize water filters. As far as perceived health concerns are drome - 2(11%) patients, poliserositis - 6(33%), ileus -1(5%), an indicator, the distribution of clay water filters in one encephalopathy - 2 (11%), psychosis - 1(5%) were revealed rural Honduran community may have had a positive health in various rates. impact. Conclusion: Outcome was lethal in 5(28%) cases due to delayed hospitalization and inadequate therapy. doi:10.1016/j.ijid.2010.02.1634 doi:10.1016/j.ijid.2010.02.1635 14th International Congress on Infectious Diseases (ICID) Abstracts e67

26.013 HIV: Epidemiology and Prevention (Poster Presenta- Epidemiology of alimentary toxiinfection in western tion) Romania 27.001 ∗ S.-M. Draghici , C. Laslau, A. Jarca The vertical transmission of the HIV/AIDS. 22 years of University of Oradea, Oradea, Romania experience in Cuba Background: Knowledge of the epidemiology of alimen- I. González Nunez˜ tary toxiinfections (AT) is one of the main tools for public Instituto de Medicina Tropical Pedro Kouri, Ciudad De La health care control in Romania. Habana, Cuba Methods: We made a retrospective study of the cases of alimentary toxiinfections in Bihor county between the years Background: Since 1986 a controlled program was estab- 2005 and 2009, emphasizing the epidemiological process. lished in the primary health care system in order to reduce Results: In the past 5 years in Bihor county (610,000 vertical transmission in Cuba. inhabitants), there were reported 601 cases (9.85%000 Methods: The usual approach followed with each HIV+ inhabitants) of AT, 442 sporadic cases, and 29 foci with 159 pregnant woman who decides to keep her pregnancy, is to cases. The 17 familial foci were prevalent (74%), versus the administer HAART independently her immunologic status, 6 collective foci (27%). We presume that 40—50% of food from week 14 to the time when a caesarean operation is borne illnesses go unreported to health departments due carried out (week 38). Maternal nursing is strongly discour- to mild symptomatology and quick recovery. Etiology was aged. The newborn child receives ZDV (2 mg/Kg/dose) every found in 220 cases (38.26%), Salmonella (29.13%), Staphy- 6 hours for the first 6 weeks. The children are followed-up lococcus (20.45%), E. coli (15.45%), Clostridium botulinum in IPK outpatient office, where their HIV infection status is (14%), Campylobacter, Pseudomonas, Bacillus cereus, asso- determined. Infected children are treated with antiretrovi- ciated germs. As sources of infection there were identified rals according to the presence of opportunistic diseases, CD4 eggs, poultry, dairy products, cream-filled cakes and pies, cell count and viral load. Quantification of CD4 is determined home-packed cans, sausages, ham, and sometimes water by flow cytometry, using a FACScan cytometer. Quantifica- contaminated by animal feces. tion of viral RNA levels was made with the Nuclisens system Improper food handling from the farm to the table cre- from Biomerieux. ates conditions for the growth of bacteria that make people Results: A total of 2074 seropositive women have been sick. Vegetables that are eaten raw may be contaminated reported between January 1st, 1986 and December 2008 by bacteria in the soil, water, and dust during washing and of all the seropositive cases (10655) reported for the packing. Home canned and commercially canned food may country (19.4%). Three-hundred thirty and seven seropos- be improperly processed at too low a temperature or for itive women (16,2%) have given birth to a total of 364 too short a time to kill the bacteria. Cooked food can also be children (22 women have delivered twice and 5 women contaminated after cooking by bacteria carried by food han- have delivered twins); of the 364 children 35 (9,6%) dlers or from bacteria in the environment. The preparation are HIV+, 33 (33/35=94,2%) have been classified as AIDS of vegetable cans and keeping of home-produced smoked patients, 21(21/35=60.0%) are under treatment with HAART; meat in unhygienic conditions in the presence of vectors 3 (3/35=8,5%) are asymptomatic and 11(11/35=31,4%) (flies, cockroaches) are also involved in producing AT in the have died. No infection has been shown in 255 chil- western region of Romania, mainly botulism. dren (255/364=70,0%) by PCR and Western Blot, and 74 Conclusion: Contaminated, adulterated, and mishandled (74/364=20,3%) are still under study. food and beverages are the key element or source for con- Conclusion: The Program of Prevention and Control tracting alimentary toxiinfections. of Vertical transmission is effective since the number of The main etiology was Salmonella, followed by Staphy- infected children is low, similar to the figures reported for lococcus, E.coli and C. botulinum. The public health developed countries. authorities must take further measures to stop the illegal commerce with alimentary products and to keep the popu- doi:10.1016/j.ijid.2010.02.1637 lation informed on the food associated risks. 27.002 doi:10.1016/j.ijid.2010.02.1636 Community involvement in HIV/AIDS prevention C. Okonkwoh Youth Repositioning Foundation, 234, Nigeria Background: Due to high prevalence rates of HIV in limited resource locations in Nigeria, communities have been trained to be more involved in designing and implementing HIV/AIDS prevention programmes .This project after months of research Identified community members as ‘‘significant others’’ in the prevention of HIV/AIDS. Mother to child transmission of HIV/AIDS have been used as a case study to butress this fact. e68 14th International Congress on Infectious Diseases (ICID) Abstracts

Methods: The data was generated through a descriptive Delivery of information by influential people is also effective cross sectional study among one hundred positive nursing in male involvement of PMCT activities. Partner counseling mothers in Ijesha community in Surulere Local Government is better than individual counseling. Basic health staff are Area, Lagos State, Nigeria. Household interviews were car- main actors in PMCT activities. PMCT activities should be ried out and these interviews were used to assess community integrated with other health activities. knowledge, beliefs, opinions, perception and attitude on Results: Address and stress on community awareness and Mother to child transmission of HIV/AIDS and the need to male involvement by different ways made improvement of reduce the gap and misinformation on the prevention of male participation in health care of pregnant women and it mother to child transmission of HIV/AIDS. enhanced the utilization of PMCT services. Partner involve- Results: The data generated revealed that seventy ment has been increased as there was no partner has taken percent of the research population responded to med- HIV testing in the project started time and now gradually ical treatments because they received support from increased in number of male HIV testing. Husbands become their families and other community members. Further- aware on safe deliveries of their wives and taking regular more mother-to-child transmission of HIV/AIDS was greatly antenatal care. In some areas, husbands got peer informa- reduced. Contrarily, thirty percent of the research popu- tion sharing from their friends and they lead and bring their lation had a high rate of mother to child transmission of wives to health sectors. HIV/AIDS due to cultural barriers from the community and Conclusion: Community awareness and male involvement fear of stigma and discrimination from the community. in sexual and reproductive health care activities includ- Conclusion: To be most effective, biomedical breaking HIV/AIDS is important and crucial for utilization of throughs on mother to child transmission of HIV/AIDS must PMCT services. If male involvement is improved, PMCT be combined with educational efforts that inform communi- programe would be improved and successful. Integration ties about HIV/AIDS prevention. Interventions to reduce the of other activities is also needed to improve the PMCT risk of mother to child transmission of HIV/AIDS will succeed programme. to a large extent when adequate information, education and services are properly packaged for community members who doi:10.1016/j.ijid.2010.02.1639 represent significant others in women’s lives. Involving community members in mother to child trans- 27.004 mission of HIV/AIDS is an excellent approach to breaking Frequency of isolated antibody to hepatitis B core antigen down barriers that influence HIV transmission from mother in HIV- HCV coinfected individuals to child. A. Ramezani 1,∗, A. Aghakhani 1, A. Eslamifar 1, M. Mohraz 2, M. Banifazl 3 doi:10.1016/j.ijid.2010.02.1638 1 Pasteur Institute of Iran, Tehran, Iran, Islamic Republic of 27.003 2 Iranian Research Center for HIV/AIDS, Tehran, Iran, Islamic Community awareness including male involvement in pre- Republic of vention of mother to child transmission of HIV infection is 3 Iranian society for support patients with infectious dis- crucial eases, Tehran, Iran, Islamic Republic of K.A. Myint Background: An association between isolated anti-HBc and HCV infection has been noted in human immunodefi- UNFPA-Myanmar, Yangon, Myanmar ciency virus (HIV)-infected persons. Isolated anti-HBc was Background: Myanmar is one of the developing coun- more frequently seen in HIV-HCV coinfected patients than tries in South East Asia and HIV prevalence among pregnant subjects with HIV infection alone. Occult hepatitis B may be women is 1.4%. UNFPA has established the Prevention of encountered in HIV-HCV co-infected patients with isolated Mother to Child Transmission of HIV infection (PMCT) pro- anti-HBc. This study describes the frequency of isolated gramme collaborated with National AIDS Programme since anti-HBc and its possible value for detection of HBV-DNA in 2005. Low education status, social, traditional, cultural, and HIV infected patients with or without HCV co-infection. financial barriers limitted many women not access to sexual Methods: 92 HIV infected patients were enrolled in this and reproductive health information and services includ- study. HBsAg, anti-HBs, anti-HBc, anti-HCV, ALT, HIV viral ing PMCT services. Therefore, number of pregnant women load and CD4 count were tested in all subjects. We compared access to PMCT services and HIV testing is still low and should 63 subjects with HIV-HCV co-infection with 29 subjects with promote community awareness including male involvement HIV infection alone regarding isolated anti-HBc (HBsAg neg- in HIV/AIDS activities. ative, anti-HBs negative and anti-HBc positive). Presence of Methods: Sharing knowledge and information via TV HBV-DNA was determined quantitatively by real-time PCR in spots, video clips, role plays, stage shows, and distribu- serum samples of patients with isolated anti-HBc. tion of pamphlets, posters, and wall sheets are effective Results: Of the 63 anti-HCV positive patients, 18 subjects and it reaches to grass root level where 70% of total Myan- (28.6%, 95% CI, 22.6%-34.6%) and of 29 anti-HCV negative mar population live and most of them are illiterate. It also patients 5 subjects (17.2%, 95% CI, 11.5%-22.9%) had isolated improves awareness on HIV/AIDS and male participation. anti-HBc. HBV-DNA was detectable in 3 out of 18 anti-HCV Peer knowledge and information sharing among men and positive patients with isolated anti-HBc (16.7%, 95% CI, 9.7%- women, health talk to targeted population with two ways 23.7%) and none of anti-HCV negative patients with isolated discussion improve knowledge and utilization of services. anti-HBc. There was no significant difference between the 14th International Congress on Infectious Diseases (ICID) Abstracts e69

HIV patients with and without HCV coinfection regarding 27.006 isolated anti-HBc and occult HBV infection. Does knowing someone who has died of AIDS affect con- Conclusion: Our study showed that HIV-HCV coinfected dom use? An analysis from Ivory Coast individuals were more likely to have isolated anti-HBc than subjects with HIV alone. It demonstrated that the presence A. Ngui Ngamini of isolated anti-HBc in HIV-HCV co-infected individuals may University of Montreal, Montreal, QC, Canada reflect occult HBV infection in these patients. Background: Prior research indicates that personally, doi:10.1016/j.ijid.2010.02.1640 knowing someone who has died of AIDS is associated with greater perceived risk behaviour risk of contracting HIV and 27.005 changes in sexual risk behaviours. HIV voluntary counseling and testing (VCT) in three sites Methods: The current study with a sample of 9,686 per- in Nigeria sons examined whether personally knowing someone who died of AIDS influence condom use using the 2005 Ivory Coast 1,∗ 2 2 2 M.L. Alkan , O.A. Akinwande , U.I. Gebi , R. Owolabi , Demographic and Health Survey (ICDHS). 2 P.S. Dakum Results: Unadjusted model suggests that those who 1 Ben Gurion University of the Negev Beer Sheva Israel, reported personally knowing someone with AIDS were1.72 84101, Israel times more likely to have used condom at last sex- 2 Institute of Human Virology Nigeria, Abuja, FCT, Nigeria ual intercourse (p < .001). After controlling for potentially confounding variables, logistic regression showed no asso- Background: VCT is an entry point to many HIV care ciation between condom use and knowing someone who and treatment programs. This operation is mostly a walk- died of AIDS. Condom use at last sex was strongly asso- in clinic, and clients come to be tested by self referral or ciated with condom use at first sex, gender, age group, following guidance from health care personnel. The question residency, employment status, information, AIDS-related of the efficacy of this method is open, and the clients mix knowledge and lack of homophobie toward Persons Living does not necessarily reflect the typical clients who need to with HIV/AIDS. be tested. In order to learn more about the characteristics Conclusion: Findings suggest that preventive efforts of this population, data were collected from three centers should be expand given the current level of AIDS mortal- of a single project in Nigeria, one in the Muslim north, one ity in Ivory Coast. Campaigns must reinforce messages that in the Christian south, and one near the central region of in the absence of vaccine against AIDS, condom is the only the capital during the years 2006—2007. best protection against AIDS during sexual intercourses. Methods: VCT rosters and client forms of consecutive clients were reviewed for demographic data and personal doi:10.1016/j.ijid.2010.02.1642 details, compared with HIV test results, from three VCT 27.007 centers: Kano (1130 clients), Nnewi (4312 clients) and Gwag- walada (1073 clients). Data were logged on EXCEL sheets and The features of HIV-infected patients at A. Wahab analyzed with EPI-INFO and ANOVA software. Sjahranie General Hospital Samarinda, Indonesia Results: In Kano 56.6%v were HIV+, in Nnewi 30.7% and C. Gunawan 53.2% in Gwagwalada. In all three sites female gender and age were risk factors. Muslims had significantly lower Mulawarman University School of Medicine/A. Wahab rates than others, and marital status was a marker for Sjahranie General Hospital, Samarinda, Indonesia HIV: Married clients were more frequently positive (66.6%) Background: Indonesia is a country with rapid growth of than single ones (41.7%) OR = 2.97), separated or widowed HIV cases. With population of more than 230 millions, it is clients had the highest prevalence of HIV (89 and 90%) estimated there will be one to five million people infected (p = 0.00024). Clients’ professions influenced the relative with HIV in 2010. In East Kalimantan Province, until August risk for HIV: Among drivers (OR = 2.7), musicians (OR = 9.3) 2009, more than 1100 cases of HIV are reported, although and restaurant workers (OR = 3.9) the prevalence was high, the exact number of cases must me much higher. while clergymen (OR = 0.5), teachers (OR = 0.4) and health Objectives: To know the features of HIV-infected patients care professionals (OR = 0.4) were less frequently afflicted. who come to Voluntary Counseling and Testing (VCT) Clinic Higher levels of education were found to be protective and treated at the Infectious Diseases Ward of A. Wahab (71.4% versus 36.7%). Sjahranie General Hospital Samarinda, East Kalimantan, Conclusion: The question of who should come to be tested Indonesia. is addressed, but not answered. We identified criteria which Methods: An observational study was performed at VCT identify high and low prevalence groups, these could be Clinic and Infectious Diseases Ward of A. Wahab Sjahranie useful when populations are targeted for promotion of coun- General Hospital Samarinda from December 2005 to August seling and testing. 2009. Data collected were included number of visits to VCT Clinic, number of positive HIV test, sex, age, specific groups, doi:10.1016/j.ijid.2010.02.1641 route of transmission, stages of HIV, CD4 counts on admission, opportunistic infections, ARV treatment, mortality. Results: During the period of study there were 2591 visits to VCT Clinic, 2176 people were tested for HIV, and positive results were 143 (6.6%). Most patients with positive e70 14th International Congress on Infectious Diseases (ICID) Abstracts

HIV were 25—34 years old (55.2%). Male patients were 87 had HH genotype and 25% had LL genotype both of which (60.8%) and females 36 (39.2%). Specific groups of infected are associated with weak binding of BSSL to DC-SIGN. On patients were customers of sex workers (32.2%), inject- the other hand, 40% of SCCs had HL genotype, 45% had LL ing drug users (IDUs) (23.8%), female sex workers (19.6%), genotype and 15% had HH genotype. SDC positives were also housewives (18.2%), children born from HIV positive mothers compared to SCCs in terms of BSSL genotype distribution. (4.9%), male sex workers (1.4%). Routes of transmission were The HH genotypes in both groups were the same (15%). The vaginal sex (69.9%), shared needles use (22.4%), perinatal HL genotype was higher in SDC positives (60%) than in SCCs (4.9%), tattoo (2.1%), anal sex (0.7%). Stages of infection (40%) and the LL genotypes was higher in SCCs (55%) than in while diagnosed were stage IV (60.1%), stage I—III (39.9%). SDC positive partners (25%). Most patients came to hospital with opportunistic infections Conclusion: SDCs could be more protected against HIV-1 (72%), including pulmonary tuberculosis (50.5%), chronic transmission from DC-SIGN to CD4 cells than SCCs. diarrhea due to parasitic infections (40.8%), oral candidiasis (16.5%). Patients on ARV treatment were 67 (46.9% of total doi:10.1016/j.ijid.2010.02.1644 patients). Initial CD4 counts were 1 - 458. Most patients had initial CD4 counts < 50 (62.5%), while others with CD4 50—100 27.009 (15.6%), 101—200 (9.4%), 201—350 (9.4%), > 350 (3.1%). Total Safety and immunogenicity of measles vaccine in HIV- mortality was 44 (10 on ARV treatment, 34 had not got ARV). infected children: Systematic review and meta-analysis Conclusion: The majority of HIV patients are young peo- P. Scott 1,∗, W.J. Moss 2, Z. Gilani 2, N. Low 1 ple 25—34 years old (55.2%). Vaginal sex is the main route of transmission (69.9%), while shared needles use is 22.4%. 1 Institute of Social and Preventive Medicine, University of Most patients come to hospital in late stage (stage IV) Bern, Berne, Switzerland (60.1%) that correlates with high mortality rate. Oppor- 2 Bloomberg School of Public Health, Johns Hopkins Univer- tunistic infections are found in 72% of patients when first sity, Baltimore, MD, USA diagnosed and the most common opportunistic infection is pulmonary tuberculosis (50.5% of cases). Background: Measles vaccines could be less immunogenic in immunosuppressed people. We conducted a systematic review to identify and synthesize evidence about the doi:10.1016/j.ijid.2010.02.1643 immunogenicity and safety of measles vaccination in HIV- 27.008 infected children. Bile salt stimulated lipase genotype distribution in Ghana- Methods: We searched eight electronic databases for ian couples discordant for HIV-1 infection studies published through February 12th 2009. Identified studies were independently screened by two reviewers for Y. Affram eligibility based on predefined criteria. Information was extracted independently by two reviewers. Meta-analysis University of Ghana Medical School, Accra, NA, Ghana was conducted where appropriate, and heterogeneity in Background: Some individuals remain HIV-1 seronegative results between studies was investigated through stratifi- despite multiple sexual exposures to HIV-1 virus. This study cation of results. analyzed the possible role of bile salt stimulated lipase Results: Seven-hundred and twenty-three articles were (BSSL) genotypes in the lack of HIV-1 transmission in Ghana- identified. Twenty-five studies with comparison groups were ian HIV-1 serologically discordant couples (SDCs). BSSL is included. Thirteen studies without comparison groups and a Lewis X-carrying glycoprotein secreted by the pancreas one case report were also examined for adverse event and present in human milk, the testes, adrenals and blood data. After vaccination at 6 months, measles antibody levels plasma of humans. BSSL has been postulated to have variant were similar in HIV-infected and HIVunexposed (combined capacity to bind Dendritic cell-specific ICAM-3 grabbing non- relative risk (RR) 1.05, 95% confidence interval (CI) 0.83- integrin (DC-SIGN) and potentially block viral transmission 1.34) or HIVexposed but uninfected children (RR 0.91, 95%CI across a mucosal surface. 0.80-1.04). Among HIV-uninfected children, slightly more Methods: A total of 32 couples were enrolled in the study. HIV-exposed but uninfected children responded when vac- These comprised of 12 SDCs and 20 serologically concor- cinated at 6 months than HIV-unexposed children (RR 1.11, dant couples (SCC). Five milliliters of blood was taken from 95%CI 0.99-1.25). By nine months of age, fewer HIV-infected couples. HIV-1 antibody testing was done using Abbott HIV- children responded to measles vaccine than HIVunexposed 1/2 Determine assay and confirmed with Innolia HIV-1/HIV/2 (RR 0.79, 95% CI 0.61-1.02,) or HIV-exposed but uninfected assay. HIV-1 negative serostatus of discordant negative part- children (RR 0.70, 95% CI 0.56-0.88). HIV-uninfected chil- ners was confirmed by polymerase chain reaction (PCR) and dren had similar levels of response after vaccination at nine BSSL genotypes of all couples were also identified by PCR. months regardless their mother’s HIV-infection status (RR Results: HIV antibody testing with PCR confirmation 1.01, 95%CI 0.98-1.04). Vaccination at twelve months of age revealed 8 SDC and 24 SCC. BSSL genotypes were grouped resulted in poorer responses in HIV-infected children relative into high high (HH), high low (HL) and low low (LL) geno- to HIV-unexposed children (RR 0.52, 95% CI 0.21-1.33) and types based on the number of repeats (ranged from 6 to 19 HIV-exposed but uninfected children (RR 0.61, 95% CI 0.50- repeats; 16 repeats or more was denoted as high (H) and less 0.73). No reference was made to adverse events in half the than 16 repeats was low (L)). Each patient had 2 types of the studies. In studies describing adverse events, most reported repeats. Fifty five percent of SDCs had HL genotype found to no serious adverse events. There were limited data compar- be associated with strong binding of BSSL to DC-SIGN, 20% ing vaccinated to unvaccinated HIV-infected children. 14th International Congress on Infectious Diseases (ICID) Abstracts e71

Conclusion: Our findings suggest that children of HIV- 27.011 infected women, regardless of the child’s HIV infection Body composition measurements and fat redistribution in status, might benefit from initial vaccination at 6 months HIV-infected children and adolescents from São Paulo city, of age in regions where children are at risk for measles. Brazil Confirmation of the child’s HIV-infection status prior to vac- ∗ cination would not be needed. Measles vaccines appear to C. Zanin Palchetti , R. Vega Patin, D.M. Machado, S. Vascon- be safe in HIV-infected children but there is an absence of celos Beltrão, E.R. Paulino, V.L. Szejnfeld, R.C. de Menezes studies reporting adverse events. Succi, F.L. Ceragioli Oliveira Universidade Federal de São Paulo - UNIFESP/EPM, São doi:10.1016/j.ijid.2010.02.1645 Paulo, Brazil 27.010 Background: Body composition changes are frequently Metabolic changes in HIV-infected children and adoles- present in HIV —infected individuals. We studied the relation cents from São Paulo city, Brazil between body composition measurements and lipodystrophy in children and adolescents infected with human immunod- C. Zanin Palchetti ∗, R. Vega Patin, A.D.F. Thomé Barbosa eficiency virus. Gouvea, F. Bononi do Carmo, A.M. Rufino, V.L. Szejnfeld, Methods: Prospective transversal study including 40 pre- R.C. de Menezes Succi, F.L. Ceragioli Oliveira pubertal children and adolescents of both gender, aged 7 Universidade Federal de São Paulo - UNIFESP/EPM, São to 12 years, attended at the Pediatric Infectious Disease Paulo, Brazil Clinic - Universidade Federal de São Paulo, São Paulo city, Brazil, from august to december, 2008. Age, gender, clini- Background: HIV infection and the use of antiretrovi- cal and immune status (CDC, 1994), weight and height were ral therapy can lead to clinical and metabolic changes first recorded. Body Mass Index (BMI) z-score and height-for-age described in adults and later in children and adolescents. In z-score was calculated according to WHO, 2007. Circumfer- this study, we evaluated the presence of lipodystrophy, dys- ences and skinfolds measurements were assessed. Body fat lipidemia, hyperglycemia and insulin resistance determined mass (%) was determined by DXA. Presence of clinical signs of by biochemical parameters and clinical assessment. lipodystrophy was assessed by a trained clinician. Statistical Methods: Prospective transversal study including 40 pre- tests such as t-distribution and chi-squared test were per- pubertal children and adolescents of both gender, aged 7 to formed. Statistical significance was considered as P < 0.05, 12 years, attended at the Pediatric Infectious Disease Clinic data were analysed using STATA 8.0 software. - Universidade Federal de São Paulo, São Paulo city, Brazil, Results: The mean age was 9,8 ± 1,2 years, 50% were from august to december, 2008. Epidemiological parame- girls and 82,5% children from B e C categories. The ters (age,sex, HIV transmission), clinical and immune status mean values of BMI z-score and height-for-age z-score (CDC, 1994) and HAART were recorded. Presence of clinical were -0,10 ± 1,58 and -0,80 ± 1,26 respectively. Lipodys- signs of lipodystrophy was assessed by a trained clinician. trophy was present in 14 (27,5%) patients; four had Lipid panel, glucose and insulin levels were evaluated after lipoatrophy (10%), three lipohypertrophy (7,5%) and four an overnight fast (Kwiterovich, 2008; ADA, 2008). HOMA-IR a mixed pattern (10%). Considering the body composi- was calculated to assess insulin resistance. Statistical tests tion measurements, the waist circumference (61 ± 7,47 cm; such as t-distribution and chi-squared test were performed. P = 0,044) and trunk-arm ratio (0,95 ± 0,28; P = 0,001) were Statistical significance was considered as P < 0.05, data were related to lipodystrophy presence. No significant associa- analysed using STATA 8.0 software. tion was found between lipodystrophy and arm and calf ± Results: The mean age was 9,8 1,2 years, 50% were circumferences (18,76 ± 2,58 cm; 25,93 ± 2,93 cm), body boys, 82,5% children from B e C categories and 97,5% were fat mass (17,61 ± 8,26%),tricipital and bicipital skinfolds infected by vertical transmission. Lipodystrophy was present (8,37 ± 2,91 mm;5,67 ± 2,13 mm). in 11 patients (27,5%), while hypertriglyceridaemia, hyper- Conclusion: Waist circumference and trunk-arm ratio cholesterolaemia, low HDL cholesterol levels and high LDL were sensitive measurements to show body composition cholesterol levels were present in 40%, 32,5%, 32,5% and changes in patients with lipodystrophy. 17,5% respectively. The prevalence of hyperglycemia (5%) and insulin resistance (2,5%) was lower in these patients. doi:10.1016/j.ijid.2010.02.1647 There was a significant association between lipodystrophy and insulin levels (P = 0,043). In our study, 52,5% patients received protease inhibitors, which showed significant association with higher levels of triglycerides (P = 0,003) and total cholesterol (P = 0,005). Conclusion: There was a higher prevalence of lipodystrophy and dyslipidemia in comparison with hyperglycemia and insulin resistance. The protease inhibitors were associated with impaired lipid metabolism, increasing the risk of early cardiovascular disease. doi:10.1016/j.ijid.2010.02.1646 e72 14th International Congress on Infectious Diseases (ICID) Abstracts

27.012 27.013 Antioxidant nutritional status and superoxide dismutase Lipodystrophy and antioxidants in school-aged children (SOD) levels in school—aged children infected with human infected with human immunodeficiency virus immunodeficiency virus R. Vega Patin, F.L.Ceragioli Oliveira, R.C. de Menezes Succi, R. Vega Patin, F.L.Ceragioli Oliveira, R.C. de Menezes Succi, D.M. Machado, C. Zanin Palchetti ∗, S. Pessoa, O.M. Silvério O.M. Silvério Amâncio, A.D.F. Thomé Barbosa Gouvea, C. Amâncio, F. Ancona Lopez Zanin Palchetti ∗, D.M. Machado, F. Ancona Lopez Universidade Federal de São Paulo - UNIFESP/EPM, São Universidade Federal de São Paulo - UNIFESP/EPM, São Paulo, Brazil Paulo, Brazil Background: To identify association between clinical- Background: Antioxidant micronutrients play an impor- metabolic repercussions of the lipodystrophy with micronu- tant role in HIV infection. Deficiencies of micronutrients trient nutritional status and the enzyme superoxide are associated with immune deficiency, rapid disease pro- dismutase in HIV-infected children. gression and mortality. The aim of the study was evaluate Methods: Prospective and transversal study was assessed antioxidant nutritional status in prepubertal school-aged in 51 HIV-infected children attended at the Pediatric Infec- children in two situations: HIV exposure and the control tious Disease Clinic - Universidade Federal de São Paulo, São group. Paulo city, Brazil. The clinical, nutritional and biochemical Methods: Prospective transversal study including 51 variables were related to the presence or absence of clinical HIV-infected children attended at the Pediatric Infectious lipodystrophy. Disease Clinic - Universidade Federal de São Paulo, São Paulo Results: Lipodystrophy was present in 25.5% of the chil- city, Brazil and their respective exposed siblings not infected dren. This group was identified for subjects of younger by HIV (n = 31) and the ones not exposed to HIV (n = 32). age at the moment of diagnosis and antiretroviral ther- Antioxidant substances related to the clinical, dietary and apy (ART) was more damaging concerning current clinical biochemical variables in the groups were evaluated. and immune status (P < 0.03). The current use and the time Results: Vitamin A, C, E, beta-carotene, licopene, zinc lapse of estavudine use (D4T) were related to lipodystro- and copper intake and plasma levels of vitamins A, C, phy presence (P < 0.04). The lipodystrophic group presented E, beta-carotene, serum copper and superoxide dismutase higher trunk-arm ratio and lower values of phase angle. The (SOD) and protein C reactive, did not significantly differ in dietary energy, macronutrient and micronutrient intake did the groups. Major probability of vitamin A inadequacy was not differ in the groups. The prevalence of hipertriglyc- identified in the HIV-infected group (43.1%) as well as in the eridemia and immune damage were verified in the first group exposed but non-infected by HIV (48.4%), when compared (P < 0.008). Lipodystrophy was related to fast insulin values, to the non-exposed to HIV (37.5%) (P > 0.05). Lower rates of glutamic piruvic transaminase (GPT) and HOMA (P < 0.02). dietary vitamin E in HIV-infected children with inadequate Biochemical levels of micronutrients and superoxide dismu- trans fatty acid intake (P < 0.005) were verified. In the three tase (SOD) did not vary in the groups (P > 0.05). Multiple studied groups, vitamin E correlated to the dietary saturated regression analysis showed that 37% of the trunk-arm ratio and polyunsaturated fatty acid (P < 0.007). Lower rates of was explained by triglycerides, HOMA and SOD variables and the erythrocyte and serum zinc (P < 0.02) were verified in the the time of protease inhibitor use, when controlled by inad- HIV-infected children, when compared to the other groups. equate saturated fatty acid intake (more than 7% of total In the same group, correlation between dietary and bio- energy). chemical values for vitamin C (r = 0.34; P = 0.01) and serum Conclusion: Although the variables assessed in this study zinc (r = 0.37; P = 0.008); serum copper with SOD (r = 0.30) were associated to trunk-arm ratio, there were other fac- and with serum zinc (r = 0.43) and an inverse correlation of tors that must be investigated in order to prevent or to the erythrocyte zinc with the serum copper (r = -0.31) and minimize the damages caused by the oxidative stress, in with SOD (r = -0.50) were found. Plasma levels of vitamin order to decrease the cardiovascular disease risk factors in E, licopene and betacarotene were related to CD4 count HIVinfected children. (P < 0.05) but negatively to the viral load (P < 0.02). Conclusion: HIV-infected school-aged children without doi:10.1016/j.ijid.2010.02.1649 severe infectious processes in the last year presented oxidative stress by the chronic viral infection, allied to 27.014 infectious processes, promoting increase in the demand of Factors influencing pregnancy among HIV positive women antioxidant. Interdisciplinary accompaniment has become receiving anti-retroviral therapy in Tororo district, essential, emphasizing adequate dietary in antioxidant Uganda micronutrient intake by HIV-infected children. M. Busuulwa doi:10.1016/j.ijid.2010.02.1648 Medical Epidemiologist, Kampala, US, Uganda Background: In Uganda HIV prevalence among women is estimated at 7.5% relative to 5.0% among men. The women are disproportionately affected at the younger age compared with men. This therefore has an implication on their fertility in the era of anti-retroviral therapy (ART). The 14th International Congress on Infectious Diseases (ICID) Abstracts e73 improvement in health in the advent of ART has resulted tance testing. Mean age was 37 years; 75% were male; 77% in high proportions of unplanned pregnancies in HIV positive African-Americans. Transmission risk in males: 60% MSM, women on treatment estimated at 97%. Purpose of study: 35% high-risk heterosexual, 2% injection drug use (IDU). establish factors for unplanned pregnancies among HIV pos- Transmission risk in females: 79% high-risk heterosexual, itive women on ART care to help health district department 9% IDU. Overall, 53% were diagnosed in outpatient clinics, implement and strengthen family planning services in HIV 29% during a hospital admission, and 10% in the Emergency care in Tororo District and prevent unplanned pregnancies Department. Reasons for HIV testing included: symptoms in women with HIV/AIDS on ART to improve their quality of suspicious for immunosupression in 45%; routine checkup for life. 29%; suspected sexually transmitted disease in 14%, part- Methods: Facility based unmatched case control study. ner notification/recent high-risk sexual contact in 12%. At Cases were women who had an unplanned pregnancy or had the time of diagnosis, 30% had an opportunistic disease: 14% ever had one whilst on ART; controls were women on ART Pneumocystis pneumonia; 10% esophageal candidiasis. Mean who had never had an unplanned pregnancy. Sample size CD4 count was 272 cells/mm3; 47% of patients had ≤200 was 414 with 207 cases and 207controls. CD4 cells/mm3; 35% had a viral load > 100,000 covpies/ml. Results: Age ≤ 31years (OR = 1.70, 95% CI = 1.140-2.53), Prevalence of transmitted drug resistance mutations was seeking FP information (p = 0.004), barriers to FP use 18.9%. Prevalence of one, two and three class mutations (p = 0.00001) and provision of male condoms (p = 0.00004) by were 13.1%, 5.1% and 0.7% respectively. NNRTI resistance the ART clinics were significantly associated with unplanned mutations occurred in 11% (K103N in 8%); 7% had PI resis- pregnancies in HIV positive women on ART. On the other tance mutations (L90 M in 5%); and 7% had NRTI resistance hand, using injectable hormonal FP (p = 0.00002) and dual mutations. Bivariate and multivariate analyses showed no contraceptives (OR = 0.22 95% CI = 0.12—0.41) was asso- significant associations between resistance mutations and ciated with less likelihood of occurrence of unplanned demographic variables. pregnancies Conclusion: Late presentation and transmitted drug resis- Conclusion: Age ≤ 31years; seeking FP information from tance mutations are common among newly diagnosed HIV health workers and presence barriers to FP use were risk infected individuals in Detroit. There is a high burden of factors to unplanned pregnancies. On the other hand, disease among young and heterosexual populations. Scaling using male condoms alone; using dual FP methods of con- up of programs to diagnose HIV infection in a timely man- traception was protective against unplanned pregnancies ner is essential for appropriate treatment intervention and in HIV positive women on ART. Providing comprehensive enhanced preventive efforts. family planning in HIV/AIDS care settings is necessary to reduce/prevent unplanned pregnancies in HIV+ women. doi:10.1016/j.ijid.2010.02.1651 27.016 doi:10.1016/j.ijid.2010.02.1650 Occupational risk of HIV infection among Nigerian dentists 27.015 C. Azodo Epidemiologic characteristics and transmitted drug resistance mutation patterns among newly diagnosed HIV University of Benin Teaching Hospital, Benin City, Edo State, infected individuals in a large tertiary care hospital in Nigeria Detroit Background: Dentists are often victims of occupational ∗ M. Huaman , J. Aguilar, N. Markowitz, D. Baxa, A. injuries by contaminated sharps of projection of contam- Golembieski, I. Brar inated fluids to mucous membranes and are therefore a occupational transmission HIV acquisition. Henry Ford Hospital, Detroit, MI, USA Objective: To analyze the occupational risk of HIV infec- Background: Although evidence is mounting for earlier tion among Nigerian dentists. initiation of antiretroviral therapy, late presentation and Methods: A multi-staged sampling technique was used to transmitted drug resistance are major obstacles for cur- select 300 practicing dentists from all parts of Nigeria. Data rent treatment and prevention strategies. We describe the collection tool was a self-administered questionnaire. Mea- epidemiology and transmitted drug resistance mutation pat- sures were: frequency of percutaneous injury, and action terns of newly diagnosed HIV individuals in a large tertiary taken and precautions to mucocutaneous exposure. care hospital in Detroit. Results: Percutaneous injury was recorded among 69.3% Methods: A retrospective analysis among adults newly of respondents and only 1.2% post-exposure prophylaxis. diagnosed with HIV infection was performed using a Those with abraded skin that will treat patient with addi- computer-based medical record system. Individuals who tional barrier was 8.6%. Percutaneous injury was positively received care at Henry Ford Hospital at the time of diagnosis related to gender, position, additional qualifications, loca- and underwent genotypic resistance testing were included. tion of practice and experience (p < 0.05) Demographic, clinical and laboratory data were collected. Conclusion: Percutaneous injury was significantly high Drug resistance mutations were detected using the Trugene and low preventive measure was utillized at such exposure. HIV-1 genotype assay. Mutations evaluated were selected This indicated obvious need for training on needle safety from the IAS-USA mutation list (12/2008). and other occupational HIV preventive measures. Results: From 01/2006-12/2008, 137 individuals were newly diagnosed with HIV and underwent genotypic resis- doi:10.1016/j.ijid.2010.02.1652 e74 14th International Congress on Infectious Diseases (ICID) Abstracts

27.017 health education, VCT and clinical management services to Outbreak investigation of HIV/AIDS in Jalalpur Jattan limit disease spread. (JPJ), Pakistan-2008 doi:10.1016/j.ijid.2010.02.1653 J. Ansari 1,∗, M. Salman 1, R.M. Safdar 2, N. Ikram 3,T. Mahmood 4, H.A. Zaheer 3, B.M. Kazi 5, H. Walke 6, R.J. 27.018 Asghar 7 A randomized controlled field trial of HIV-STI risk reduction program among undergraduate students at a 1 Public Health Division, National Institue of Health, Islam- University in Northern Nigeria abad, Pakistan 2 Public Health Laboratories Division, Islamabad, Pakistan A. Saad 1,∗, L. Rampal 1, K. Sabitu 2, H. AbdulRahman 1,B. 3 National AIDS Control Program (NACP), Islamabad, Pak- AbuSamah 1, A.Y. Ibrahim 3, A. Awaisu 4 istan, Islamabad, Pakistan 1 4 Department of Health, Punjab, Islamabad, Pakistan Universiti Putra Malaysia, Serdang, Selangor DE, Malaysia 2 5 National Institute of Health, Islamabad, Pakistan Ahmadu Bello University, Zaria, Kaduna, Nigeria 3 6 Centers for Disease Control and Prevention, Iatlanta, GA, Infectitious Disease Hospital, Kano, Kano, Nigeria 4 USA Universiti Sains Malaysia, Penang, Malaysia 7 Centers for Disease Control and Prevention, CDC, USA, Background: Nigeria with over 2.9 million people living Islamabad, Pakistan with HIV is at risk of increased burden and transmission HIV. Background: In Summer, 2008 an NGO in Jalalpur Jat- It has the second largest burden of HIV infection in the world tan (JPJ) arranged two voluntary HIV screening camps after with young people at higher risk. The aim of this study was to observing many HIV infected persons in their treatment cen- evaluate the effectiveness of a peer-led HIV-STI intervention ter. 88 (35.8%) of 246 persons screened were positive by program framed on the Information-Motivation-Behavioral rapid test. Intense media coverage made village residents skills model among undergraduate students at Ahmadu Bello hostile to further inquires. The Pakistan Field Epidemiol- University, Zaria- Nigeria. ogy Training and Laboratory Training Program(FELTP) was Methods: Randomized controlled field trial design was requested by the Provincial AIDS Control Program to carry used to investigate the effectiveness of an intervention out an epidemiological investigation. program developed for HIV-STI risk reduction. Participants Methods: HIV-positive persons or family members of were randomized to either the intervention group or con- patients who died of AIDS and consented for an inter- trol group. An 8-hour integrated HIV-STI prevention program view during 15 December 2008 to 2nd January 2009 were comprising of four structured modules was developed and investigated. Enhanced contact tracing was done to iden- delivered to the intervention group while the control tify additional cases. A structured questionnaire was used group received another 8-hour program on career devel- to collect data regarding clinical history, HIV knowledge opment. Both programs were delivered by trained peers. & practices. The national HIV/STI Referral Laboratory col- Two-way repeated measure ANOVA was applied to assess lected blood samples for HIV serology and molecular studies the effectiveness of the intervention. The outcome mea- independently following pre and post counseling. sures including HIV-related and STI knowledge, sexual risk Results: Of 53 HIV-infected persons investigated; 47 behaviors, attitude and stigma were assessed at baseline, (88.7%) were alive, 27 (50.9%) female. Median age was 35 immediately post-intervention, at 3 months and 6 months years (mean 34.7, range 3-70), including six children of 10 postintervention. years or less. Clinical symptoms included; unexplained fever Results: Respondents in the intervention arm showed (79.2%), diarrhea (64.15%) and skin infections (50.9%). 24.5% significant improvements in HIVrelated and STI knowl- had co-infection with tuberculosis and 18.9% with hepati- edge, sexual risk behaviors and attitudes towards HIV-STI tis (B or C). Unsafe injections (96.2%), dental procedures prevention. Conversely, there was no difference in tol- (40%) and barber shop visits among males (72%) were com- erance towards PLHIV, which was assessed using the mon risk factors. Extramarital sex was reported by 9.4% stigma scale. There were significant main effects for ␩ including 3.8% who admitted paid sex. Only 19 (35.8%) were group [F = 155.94, p = < 0.001, 2 = 0.401]; time [F = 248.35, ␩ aware that HIV can be sexually transmitted or transmitted p = < 0.001, 2 = 0.516] and group x time interaction ␩ by blood, 18 (34%). Phylogenetic analysis revealed HIV infec- [F = 162.96, p = < 0.001, 2 = 0.412] for HIV-related knowl- tion in this group was HIV-1 Subtype A, transmitted over a edge. Similarly, the main effects for group, time, and group decade, likely endemic, and not an outbreak. x time interaction for STI knowledge, sexual risk behaviors, Conclusion: Investigation indicates high rates of HIV and attitudes were also significant. infection in JPJ. Unlike other studies from Pakistan, Conclusion: The peer-led HIV-STI intervention program increased rates were observed in females and under 12 developed was effective in improving knowledge and atti- children. Sociocultural norms and stigmatization limited in- tudes towards HIV prevention and reducing sexual risk depth investigation of sexual practices and history of drug behaviors among Nigerian university students. abuse. Shift of HIV from high-risk to general population was evident and requires vigilant surveillance besides targeted doi:10.1016/j.ijid.2010.02.1654 14th International Congress on Infectious Diseases (ICID) Abstracts e75

27.019 27.020 Qualitative analysis of a new web-based system for mon- HIV infection in elderly (patients over 65 years) itoring and evaluation of HIV/AIDS, El Salvador 2009 F. Almasi Nokiani M. Mengel 1,∗, J. Armero 2, F. Job 1 University Paris 6, Courbevoie, France 1 Instituto Carlos III, Madrid, Spain Background: After 1996 with highly active antiretroviral 2 Minstry of Public Health and Social Assistance, San Sal- therapy, not only HIV infected people live longer but also vador, El Salvador new HIV infection occurs in older people. Background: In February 2009, the Ministry of Health Methods: This is a Retrospective observational study in (MoH) of El Salvador launched SUMEVE, a unitary web-based Registered HIV infected patients older than 65 years old in system for monitoring and evaluation of HIV/AIDS. SUMEVE order to review special epidemiologic, clinical and biologic collects data on every person seeking testing or treatment aspects of HIV infection in elderly. for HIV/AIDS. In May 2009 we performed an early, qualita- Results: Among 1680 registered HIV infected patients in tive analysis to verify whether the system was operating as this center, there are 61 HIV infected patients older than 65 designed. years old including 13 women (21%) and 48 men (79%). The Methods: We selected a convenience sample of 5/30 oldest patient is an 84 years old man and male-female ratio collection centres and 6/30 laboratories at regional and is 4/1. There are 29 homosexualbisexual transmission (47%), central level and performed a qualitative analysis assess- 24 heterosexual transmission (40%), only one patient blood ing the system’s resources and functioning, following transmission and 7 patients who denied any risk factors CDC (Atlanta)’s ‘‘Updated Guidelines for Evaluating Pub- (11%). 23 patients (38%) are coming with AIDS defining con- lic Health Surveillance Systems’’. Standardized interviews dition (stage C), 13 patients (21%) are symptomatic (stage with SUMEVE-professionals were conducted to explore the B) and 25 patients (41%) are asymptomatic (stage A). Before system’s strengths, weaknesses, opportunities and threats antiretroviral treatment, CD4 count was between 9 and 493 (SWOT-format). as a mean 231cell/ml. There were 24 patients (40%) with Results: Patient data are entered on paper forms when CD4 count less than 200 and 7 patients (11%) with CD4 count HIV rapid testing is requested at primary health-care facil- less than 100 cells/ml. Recent CD4 count, was between10 ities and forwarded with the HIV test results to the and 1080 and as a mean 478. There is an important increase collection-centres for entry into the online database. in CD4 count (247 cells/ml) after antiretroviral treatment. 97% of primary health care facilities and 100% of HIV labo- Viral load before treatment was ranged between 6410 to ratories are reporting to SUMEVE, producing exhaustive data 1740000 copies/ml. Mean viral load was 230184. There are and showing wide system acceptability. Timeliness varies 1- only 5 untreated patients (8%). After antiretroviral treat- 7 days between generating and digitizing notification forms ment 8 patients present viral load more than 500 copies/ml for instant analysis. including 2 untreated patients. It means 6 patients (10%) SWOT analysis shows as strengths a comprehensive legal suffered from confirmed virologic failure and 7 patients framework for SUMEVE which is part of the National HIV/AIDS (11%) present detectable viral load but less than 500 plan. Registration by name avoids double notification. copies. Results are regularly published on MoH website. Conclusion: 80% of HIV infected people older than 65 are Data confidentiality is guaranteed by password-restricted men. Homosexual contact is the major risk factor in this access. group. In spite of 40% asymptomatic patients there are near The system has a flexible modular design allowing to 40% stage C. 40% of patients were coming with low CD4 count amend and remove indicators. (less than 200). Mean CD4 count before treatment was 231 Identified weaknesses were: lacking reliable internet which is less than younger HIV infected patients, may be connection at two of the centres and that notification forms because of low CD4 count in older patients and/or late diag- there could not be stored confidentially. nosis of HIV infection in elderly. Virologic response is as well As opportunities, we identified advocating renewed polit- as younger patients even better. ical commitment of the current government to guarantee the stability of SUMEVE and take actions in benefit of vul- doi:10.1016/j.ijid.2010.02.1656 nerable groups identified by SUMEVE. No current threats to the system performance could be 27.021 identified. Primary human immunodeficiency virus-1 infection: Clin- Conclusion: SUMEVE is operating as planned on all levels, ical, virological and immunological characteristics of a collecting exhaustive data of at least 97% of primary health braziliam cohort care facilities. Identified weaknesses are being improved. D. Pellegrino ∗, E. Boccardo, M. Eira, R. Silva, I. Moreira, M. SUMEVE is the only surveillance system to direct public Bocoli Rossi health interventions for HIV/AIDS. We recommend performing a re-evaluation after one year to assess the value of the Institute of Infectious Diseases Emilio Ribas, Sao Paulo, SUMEVE for planning and executing intervention measures. Brazil Background: Primary HIV-1 infection (PHI) consists in the doi:10.1016/j.ijid.2010.02.1655 period of time between viral acquisition and seroconversion, its hallmark is high viremia and consequently increased e76 14th International Congress on Infectious Diseases (ICID) Abstracts infectiousness. The occurrence, severity and duration of syndrome (MS) components among HIVinfected patients ART- symptoms are predictive factors of clinical deterioration. treated and ART-naïve. We report here the epidemiological, clinical, virological and Methods: This was a cross-sectional study of HIV-infected immunological characteristics of a cohort of patients with subjects ART-treated (n = 29), HIVinfected patients ART- PHI. naive (n = 28) and controls without previous CVD events Methods: Prospective observational study of patients (n = 32). Subjects were selected for common age range with PHI at the Emilio Ribas Institute of Infectious Dis- (20 to 69 years) from the Instituto de Infectologia Emilio eases, a tertiary hospital in Sao Paulo, Brazil. Inclusion Ribas, São Paulo. We assessed cardiovascular risk factors, criteria included negative or undetermined HIV-1 serology HIV viral load, nadir CD4 count, high-sensivity C-reactive associated with viral detection, or clinical and serological protein (hs-CRP) and plasma lipid concentrations. MS compo- evidence of seroconversion during the last 6 months. Epi- nents included low LDL cholesterol, high triglycerides, high demiological history, clinical data, HIV-1 plasma viral load, BMI, hypertension and diabetes. The statistical analysis were CD4 cell count, genotypic resistance testing, serology for done using a SPSS 16.0. hepatitis B, C, A, toxoplasmosis, cytomegalovirus, herpes Results: Groups were matched for age (mean 43.6 years and syphilis were recorded as well as the use of highly active for ART-treated vs 42.0 years for ART-naïve vs 42.8 for con- antiretroviral treatment (HAART). trols); 31%, 35.7% o and 46.8% are women, respectively. Results: Between 2007 and 2009, 10 patients met the The mean duration of HIV infection was 10 years for ART- inclusion criteria (8 males and 2 females, median age treated and 6 years for ART-naïve subjects. The mean nadir was 34). Two patients were asymptomatic and eight were CD4 count (cells/␮L) was 208 for ART-treated and 449 symptomatic. The main symptoms were fever (80%), myal- for ARTnaïve subjects (p < 0.0001); current HIV-RNA levels gia (60%), rash (30%), hepatitis (20%) aseptic meningitis were undetectable on ART-treated and 13.683 copies/ml on (20%) and renal failure (10%). Only 4 patients had a ART-naïve subjects (p = 0.005). There were no significant dif- mononucleosis-like illness. Homosexual transmission route ferences between the groups in levels of hs-CRP, HDL and was more frequent (60%). Five patients had plasma viral LDL-cholesterol. Total cholesterol was higher in ART-treated load above the upper limit of detection and the median than in ART-naïve (mean 209 vs 182 mg/dl, respectively; CD4 cell count was 395cel/mm+ (range: 47—835cel/mm+). p = 0.02); triglycerides was higher in ART-treated than in Five patients received HAART and among 5 patients who ART-naïve subjects (mean 234 vs 137 mg/dl, respectively; did not receive HAART, 2 patients had clinical and immuno- p = 0.02). Hypertension was more frequent in ART-treated logical criteria for initiating HAART after 12 months of compared to the others groups (p = 0.01). 41.4% of ART- follow-up. Genotypic resistance testing was available for 4 treated patients had MS, compared to 25% of ARTnaïve and patients. Overall patients had triple class susceptible HIV- 28.1% of controls (p = 0.0001); 27.6% of ART-treated had a 1 sub-type B strain. One patient had primary resistance to high (> 20%) 10-year FRS compared to 0% in the others groups non-nucleoside reverse transcriptase inhibitors and several (p < 0.0001). protease inhibitors mutations and this finding was correlated Conclusion: Our results shows a high prevalence of MS with clinical severity. and high FRS in HIV-patients under treatment, which can Conclusion: Clinical, virological and immunological be used to predict cardiovascular risk stratification in this parameters in PHI may be heterogenous, atypical clinical population. presentation is frequent. Determinating resistance profile is useful for early therapeutic intervention, which is associated doi:10.1016/j.ijid.2010.02.1658 with better outcome. 27.023 doi:10.1016/j.ijid.2010.02.1657 Factors affecting acceptance of HIV testing among antenatal care attendees in Ethiopia: With emphasis on role 27.022 of male partners Prevalence of metabolic syndrome and estimated Fram- T. Zewde ingham risk score among Brazilian HIV-infected patients ,∗ EngenderHealth, Hawassa, Ethiopia E. Margareth 1 , E.L. Dorea 2, I.M. Bensenor 3, I.R.S. Oliveira 2, G.A. Pinto 2, A.L. Sassaki 2, P.A. Lotufo 3 Background: Counselling and testing is an entry point for PMTCT of HIV infection. To increase uptake of PMTCT inter- 1 Instituto de Infectologia Emílio Ribas, Sao Paulo, Brazil ventions and to benefit more generally from HIV testing, the 2 Hospital Universitário, University of Sao Paulo, Sao Paulo, greater involvement of men is important. This study was Brazil designed to assess factors affecting acceptance of HIV test- 3 Faculdade de Medicina, University of Sao Paulo, Sao Paulo, ing among antenatal care (ANC) attendees with emphasis on Brazil role of male partners, in Wolaita zone, southern Ethiopia. Background: Recent studies suggest that HIV infection Methods: Cross-sectional study was conducted on 412 itself or combination ART (cART) were both associated with pregnant women using structured questionnaire from March increased risk for cardiovascular disease (CVD). The 10-year to April 2008 in three public health centers of Wolaita zone, Framingham risk score (FRS) is used to predict cardiovascular southern Ethiopia. The study was complimented and trian- events in the non-HIV-infected patients, and its applica- gulated by focus group discussions (FGDs). In the absence of tion in the HIV-infected subjects is under discussion. We similar study, the sample size was determined based on the evaluated the traditional CVD risk factors and metabolic assumption that 50% of women would make joint (with their 14th International Congress on Infectious Diseases (ICID) Abstracts e77 partner) decisions about HCT. The margin of error was set Women focused on cost, cultural differences, circumcised at 5% and degree of confidence 95%. family members and decision making for circumcising chil- Results: Acceptance of HIV testing among the inter- dren. Attitudes regarding MC differed between national/ viewed pregnant women was 74.5%. Stigma and discrimina- cultural group and gender; excepting the Mohel, Hispanic tion by the community, husband reaction and fear of positive male providers related MC acceptability to American Pedi- test result were reasons that impede higher acceptance atric Association guidelines, personal circumcision status of HIV testing. Acceptance of HIV testing was significantly and were skeptical regarding its health benefits for STD/HIV associated with pregnant women who had attended formal risk reduction. Female providers focused on the financial education, reside in urban area, living with their partners burden to parents in its provision to neonates, lack of and those mentioned ART as PMTCT. Only 27% of pregnant information and the need to increase acceptability among women could decide independently on accepting HIV test- Hispanic men. ing. Male partners, who came to health centers along with Conclusion: Both women and men appeared accepting their partners for ANC and HIV testing, were only 5.1%. Two of neonatal circumcision, and the women were assertive third of the study participants (65.5%) have no habit of open regarding their role as decision makers regarding the pro- discussion on HIV/STI with their male partners. Most women cedure. with positive test result do not disclose their test result to their partners. Pregnant women who could get partner sup- doi:10.1016/j.ijid.2010.02.1660 port with positive test result were more likely to accept HIV testing than their counterparts. 27.025 Conclusion: HIV testing acceptance is encouraging but Patients with newly-diagnosed HIV in 2004 versus 2008: men’s involvement was found to be low and they appear No apparent difference in progression to be the secrete ingredient of PMTCT intervention. Gen- A. Brown 1,∗, C. Ní Bhuachalla 1, C. de Gascun 2, R. Hagan 3, erally, pregnant women need their male partners’ positive C. Bergin 1 attitude and support to accept HIV testing. Hence PMTCT programs should give emphasis on involvement of male 1 St. James’s Hospital, Dublin, Ireland partners. 2 National Virus Reference Laboratory, Dublin, Ireland 3 National Blood Transfusion & Histocompatibility Service, doi:10.1016/j.ijid.2010.02.1659 Dublin, Ireland 27.024 Background: Trends have recently been observed suggest- Attitudes towards neonatal male circumcision among His- ing more rapid progression in newly-diagnosed HIV-positive panic men and women in Miami, Florida patients. This data is limited by an inability to specifically identify the time of infection. Our HIV-positive cohort ,∗ J.G. Castro 1 , D. Jones 2, I. Barradas 2, M. Lopez 1, S. Weiss 2 displays heterogenous acquisition risk and significant immigration from countries of high prevalence, and is ideal to 1 University of Miami, Miami Shores, FL, USA study changing epidemiology. 2 University of Miami, Miami, FL, USA Methods: A retrospective cohort study was undertaken Background: Hispanics in the U.S. with the lowest rates comparing newly diagnosed HIV patients attending in the of circumcision (MC) and relatively higher rates of hetero- first half of 2004 with those in 2008. Baseline demograph- sexual HIV transmission may benefit with higher rates of MC. ics and virological parameters were gathered. Progression Before interventions to promote MC can be introduced in the was followed for the first year after diagnosis. Patients Hispanic community, additional information is necessary to with known seroconversion were of particular interest — determine the factors that are related to its acceptability including those certain of time of infection, who recalled sig- in this population. nificant seroconversion illness and/or a negative test within Methods: We conducted a qualitative study to assess the the preceding 6 months. Others with previous negative tests attitudes towards neonatal MC in Hispanic pregnant females outside this window were not designated as known serocon- and males and intensive interviews with 12 providers of the verters. Rapid progressors (RPs) were defined as those with Hispanic community. Gender concordant focus groups were documented seroconversion window < 2 years prior to pre- held to address the relative acceptability of MC. Each focus sentation, who progressed to CD4 ≤350 cells/mm3 within group (2 male, 4 female) was lead by 2 trained facilita- first year of follow-up. Results were analysed using Graph- tors (medical, psychosocial). Key informants of the Hispanic PadInStat. community had an individualized indepth structured inter- Results: Of the 200 charts reviewed, 96 met inclusion views. criteria. Baseline characteristics are summarized in Table 1. Results: Qualitative data was analyzed for dominant CD4 ≤350 cellls/mm3 at first presentation in 2004 and 2008 themes and collapsed into overarching themes. Thirteen respectively was seen in 20(48%) and 31(57%) p = 0.42. CD4 themes emerged, including acceptability, appearance, cir- count ≤350 by end of year 1 was 25(60%) vs 35(65%) p = 0.67. cumcision and children, circumcision and HIV, cost, cultural Mean change in CD4% from diagnosis to end of year 1 or pre- differences, health benefits, knowledge and personal expe- ART was -2.9%(SD5.1) vs +7.2%(SD 11.0) p < 0.0001 (95%CI, riences, pain and injury to the penis, perceived HIV risk, -13.7718 to -6.4882). AIDS-defining illness in first year was religion, sexual performance and sexual pleasure. Men seen in 6(14%) vs 7(13%) p = 1.0. Of those with CD4 ≥350 associated acceptability with the attitudes of health care cells/mm3 at first presentation, 18 (82%) vs 18 (78%) main- professionals, knowledge about the procedure and hygiene. tained CD4 ≥350 at end of year 1 untreated. Of those with e78 14th International Congress on Infectious Diseases (ICID) Abstracts known seroconversion window <2 years, rapid progression 27.027 was seen in 3/7 in 2004 and 9/20 in 2008 (p = 1.0). Demographic and psychosocial factors associated with Conclusion: In a diverse group, there was no difference appointment attendance among HIV positive outpatients in progression to CD4 ≤350 cells/mm3 in the first year of attendance between cohorts. Knowledge of time of infec- L. Bofill tion eliminates bias of late presentation in assessing true University of Miami, Miami, FL, USA progression. Further large-scale prospective studies should focus on progression from seroconversion and minimising Background: Appointment attendance is an important late presentation. strategy for ensuring adherence to antiretroviral treatment (ARV), and also provides valuable opportunities for doi:10.1016/j.ijid.2010.02.1661 HIV care professionals to assess the patient’s need for medical advice, individualized treatment, and implement 27.026 behavior interventions when needed. The purpose of the Effectiveness of ‘‘positive prevention’’ among people liv- present study was to identify individual and psychosocial ing with HIV/AIDS in Yunnan Province, China characteristics associated with HIV-related medical appointment non-attendance among adult participants attending L. Li ∗, Y. Guo the Outpatient Adult HIV/AIDS Immunology Clinic at Jackson Peking University Health Science Center, Beijing, China Memorial Hospital (JMH) in Miami, Florida over a 12-month period. Background: HIV/AIDS prevention needs not only a par- Methods: Patient selection: Treatment naïve or no ticipation of HIV-negative people, but also the HIV-positive. ARV for the previous 6 months at study entry. Baseline ‘‘Positive prevention’’, which mainly targets on people live questionnaire included demographic, social and behav- with HIV/AIDS (PLWH), aims to improve PLWH’s health knowl- ioral determinants, depression level, CD4 cell count and edge, self-esteem and life quality, protect their families and viral load. Data on medical appointment attendance was communities, and helps reducing HIV related infections as obtained from the Jackson Computer Data System retro- well as HIV transmission.This project evaluated the effec- spectively for 12 months from baseline. Mean percent of tiveness of ‘‘Positive Prevention’’ among multiethnic people missed appointments was obtained. Pearson and Spearman living with HIV/AIDS in Yunnan province, China. correlations were used to analyze the relationship between Methods: Using a quasi-experiment design and doing sur- potential predictors. A hierarchical linear multiple regres- veys before and after intervention. sion (HLMR) analysis testing the relation of the factors above Results: On baseline, total 620 qualified questionnaires to appointment non-attendance was conducted. One-way were finished, 312 from R county and 308 from L. 227 partici- ANOVA was performed to examine whether missed appoint- pators of R county enrolled in training, 6 months later 89.43% ments would vary based on CD4 count at baseline. were followed, as well as 88.96% of L county. There were Results: A total of 178 patients, 110 males (61.7%) and no significant differences between initial and tracing pop- 68 females (38.2%) were included. African Americans rep- ulation of both counties. Through interventions, R county resented 70.2% (p < 0.001) of participants. The average age got higher knowledge rates than L in most questions; its was 41.05 ± 10.04 for men and 43.2 ± 12.23 for women. 131 average scores on 4 belief factors - perceived susceptibility (73.6%) missed at least one appointment, 29 (16.29%) missed and severity of diseases, perceived benefits of engaging in all appointments, and 18 (10.1%) attended to all sched- health behaviors, self norms- remarkably increased; in past uled appointments. Missed appointments averaged 27.9%. 3 months, the condom using rate raised slightly (from 89.91% HMLR was significant (R2: 0.064, F(3,142) = 3.17, p = 0.026). to 92.17%) whenever having sex with his/her married part- Greater non-attendance was associated with younger age ner, and unprotected intercourses with the out-of-marriage (b = -0,21 t = -2.5, p < 0.014), and no family support (b =- decreased from 23.08% to 5.88%, and for the latest sex, 0.19, t = -2.23, p = 0.028). the condom using rate increased from 77.97% to 97.69%. Conclusion: Medical appointment non-attendance has However, there were insufficient evidences on reducing drug been associated with younger age and lack of family support. using and syringe sharing. Non-attendance has been consistently demonstrated in simi- Conclusion: ‘‘Positive Prevention’’ effectively improved lar studies to be associated with younger age. Interventions R county participators’ pertinent knowledge and belief, and targeted to young patients and strengthen family support also reduced high risk sexual behaviors to some extent. could address and improve medical appointment attendance Moreover, with participators’ praise and welcome, the train- as part of the complexity of long term HIV patients adher- ing was proved to be feasible and proper. ence. doi:10.1016/j.ijid.2010.02.1662 doi:10.1016/j.ijid.2010.02.1663 14th International Congress on Infectious Diseases (ICID) Abstracts e79

27.028 (SPVL) may evolve due to between-host selection as inter- The role of HIV Viral Load and CD4+ Cell Count in the mediate values maximise transmission potential. There is prolongation of the QT interval in patients from an HIV also evidence for heritability of SPVL from one infection to outpatient clinic the next. Methods: We developed three models to examine the ,∗ H. Shaaban 1 , A. Qaqa 1, J. Slim 2, G. Perez 2 evolution of the SPVL distribution. One modelled change in strain prevalence in discrete generations of infection. 1 St Michael’s Medical Center, Newark, NJ, USA Another incorporated continuous time into this framework. 2 St. Michael’s Medical Center, Newark, NJ, USA The third was extended to include explicit modelling of host Background: QTc Interval prolongation is associated with dynamics and variable population size. Comparison of the life-threatening arrhythmias and it has been reported to simulated distribution with observed data allowed estima- occur more frequently in the HIV-infected population. tion of parameter values. Methods: The data was collected from the charts of a Results: All three models demonstrated that SPVL dis- cohort of 135 consecutive HIV-infected patients from our HIV tribution would converge on the optimum relatively rapidly outpatient clinic. QTc interval was corrected to the heart regardless of the initial distribution of genotypes. The dis- rate using Bazzets formula .The cohort was divided into two crete generation model provided a robust measure of the groups(prolonged QTc and normal QTc interval). QTc inter- amount of variation attributable to nonviral effects and val was considered prolonged if it was >440 ms in males and mutation from one individual to the next. The dynamic pop- >460 ms in females. Multiple variables and potential risk fac- ulation model showed the response of the SPVL distribution tors were collected including the CD4+ cell count and Viral to host dynamics. Load (VL) measurements which were done at the same day Conclusion: The models described can be used to simu- or within few days from the time the ECG was done. late the response of SPVL to widespread interventions such Results: 23 patients were found to have prolonged QTc as circumcision or treatment, or the response to changing (17%).No significant difference between the groups was demography. observed for any baseline characterestics;however stastis- tically significant differences were observed with regard to doi:10.1016/j.ijid.2010.02.1665 the CD4+ cell count and VL. The ROC curves for both CD4 count and VL were obtained to establish cut-off points .The 27.030 cutoff points for CD4 count and VL were 144 and 17.9 x 103 Large scale HIV survey in Cameroon by mass HIV testing respectively. Sixteen of 23 subjects (70%) with prolonged QTc mobile units: Evidence of HIV epidemic hot spot areas and had CD4+ cell counts < 144 cells/mm3 as opposed to only 27 high HIV vulnerability of women over time of 112 (24%) of subjects with normal QTc interval (OR: 7.20; F.-X. Mbopi-Keou 1,∗, G.C.M. Kalla 2, R. Guiadem 3,H. 95% CI: 2.88 to 19.33; p < 0.0001). For VL, 18 of 23 subjects Tchouamani 3, R. Mbele 3, C. Nkada 3, E. Voundi 3,G. (78%) with prolonged QTc had levels ≥17.9 × 103 copies/ml, Ondobo Andze 1, I. Takoungang 4, L. Bélec 5, P. Ndumbe 6,F. whereas 43 of 105 (41%) of patients with normal QTc had Angwafo III 1 VL greater than the cut-off value (OR: 5.19; 95% CI: 1.79 to 15.05; p = 0.002). The simultaneous presence of both risk 1 Ministry of Health & University of Yaounde I, Yaounde, factors increased the OR to 14.74 (95% CI: 3.84 to 56.55; Cameroon p < 0.0001). 2 University Teaching Hospital, Yaounde, Cameroon Conclusion: Our study confirmed that the risk of QTc 3 Ministry of Health, Yaounde, Cameroon prolongation increases with the progression of the HIV infec- 4 University of Yaounde I, Yaounde, Cameroon tion. Low CD4 cell count and high Viral load could be 5 University Rene DEscartes & Georges Pompidou University considered as independent potential risk factors for QT pro- Hospital, Paris, France longation in HIV patients in the outpatientclinic settings. 6 University of Buea, Buea, Cameroon Background: In Africa where the majority of HIV-infected doi:10.1016/j.ijid.2010.02.1664 adults do not know their HIV status, the use of HIV test- 27.029 ing mobile units offers relevant public health prospects. In Modelling the between-host evolution of set-point viral order to increase the HIV testing capabilities of voluntary load in HIV infection counselling and testing centres, we developed a decentralized, large scale strategy based on bringing the needed ,∗ G. Shirreff 1 , T.D. Hollingsworth 2, W.P. Hanage 2,C. services closer to the people, through the use of mobile Fraser 2 units. Methods: The National Public Health Laboratory 1 Imperial College, London, W2 1PG, United Kingdom ‘‘Hygiene Mobile’’ acquired a van (in order to propose vol- 2 Imperial College, London, London, United Kingdom untary HIV screening) comprising separate compartments Background: The Human Immunodeficiency Virus (HIV) is for the driver, the medical team, and laboratory facilities. capable of evolving rapidly and responding to diverse selec- The screening of HIV-specific antibodies in serum samples tion pressures. Previous research has generally focused on was carried out using SD Bioline HIV, (Standard Diagnostics) the responses of HIV to selection within-host, comparatively & Determine (Inverness Medical Innovation). Indeterminate little has been done on the response between-host selec- or positive samples were immediately retested by the tion. Previous work has proposed that the set-point viral load ImmunoComb®II HIV 1 & 2 Bispot /Hexagon HIV. People e80 14th International Congress on Infectious Diseases (ICID) Abstracts diagnosed as HIV-infected were referred to health care scores from 5 to 9; attitude from 39 to 57, p < 0.05). centres. Upon completion of the program, majority of the trainees Results: From April 2005 to November 2008, 114 cam- (80—100%) believed that they were competent and confi- paigns were organised in Cameroon (average of 277 dent in performing most of the sexual health intervention volunteers tested per day). Out of 31,610 volunteers who activities. received a pre-test counselling, 31,512 (20,330 males; Conclusion: This preliminary study suggests that a 11,182 females) tested for HIV (acceptance rate of 99.7%). customized on-site training program on sexual health inter- Their average age was 31 years. Amongst those, 31,210 vention designed for and delivered to peer-facilitators (99.04%) received post-test counselling. The overall HIV could significantly improve their knowledge, attitude prevalence was 6.06% (HIV infection in women significantly and confidence to deliver program related to HIV-STI increased from 6.7% in 2005 to 9.73% in 2008). The North prevention. West region of Cameroon was the most affected with a prevalence of 15.76% in females and 7.27% in males. doi:10.1016/j.ijid.2010.02.1667 Conclusion: HIV testing through mobile units likely constitutes a useful tool to promote large scale up HIV testing 27.032 in sub-Saharan Africa and should be integrated into national Molecular epidemiology of HIV-1 in newly-diagnosed HIV control programmes. Successive campaigns in a given treatment-naïve patients in Singapore area allow to evidence hot spots of the HIV epidemic, and Y.-J. Sun 1, P. Kaur 1,∗, Y.S. Leo 2 to follow the variations of HIV prevalence over time. 1 Tan Tock Seng Hospital, Singapore, Singapore doi:10.1016/j.ijid.2010.02.1666 2 Communicable Disease Centre, Tan Tock Seng Hospital, Sin- gapore, Singapore 27.031 Potential impact of a customized peer-facilitators training Background: The molecular epidemiology of HIV-1 has not program on sexual health intervention been well studied in Singapore. Information on HIV-1 molecular epidemiology obtained from previous studies was either ,∗ A. Saad 1 , L. Rampal 1, K. Sabitu 2, H. AbdulRahman 1,B. based on a small sample size or on a specific HIV-1 popula- AbuSamah 1, A. Awaisu 3, A.Y. Ibrahim 4 tion (seroconverters). In this study we aimed to have a better understanding to HIV-1 molecular epidemiology in newlydi- 1 Universiti Putra Malaysia, Serdang, Selangor DE, Malaysia agnosed treatment-naïve patients on the basis of a larger 2 Ahmadu Bello University, Zaria, Kaduna, Nigeria sample size. 3 Universiti Sains Malaysia, Penang, Malaysia Methods: Newly-diagnosed treatment-naïve HIV-1 4 Infectitious Disease Hospital, Kano, Kano, Nigeria patients were prospectively, consecutively recruited from Background: The human immunodeficiency the Communicable Disease Centre, Tan Tock Seng Hospital, virus/acquired immune deficiency syndrome (HIV/AIDS) Singapore. PCR products of pol gene that encompass the epidemic remains of global significance. Targeting the youth entire protease gene and two-third of the reverse transcrip- in which most new infections occur especially in Nigeria tase (RT) gene were amplified based on PBMC-associated where the second greatest burden of the epidemic lies is viruses using an inhouse method. Direct sequencing was pivotal in HIV prevention. The use of peer facilitators to used to sequence the pol gene PCR products. The pol deliver an integrated sexual health intervention on HIV/AIDS sequences were used for phylogenetic analysis and for and sexually transmitted infections (STI) in this age group genotypic analysis of drug resistance. is an important prevention strategy.This study aimed to Results: One hundred fifty-one patients were analyzed in determine the feasibility of developing and implementing this study. Of whom 92% (n = 139) were men, 49.7% (n = 75) a customized training program related to the delivery of were men who have sex with men (MSM), and 49% (n = 74) an integrated HIV/AIDS and STI risk reduction intervention were heterosexuals. Five HIV-1 subtype/CRF were identi- for peer facilitators and to evaluate its potential impact on fied, including CRF01 AE (n = 94, 62.3%), subtype B (n = 53, their knowledge, attitudes, and perceived competence. 35.1%), CRF33 01B (n = 3, 2%), and one each of CRF34 01B Methods: We developed and delivered a structured and CRF07 BC. MSM accounted for 35.1% (n = 33) of the training program and materials about HIV/AIDs and STI pre- CRF01 AE infections and 77.4% (n = 41) of the subtype B vention in a university setting. The training was offered infections. Phylogenetic analysis showed that 55.3% (n = 52) to facilitators who were planned to be involved in a of 01 AE sequences were clustered in each of 8 clusters and larger project, known as Integrated HIV-STI Risk Reduction 73.6% (n = 39) of subtype B sequences were clustered in each Program. A pretest-posttest survey of single group was con- of 5 clusters; in addition, MSM was more common in one of ducted. Changes in scores before and after the training the clusters compared to heterosexuals in both 01 AE clus- program in knowledge, attitude, stigma scores and per- ters (55.7% vs. 37.7%, OR 11.9, 95% CI 3.9-36.7) and subtype ceived confidence and competence were measured. B clusters (87.8% vs. 25%, OR 21.6, 95% CI 4.6-101.5). There Results: Ten potential facilitators participated in the pro- was no any known drug-resistant mutation was detected by gram and completed both the pretest and posttest survey direct sequencing. questionnaire. The trainees’ median scores in HIV-related Conclusion: CRF01 AE and subtype B remain the primary and STI knowledge, attitude and stigma scores had signifi- etiology for HIV-1 infections in Singapore. The high extent cantly increased compared to the baseline (HIV knowledge of clustering of MSM suggests active transmission of HIV-1 from 22 to 30.5; STI knowledge from 8 to 22.5; stigma in this specific population, and therefore, more effective 14th International Congress on Infectious Diseases (ICID) Abstracts e81 prevention intervention measures for HIV-1 transmission are tions increasing access to HIV care to target; specific age needed for this group of individuals. groups, females, rural residents, ensure constant stock of medicines in health facilities and improve client family sup- doi:10.1016/j.ijid.2010.02.1668 port. 27.033 doi:10.1016/j.ijid.2010.02.1669 Factors influencing access to HIV care services by clients referred from a district home based HIV counseling and 27.034 testing program in eastern Uganda, 2009 Adherence to infant feeding practices among HIV positive women with infants aged less than six months in Rakai D. Lubogo 1,∗, H. Wamani 1, J. Ddamulira 2, R. Tweheyo 3 district, South-western Uganda 1 Makerere University School of Public Health, Kampala, ,∗ V. Kawooya 1 , B.T. Kirunda 1, W.G. Maina 1, R. Tweheyo 2 Uganda 2 Makerere University School of Public Health, UGANDA, 1 Makerere University School of Public Health, Kampala, Kampala, Uganda Uganda 3 Makerere University School of Public Health, Kampala, 2 Makerere University School of Public Health, Kampala, Kampala, Uganda Kampala, Uganda Background: Between 2006 and 2008 only 64.6% of all HIV Background: In 2001, the Ministry of Health, Uganda, positive referrals from the Home Based HIV Counselling and developed and adopted policy guidelines on feeding of Testing (HBCT) program in Kumi district of Eastern Uganda infants and young children in the context of HIV/AIDS, how- accessed HIV care services at health facilities. This study ever, little is known about the adherence to infant feeding to determined the factors influencing access to HIV care practices. The study aimed at identifying factors affecting services for clients referred in the district adherence to infant feeding practices among HIV positive Methods: We conducted a descriptive, cross-sectional mothers with infants aged below six months in Rakai district, study in February 2009. The study population comprised of South — western Uganda. HIV positive adults aged ≥18 years identified by the district Methods: We conducted a cross-sectional study in Rakai HBCT program and referred to public and private health district, Uganda between February to May 2008. HIV pos- facilities for HIV care services. We administered face-to- itive mothers, who had infants, aged less than 6 months face interviews to 352 respondents using a semi-structured and had attended ANC were enrolled consecutively on every questionnaire. Respondents were selected by systematic clinic day, using a semi-structured interviewer administered random sampling using a sampling interval of 15 out of questionnaire. Purposive sampling of five government and 5044 HIV positive clients identified in the HBCT program. three private health facilities offering PMTCT in the district The main outcome measure was access to HIV care defined was done. The outcome measure was adherence to recom- as access to Cotrimoxazole prophylaxis in the facility HIV mended infant feeding practices categorized as a binary program. Data was entered in Epi-Info version 3.5.1 and ana- variable (yes, no). Logistic regression analysis was per- lyzed using Stata/SE 10.0. Logistic regression analysis was formed in S.P.S.S version 12.0 with the level of significance done and the level of significance used was p < 0.05 at 95% considered at p < 0.05. confidence interval. Results: Mixed feeding was the most practiced. Factors Results: About 80.7% (284/352) of respondents in found to favor adherence to infant feeding practices were; this study accessed HIV care. Access to HIV care ser- having ≤3 children (AOR 2.5, CI: 1.1-6.4) and having an vices was positively influenced by; Age (25-34) compared infant aged ≤3 months (AOR 3.9, CI: 1.7-9.0). to (18—24) year-olds (AOR = 5.07,95%CI:1.50-17.12); being Factors found not to favor adherence to infant feeding male (AOR = 2.26, 95% CI:1.17-4.39); urban residence were; Low education (≤primary seven) (AOR 0.2, CI: 0.1- (AOR = 2.53,CI: 1.09-5.89); and availability of drugs at health 0.8), received group infant feeding counseling (AOR 0.3, CI: facility (AOR = 8.42,CI:3.2122.09). Access to services was 0.1-0.7), had one counselling session (AOR 0.1, CI: 0.1-0.4), negatively influenced by lack of family support to the client and knowing one route of MTCT of HIV (AOR 0.3, CI: 0.1-0.7). (AOR = 0.46,CI: 0.23-0.94). Conclusion: The study found a four-fold higher level of Conclusion: Age (25—34), male sex, urban residence, adherence in the first three months of infancy. Adherence availability of drugs at facilities and lack of family sup- can be improved through the district health team and health port are the main influencing factors of access to HIV care. workers encouraging HIV positive mothers to practice accel- Study findings emphasize the importance of the district to erated weaning (exclusive breast feeding for three months); place considerations within existing and planned interven- to attend at least three infant feeding counseling sessions; e82 14th International Congress on Infectious Diseases (ICID) Abstracts and to improve individual counseling which provides privacy. There is a need to use a robust analytical study design to ascertain the influence of numerous factors on adherence to chosen infant feeding options. doi:10.1016/j.ijid.2010.02.1670

Influenza (Poster Presentation) 28.001 The new North American strain of influenza A virus (H1N1) may not be a novel variant of H1 subtype Y.-H. Lu ∗, L.-W. Ju, C.-Y. Jiang, Y.-J. Zheng, Q.-W. Jiang School of Public Health, Fudan University, Shanghai, China Background: The current influenza A virus (H1N1) epidemic raises a serious concern about the nature of the virus. The transmissibility was substantially higher for this virus compared with seasonal flu viruses and close to those from previous influenza pandemics. It’s reported that the virus had been already evolving for some time. Methods: The present study was based on HA (hemagglutinin) fragment. A total of 558 H1 full-length sequences collected since 1930 were selected from the GenBank, including 76 H1N1 isolates from 2009 outbreak, 439 H1N1 Phylogenetic tree of HA fragment produced with posterior and 48 H1N2 sequences collected previously. If there probability were many sequences isolated simultaneously in the same Conclusion: The present study suggested that H1 virus area, three were randomly included. A Bayesian approach was originally circulating in human and animals simultane- (http://beast.bio.ed.ac.uk/) was used to construct genetic ously and separately. In addition there was marked spatial phylogeny and to explore evolutionary history with incorpo- clustering in the evolution of H1 in animals. It’s likely that ration of a time-scale. there was a long-term cross-species circulation of swine- Results: All the H1 sequences were classified into 5 main origin H1 virus in the US and that the current outbreak was clusters. There was a little diversity within Swine 1 (swine attributable to an accumulated genetic mutation induced by H1 in the US, Canada, Japan, Korea, Thailand, Philippines, zoonosis rather than a novel variation. China Mainland and Taiwan) and Swine 2 (swine H1 in Europe and China Mainland). Swine 2 was more close to clusters doi:10.1016/j.ijid.2010.02.1671 Avian 1 (avian H1 in the US and Canada) and Avian 2 (avian H1 in other areas) phylogenetically. Cluster Human con- 28.002 sisted of human H1 worldwide with a similar identity. Further NS1 protein of avian influenza A virus prevents activation research revealed that the time to most recent common of NF-␬B through binding to IKK␣ and IKK␤ ancestor (tMRCA) of animal H1 sequences was 93.6 years ,∗ ago and that of human H1 sequences was 91.6 years ago. S. Gao 1 , H. Peng 2, W. Jiang 2, L. Song 2 The H1 isolates in 2009 outbreak remarkably clustered 1 Institute of microbiology, Chinese academy of Sciences, within Swine 1 with tMRCA being 9.1 years ago. It was Beijing, China noted that there were other 7 human H1 sequences clus- 2 Beijing, China tered within Swine 1. Among them, six were isolated in the US with the earliest isolation time of 1976. Background: Highly pathogenic strains of avian influenza A virus H5N1 have caused the deaths of more than 262 people since 2003, corresponding to a death rate of about 60% for known infections (information from WHO website). If these viruses acquire the ability for efficient transmission between humans, the next pandemic will come. Therefore, it is important to study the factors that limit the transmission of avian viruses within humans. Methods: The non-structure protein NS1 of H5N1 influenza virus contributes to virulence during virus infection by allowing the virus to disarm the IFN-based defence system of the host cell. To identify new potential antiviral genes regulated by NS1, we measured the expression pattern of cellular gene using DNA microarray technology. The downregulation of several NF-␬B-mediated downstream genes, 14th International Congress on Infectious Diseases (ICID) Abstracts e83

IL-6, IL-8, COX-2, CCL-20, etc, was observed in the pres- activity. Demonstrate the importance of the NS1 protein in ence of NS1. Real-time PCR and ELISA were used to further regulating the host cell response triggered by virus infection. confirm the microarray results. Luciferase activity assay indicated that the NF-␬B binding sites were essential for the doi:10.1016/j.ijid.2010.02.1673 regulation of IL-6 and IL-8 by NS1 protein. Further studies demonstrated that NS1 protein can suppress NF-␬B activity 28.004 in a dose-dependent manner. Western blot assay suggested Novel influenza A H1N1 infection among healthcare work- that NS1 did not alter the expression level of NF-␬B, but pre- ers vented the translocation of NF-␬B from cytosol to nucleus. M. Querci, F. Herrera, E. Temporiti, W. Alcala, L. Figueras, This inhibitory property of the NS1 protein was dependent F. Barberis, G. Carballal, M. Echavarria, M. Stryjewski, P. on its ability to bind IKK␣ and IKK␤, which confirmed by the Bonvehi ∗ GST pull down, co-immunoprecipitation and confocal assay. Results: We for the first time demonstrated that NS1 can Cemic, Buenos Aires, Argentina prevent activation of NF-␬B through binding to IKK& and IKK$. Background: Knowledge of epidemiological, clinical char- Conclusion: NF-␬B, an important transcription factor, acteristics and outcomes in healthcare workers (HCW) plays an essential role in the regulation of immune and exposed to novel Flu A H1N1 could be useful in order to inflammatory responses. Therefore, NS1-mediated inhibi- improve protection measures. tion of the NF-␬B pathway may thus play a key role in Methods: A longitudinal study was carried out at CEMIC regulating the host innate and adaptive immune responses among 1,465 HCW from June-July, 2009. Those with during virus infection. influenza like illness (ILI) were swabbed for detection of novel Flu A H1N1 virus by RT-PCR. Fisher’s exact test or Wilcoxon were employed. Logistic regression (LR) model to doi:10.1016/j.ijid.2010.02.1672 identify variables associated with H1N1 virus were analyzed. 28.003 Results:HCW with ILI H1N1 positive H1N1 negative p H5N1 NS1 change the cell cytoskeleton and interferes n=85 with host cell motility through the GTPase n=43 (%) n=42 (%) 1 1 1 2 2,∗ W. Jiang , Q. Wang , S. Gao , L. Song , W. Huang Female 26 (60) 24 (57) 0.83 1 Institute of Microbiology, Chinese Academy of Sciences, Age, mean (±SD) 33.4 (9) 34.1 (9) 0.72 Beijing, PR, China Nurse or physician 33 (77) 31 (74) 0.81 2 Beijing, China Comorbidities 6 (14) 7 (17) 0.77 Contact with sus- 30 (70) 35 (83) 0.20 Background: NS1 protein of highly pathogenic avian pected/confirmed influenza virus H5N1 contributes significantly to disease case pathogenesis by modulating virus replication. It can inhibit Use of adequate 28 (65) 26 (62) 0.82 innate immunity by preventing type I IFN release and protection inhibit adaptive immunity by attenuating human DC matu- measures ration. The ability of the protein NS1 to induce cytoskeleton Flu vaccination † 32 (76) 32 (78) 1.0 changes and alter the cell motility in infected host cells Fever 37 (86) 34 (81) 0.57 is a key event in these processes. And all these may asso- Asthenia 31 (72) 02 (48) 0.03 ciate with the Rho subfamily of small GTP-binding proteins Cough 34 (79) 18 (43) 0.008 which mediates many fundamental cellular functions. The Diarrhea 4 (9) 12 (29) 0.03 commonly studied members (Rho, Rac, and Cdc42) regulate Complications 5 (12) 4 (9.5) 1.0 actin reorganization, affecting diverse cellular responses, Pneumonia 2 (5) 1 (2) — including adhesion, cytokinesis, and motility. Oseltamivir Methods: In our experiment, we use the three- Prophylactic 2 (5) 13 (31) 0.002 dimensional cell culture system and the scanning electron Therapy 41 (95) 36 (86) 0.16 microscope to detect the cell surface change after trans- Days of oseltamivir, 5 (5-5) 5 (3-5) 0.002 fection of NS1 in A549 cell. median (IQR) Results: We found forced expression the NS1 in A549 Adverse events with 12 (28) 8 (19) 0.44 cell could curve the stress fibers, decrease lamellipodia and oseltamivir inhibit cell migration. And we found a new interaction about Days off, median 7 (5-7) 4 (2-6.5) 0.0004 the NS1 and Rap1$, a member of the Ras family of small G (IQR) † proteins, which has been recognized as an important regula- Hospital admission 1 (2.33) 0 1.0 tor of cell proliferation, differentiation, and adhesion, may Death 0 0 — impact the Rac1 activity and interfere the cell morphology † and motility. In 94/96 HCW. Conclusion: Taken together, our results suggest that the LR with H1N1 as dependent variable showed: cough (OR avain influenza A virus NS1 protein is a multifunctional vir- 6.93; 95%CI 2.24, 21.4); prophylactic oseltamivir (OR 0.08; ulence factor which can also inhibit the cell motility and 95% CI 0.01, 0.43); and diarrhea (OR 0.17; 95% IC 0.04, 0.74). change the cell morphology through interfere the GTPase’ e84 14th International Congress on Infectious Diseases (ICID) Abstracts

Conclusion: Incidence and complications of ILI was low of 63%. Complicated cases of probable and/or confirmed among HCW. Seasonal flu vaccination seems to give low pro- influenza A/H1N1 were admitted to the intensive care unit tection against pandemic strain. Prophylactic oseltamivir of which 5 patients (6%) died. was associated with decreased risk of H1N1 infection. doi:10.1016/j.ijid.2010.02.1674 28.005 Demographic and epidemiological characteristics of influenza in HIMA, San Pablo Caguas Hospital, Puerto Rico M. Collado ∗, L. Collado, C. Cortes

HIMA San Pablo Caguas Hospital, 00725, PR, USA Reported cases of Influenza-like illness tested with RT- Background: On 24 April 2009, the World Health Organi- PCR (n = 119) zation (WHO) informed of an epidemic caused by a novel Conclusion: This was an observational study demon- influenza A/H1N1 originating from Mexico. On 25 May 2009, strating demographic and epidemiological information of • Puerto Rico confirms its first case. About a month later, 11 influenza in HIMA San Pablo Caguas Hospital. July 2009, WHO declares a worldwide pandemic (phase 6), but not before Puerto Rico reports its first death on 15 June doi:10.1016/j.ijid.2010.02.1675 2009. Nevertheless, after results of submitted specimens 28.006 were reported from CDC, HIMA•San Pablo Caguas Hospital received its first positive confirmation for influenza H1N1 Influenza disease burden study on 2 sentinel sites of Mon- from a specimen collected on May 23, 2009. The purpose of golia, 2008/09 season this presentation is to assess the emergence and character- N. Nukiwa 1,∗, A. Burmaa 2, T. Naranzul 2, T. Kamigaki 1,B. • istics of influenza A/H1N1; specifically focused in HIMA San Darmaa 2, B. Gantsooj 2, H. Oshitani 1, P. Nymadawa 2 Pablo Caguas Hospital. The correlation between severity of illness and clinical outcome will be analyzed in cases 1 Tohoku University Graduate School of Medicine, Sendai, admitted to ICU. We will also determine the distribution Japan among demographical characteristics, such as age, gender, 2 National Influenza Center, National Center of Communica- and locality. ble Diseases, Ulaanbaatar, Mongolia Background: Influenza may pose a large public health issue besides of ongoing pandemic (H1N1) 2009 in Mongo- lia. However detailed burden of seasonal influenza remains unknown. Here we conducted an active surveillance during 2008/09 influenza season in Mongolia. Methods: Active data and sample collection was performed in both Baganuur District, Ulaanbaatar City and Selenge Province during October 2008 to April 2009. Cases of influenza-like illness (ILI) who visited Family Group Practi- Epidemic curve of collected specimens (n = 379) of tioners as well as territorial hospital outpatient departments influenza A/H1N1 by date of symptom onset, 26 April 2009 were enrolled in this study. In addition, contact person to to 14 September 2009. cases of ILI and hospitalized cases of severe acute res- Methods: Clinical specimens, oral pharyngeal and/or piratory infection (sARI) were also enrolled. Laboratory blood, were collected and tested using rRT-PCR, rapid screening for influenza viruses using rt-RT-PCR has been per- antigen testing, or influenza titers from April 26 2009 to formed in NIC/NCCD and statistical analysis was performed September 14, 2009. in NIC/NCCD and Tohoku University, Japan. Results: Influenza A, B, and both A and B viruses were Results: 1,102 and 686 cases of ILI were registered from identified in 47, 6 and 3 of the Oseltamivir-treated popu- Baganuur and Selenge with 82 (7.4%) and 55 (8.0%) labora- lation (n = 375), correspondingly. Less often associated with tory confirmed influenza cases respectively. Almost half of laboratory-confirmed cases of influenza A/H1N1, were the the cases of ILI were in the age group of 0-4 while only 2% incidence of mortality in obstetrical cases. Of the 379 con- were in 60 year old age group. Total of 133cases were reg- firmed and probable cases of influenza A/H1N1, 2.6% and istered as contact cases, but none of them had positive for 8.7% were reported as deceased and pregnant, respectively. influenza by rt-RT-PCR. Majority of them were either parents Among the 379 clinically suspected cases for influenza H1N1, or siblings. There were 286 sARI cases from both sentinel only 3 were confirmed by RT-PCR sent to the Centers for sites, but no death was reported. Duration time of onset Disease Control and Prevention in Atlanta. The median age to hospitalization was approximately 5.2 days and average for the 79 confirmed cases for influenza A and/or B was 18 length of hospitalization was 9.1 days. Temporal distribution years (range, 6 month to 65 years) with a female prevalence was analyzed together with laboratory confirmation done. 14th International Congress on Infectious Diseases (ICID) Abstracts e85

The weekly ILI morbidity and influenza positive samples in selected sites Conclusion: This active surveillance showed a certain existence of ILI morbidity and hospitalization especially Acute Respiratoty Distress Sindrome was present in 60 p. among 0-4 age children, but there was no death observed Invasive Mechanical Ventilation was instituted in 54 p. Alve- during this period. In addition there were some cases of ILI olar recruitment maneuvers were necessary in 36 p; in 20 seen while no influenza was detected. A multiple year study of which oxemia improved. When recruitment failed prone is necessary to figure out the disease burden of influenza and position was instituted: 7/12p also improved St pneumo- at the same time further study including etiological study niae was identified in 22 p (18 in tracheal aspirates and 4 in is also necessary. At the moment, this community based blood cultures). In 84 p Oseltamivir was indicated; average information is useful to respond current pandemic (H1N1) dose 150 mg per day for 7 days. Pts who did not respond to 2009. treatment or in obese the dose was increased to 450 mg. Cor- ticosteroid were indicated most due to bronchospasm(61p) doi:10.1016/j.ijid.2010.02.1676 The most important complications were trombosis (7p) and Septic shock (35p).The most common cause of death (24/28) 28.007 was respiratory failure Clinical profile and outcome in 100 patients admitted with Conclusion: The vast majority of our patients were pandemic influenza in four intensive care units in Uruguay younger than 60. High frequency of bronchospasm, myal- during the winter of 2009 gia and obtundness. Obesity and pregnancy, are special risk factors. Lymphopenia, elevated LDH and CPK represent lab- H. Bagnulo 1,∗, A. Soca 2, M. Buroni 3, G. Limongi 4,E. oratory findings. Both lungs are usually compromised. Echavarria 5, S. Noveri 6, M. Godino 7 These patients have high mortality linked to respiratory 1 Hospital Maciel, Montevideo, Uruguay refractory failure. 2 Hospital Pasteur, Montevideo, Uruguay 3 Hospital Espanol,˜ Montevideo, Uruguay doi:10.1016/j.ijid.2010.02.1677 4 Asociacion Espanola,˜ Montevideo, Uruguay 5 Hospital Maciel, Montevideo, Uruguay 28.008 6 Hospital Pasteur, Montevideo, Uruguay Intravenous peramivir for treatment of influenza A and B 7 Hospital Maciel, Montevideo, Uruguay infection in high-risk patients Background: Pandemic Influenza Virus (AH1N1) has been S. Kohno 1,∗, H. Kida 2, M. Mizuguchi 3, N. Hirotsu 4,T. identified as the cause of respiratory infection worldwide, Ishida 5, J. Kadota 6, J. Shimada 7 has been linked to severe respiratory failure requiring fre- 1 Nagasaki University, Nagasaki, Japan quently ICU admissions 2 Hokkaido University, Sapporo, Japan Methods: We describe the clinical and epidemiologic 3 Tokyo University, Tokyo, Japan characteristics of 100 patients(p) hospitalized at these 4 Hirotsu Clinic, Kawasaki, Japan intensive care units with laboratory confirmed (RT-PCR) or 5 Kurashiki Central Hospital, Kurashiki, Japan acute febrile respiratory illness epidemiologically linked. 6 Oita University, Yufu, Japan Results: 60p were confirmed and 40 were epidemiogically 7 St. Marianna University School of Medicine, Kawasaki, suspected cases. Mean Age: 45 yrs (± 16,8); 84%< 60yrs Japan Clinical profile: cough (96%), dyspnea (93%), fever(90%), bronchospasm (51%), headache (41%), myalgias(42%), Background: The ongoing pandemic of 2009/H1N1 obtundness (35%) influenza has increased the awareness of the impact and Risk Factors: 31p had a body mass index >30; in 13% obe- unpredictable nature of influenza. This in turn has raised sity was the only risk factor. COPD (33%), cardiovascular the interest in the development of additional drugs to treat disease(19%), diabetes(16%), asthma(14%), pregnancy(10%). the disease when vaccinations fall short. The patient pop- White count cell in 70p was less than 10.000. 76p had less ulation of most concern are those classified as ‘‘high-risk’’ than 1000 lynphocites, CPK wes elevated in 60p All tested where influenza causes substantial morbidity and mortality. patients had elevated LDH; in 37/80 p>1000 IU, Most p (82) This high-risk group comprises individuals with underly- showed bilateral interstitial alveolar images. ing chronic disease. In this study, efficacy and safety of intravenous administration of peramivir were evaluated in e86 14th International Congress on Infectious Diseases (ICID) Abstracts influenza patients with one or more high-risk co morbidities. N1 isolates:253 bp amplified product of N1 isolates which Methods: The study was a double-blind, multi-center included the established mutation site H274Y leading to study of intravenous peramivir with dosing over multi- oseltamivir resistance was analyzed by sequencing. All N1 ple days. The study enrolled 42 influenza patients with isolates were sensitive to oseltamivir. N2 isolates: To check complications due to one or more qualifying conditions: the mutation sites for N2 (E119V, I222V, R292K, N294S and diagnosis with poorly controlled diabetes mellitus, a chronic - 244- 247); further 1103 bp products were amplified. All 44 respiratory disease requiring pharmacotherapy, or current N2 isolates were sensitive to both the drugs oseltamivir and treatment with any immunosuppressive drug. Peramivir was zanamivir. administered at 300 mg or 600 mg per day, and the dura- Conclusion: All seasonal influenza A viruses A/H1N1 and tion was adjusted (up to five days) on a case-by-case basis, A/H3N2 were sensitive to neuraminidase inhibitors. Antivi- depending on the patient’s temperature and clinical condi- ral drugs against influenza are rarely used in India as a tion as determined by the treating physician. therapeutic agent. However due to globalization, resistant Results: In this study, the median time to alleviation viruses could be seeded in Pune from elsewhere.Though no of symptoms in all 37 evaluable patients treated with resistant viruses were detected, continuous surveillance of either 300 mg or 600 mg peramivir daily was 68.6 hrs (90% influenza viruses is needed to monitor circulating strains, CI, 41.5 hrs - 113.4 hrs). The median time for each group and their drug susceptibility in view of pandemic potential (300 mg and 600 mg) was 114.4 hrs and 42.3 hrs respectively, of influenza virus. while the time for each group categorized as single-dosed (n = 10) and multipledosed (n = 27) was 92.0 hrs and 64.1 hrs, doi:10.1016/j.ijid.2010.02.1679 respectively. The incidence of pneumonia, which was the main complication resulting from influenza was 8.1% (3/37). 28.010 There were no drugrelated SAEs throughout the study. Influenza in the tropics - Epidemiology and burden Conclusion: The results suggest that intravenous L. Da Silva ∗, M.H. Kyaw peramivir was effective for treatment of influenza patients with a high-risk for complications co morbidities and Novartis Vaccines and Diagnostics, Cambridge, MA, USA increased risk for complications due to influenza infection. Background: Although influenza presents a significant burden in the tropics, the belief that this disease primarily doi:10.1016/j.ijid.2010.02.1678 affects people in temperate climates and developed coun- 28.009 tries persists because of peculiar circumstances of disease Neuraminidase sub typing and drug resistance among epidemiology, other local causes of morbidity and mortality, influenza A viruses circulating in western India and better surveillance systems in countries in temperate regions. The public health burden of influenza is high in the ∗ V. Potdar , M. Dakhave, M. Chadha, A. Mishra tropics, particularly in children, yet it has been suggested that vaccination programs would not be cost-effective in this National Institute of Virology, 421001, India region because little is known about the true impact of the Background: Influenza viruses are important respira- disease. tory pathogens in India. Clinical, virological and molecular Methods: Systematic literature review of Medline using surveillance is being carried out under a Multi- site Influenza search terms of influenza, tropical, and epidemiology. Surveillance project (Indian Council of Medical Research- Results: In Medline, 155 manuscripts were published Centers for Diseases Control). National Institute of Virology, between 1969 and 2009. Influenza in tropical regions has Pune, India monitors genetic variations and drug suscepti- gained more attention in the medical literature in the bility in circulating influenza viruses. Most of the influenza twenty-first century; 118 of 155 papers (76%) appeared after A viruses are amantadine resistance worldwide and hence 1999. Twenty-three studies presented data on laboratory- neuraminidase inhibitors (NAI) oseltamivir or zanamivir are confirmed cases of influenza in tropical regions. Outbreaks recommended for the treatment of infection with influenza and epidemics present a significant public health bur- viruses. den in tropical regions. For example, in Madagascar in Methods: Neuraminidase sub typing of 42 H1 and 48 H3 2002, more than 27,000 cases of influenza and 800 deaths viruses from the year 2003 to April 2009 were carried out occurred within a period of three months despite rapid pub- by one step diagnostic RT PCR using published primers. lic health intervention. In tropical regions, viral transmission Universal M13 primers forward and reverse were used for is usually year-round and commonly has two peaks annu- Sequencing and subtypes of isolates were confirmed by blast ally. Co-circulation of what are considered ‘‘northern’’ or analysis. 253 bp product of N1 isolates contains established ‘‘southern’’ strains occurs year-round in tropical regions. mutation site H274Y leading to oseltamivir resistance .To Tropical regions, thus, may be the source of new strains check the mutation sites E119V, I222V, R292K, N294S and - that are then disseminated to other latitudes. However, the 244-247 for N2 isolates; further 1103 bp N2 gene was ampli- clinical characteristics, impact on healthcare services, and fied using specific primers. seasonal variation of influenza in tropical regions are still not Results: NA Subtyping: 90 influenza A isolates from 2003- clearly understood, based on the current literature. A third April 2009 circulating in Pune were amplified. 90 influenza category of strain recommendation for influenza vaccines A isolates were confirmed as 42 N1 and 48 N2 respectively may be needed for tropical regions. by sequencing. No unusual combinations were observed Conclusion: The burden of influenza in tropical countries Detection of drug resistant sites for N1 and N2 isolates: may be higher than in North America or Europe. More stud- 14th International Congress on Infectious Diseases (ICID) Abstracts e87 ies in the tropics are necessary to define the impact and Admissions by NIA were twice higher than seasonal flu seasonality of influenza in these regions. These data could annually help identify the optimal timing of vaccination programs and Os was well tolerated by children other measures for the prevention and control of seasonal Os statistically reduced duration of F and Co and pandemic influenza in the tropics, including protection Os was effective to prevent secondary cases in CC for travelers and control of emerging strains. Mortality was low in hospitalized children, associated to Comorbidity doi:10.1016/j.ijid.2010.02.1680 doi:10.1016/j.ijid.2010.02.1681 28.011 Novel influenza A H1N1 (NIA) infection in Argentinean 28.012 Children — Experience at Hospital de Ninos˜ ‘‘Ricardo Assessing the risk of Influenza virus strains isolated from Gutiérrez’’ birds and mammals to humans E.L. Lopez ∗, A. Fallo, M.M. Contrini, A. Mistchenko, C. G. Vdovichenko 1,∗, A. Sergeev 1, O.K. Demina 1,A. Molise, S. Neyro, N. Gonzalez, D. Lazzarini, G. Manonelles, Kabanov 1, A.S. Kudriavcev 2, A.V. Pal’cev 2, U.E. Narov 2, J. Grichener, M. Dastugue, A. Teper, N. Study Group L.N. Shishkina 1, I.G. Drozdov 1 Hospital de Ninos˜ ‘‘Ricardo Gutiérrez’’, Buenos Aires, 1 FRSI State research center of virology and biotechnology Argentina ‘‘Vector’’, Novosibirsk, Russian Federation 2 Novosibirsk Regional Oncological Clinic, Novosibirsk, Rus- Background: NIA pandemia (P) began in Argentina dur- sian Federation ing respiratory virus season. Hospital Gutiérrez (HG) set up special outfitted examination room trailler; 5000 sus- Background: Influenza A virus is the subject of research pected cases were attended in 2 mo. Health care for P of many scientists in the world. So now the attention of sci- included 2 different stages: May24-June12, 695 outpatients entists focused on the problem of influenza, first because mainly school-age were attended [Containment Phase(CP)]. of the increased outbreaks of avian influenza in the world After 17 ds with a widespread disease: June12-July11, 110 and the incidence of transmission of the disease to people children were admitted to HG due to respiratory failure [Mit- who were in contact with sick birds. Secondly the threat igation Phase(MP)] today is the influenza virus of H1N1 subtype, which caused Objective: to characterize clinical, lab and treatment of many diseases among people around the world. In this con- confirmed NIA patients (pts) nection assessment of risk to human influenza virus strains Methods: IFA was used to rule out other RV; confirmation of various origins is essential for timely implementation of by RT-PCR effective anti-epidemic measures in order to prevent the Results: CP: 220/695(61.3%) cases were confirmed; development of an epidemic or pandemic influenza. We have 191students, 15 close contacts (CC), 8 international trav- evaluated parameters of infectivity of influenza virus strains elers, 3 teachers; 2 health-workers. The 191 confirmed (H5N1, H1N1 and H3N2 subtypes) for primary cell culture student cases are reported: mean age: 9 ± 3(4-17) yr; 16(8%) obtained from human lung tissues. had comorbidity(C). Most frequent symptoms: fever(F) Methods: Three influenza A/Chicken/Suzdalka/2/05 178(93%) and cough(Co)160(64%). Oseltamivir(Os) was pre- (H5N1), A/Novosibirsk/1/09 (H1N1) and A/Aichi/2/68 scribed to 150(78.5%); none of them was hospitalized. (H3N2) virus strains from the collection of research insti- Duration of F and Co was lower in treated than untreated 2,1 tute of FRSI SRC VB ‘‘Vector’’ and primary cell cultures vs 3.6 ds, and 4.2 vs 7 ds respectively(p < 0.001). Secondary obtained from pieces of human lung tissue kindly provided by cases occurred in 41/297(15%) of CC, 12/31 in CC without colleagues from the Regional Oncology Center of the Novosi- Os prophylaxis (OsP) and 29/266 in CC with OsP(p = 0.0002). birsk, Russia have been used. Mild adverse events(AE) by Os were reported in 12% of Results: A comparison of the values 50% cell infect- treated pts and in 6.3% of CC ing dose (CID50) of strains found that the susceptibility MP: 110 NIA cases represented 6.9% of admis- of human lung cells to influenza A/Chicken/Suzdalka/2/05 sions during this period (double of usual seasonal flu virus strain in the 10 and 100 times more than values both cases/yr). Mean age 43.4(±54.4) mo; 61(55.5%) were A/Novosibirsk/1/09 and A/Aichi/2/68 virus strains respec- younger than 24 mo. Main symptoms on admission: F tively. However influenza A/Chicken/Suzdalka/2/05 strain 106(97.4%) and bronchiolitis 70(63.6%). C was present in had a 10 times lower progeny yield during 20 hours of repli- 84/110(76.4%), it was more frequent in children > 24 mo: cation in human lung cells compared with other strains. 38/61(62.3%) than younger 46/49(93.9%)(p < 0.0003). Fif- Conclusion: Thus, our studies revealed influenza teen(13,6%) required ICU. Complications: 69/110(62.7%) A/Chicken/Suzdalka/2/05 virus strain is able to pts; pneumonia 52/110(47.3%); pneumonitis 31/110(28.2%) more easily infect cells of the respiratory tract of [16/52(30.8%) had both X-Ray patterns]; encephalitis 1/110 man, but has a lower replicate activity than both (0.9%). Os treatment: 108(98.2%); AE 1/108(0.9%): unspe- A/Novosibirsk/1/09 and A/Aichi/2/68 virus strains. cific exanthema. Mortality 6/110(5.5%); all of them had C; Influenza A/Chicken/Suzdalka/2/05 virus strain was iso- median age:87mo lated during an outbreak of avian flu among wild birds and Conclusion: NIA was mild in school-age pts poultry in the Novosibirsk region. During this period of the outbreak have not been established cases of avian influenza transmission from birds to local residents. Perhaps this is due e88 14th International Congress on Infectious Diseases (ICID) Abstracts to the low replicate activity of A/Chicken/Suzdalka/2/05 28.014 virus strain, which we evaluated in our studies. Development of new effective antiinfluenza drugs based on extracts of basidiomycetes doi:10.1016/j.ijid.2010.02.1682 A. Kabanov ∗, A.O. Sementsova, M.O. Skarnovich, T.V. 28.013 Teplyakova, L.N. Shishkina, A.N. Sergeev In vitro inactivation of avian influenza virus by Capryilic FSRI State research center of virology and biotechnology acids and its derivatives ‘‘Vector’’, Novosibirsk, Russian Federation N.I. Hariastuti ∗, S. Babapoor, Y. Huang, M.I. Khan Background: Due to the high incidence of respiratory University of Connecticut, Storrs, CT, USA diseases in humans caused by influenza viruses of different subtypes are now particularly relevant search for Background: Avian influenza is an important disease as new curative and preventive drugs against influenza. Many it causes significant economic losses to the poultry indus- species and strains of basidiomycetes are producers of try. Further, transmission of the virus to humans enhanced natural compounds exhibiting anti-tumor and antiblastic the major public health significance. Since the virus is activity, cytostatic effect and antiviral effect. Specific highly contagious, strict hygienic measures employed at the components of different bio-genetic origin, with antibac- poultry farms can greatly help prevent the virus from spread- terial, antifungal, nematodocidal, cytotoxic, antiviral, and ing. Contaminated food, water, and poultry manure are other pharmacological properties of the basidiomycetes most important vehicles of the virus to infect animals and were identified in different investigations. Study of antivi- humans. Effective and safe antimicrobials that kill the virus ral activity of extracts isolated from basidiomycetes against in the aforementioned vehicles could greatly reduce spread influenza virus, including highly pathogenic avian influenza of the virus. Caprylic acid is a natural fatty acid and its other and creation on their basis of new non-toxic antiviral drugs is chemical forms, namely sodium caprylate and monocaprylin essential for health. In the present investigation was carried are highly effective in killing a variety of disease causing out screening and studying of antiviral activity of basid- bacteria and viruses. iomycete extracts in experiments on MDCK cells for avian Methods: Low pathogenic avian influenza viruses H5N1 influenza A/H5N1 virus. and H5N2 were subjected to caprylic acid, sodium caprylate Methods: In present study more than 70 water extracts and monocaprylin. Concentrations of viruses were deter- of fungi of the genera Rleurotus, Ganoderma, Laeti- mined using TCID50 in the cell culture. Plaque assays were porus, Inonotus, Lentipus obtained from the laboratory optimized and 100 PFU viruses were used to infect chicken collection of fungal cultures and the simplest of SRC VB embryo kidney cells. Serial dilutions of fatty acid compounds ‘‘Vector’’ were used. The antiviral effect of extracts of were made from 0.005% to 0.5% for each virus to observe fungi was assessed by highly pathogenic avian influenza their virucidal effects in plaque assays. The effect of the A/chicken/Kurgan/05/2005 (H5N1) virus strain and MDCK caprylic acid to virus particles was observed using the trans- cells. mission electron microscope. Results: The results showed that many of the studied Results: Caprylic acid and its derivatives were able extracts of basidiomycetes have not toxicity to MDCK cells to inhibit the plaque forming in chicken embryo kidney and thus exhibit a high antiviral efficacy. This fact was noted cells. The minimum inhibitory concentrations were 0.5% for in the evaluation of A/chicken/Kurgan/05/2005 infectivity caprylic acid, 0.1% for sodium caprylate and 0.05% for mono- in model of MDCK cells, when cultured with influenza virus caprylin. Using transmission electron microscope, negative strain in the presence and absence of tested drugs. Some staining of avian influenza virus particles treated with 0.5% aqueous extracts of fungi Ganoderma, Laetiporus, Inono- caprylic acid indicated disruption of cell membrane and tus and Lentipus has been shown in vitro to have high up envelope of the viral particle. to 1000- 10000 times neutralization activity for influenza Conclusion: Low concentration of caprylic acid and its A/chicken/Kurgan/05/2005 virus strain. derivatives in-vitro can reduce or inhibit avian influenza Conclusion: One possible reason for the effectiveness of virus. Therefore, caprylic acid and its derivates are poten- the audited extracts isolated from the basidiomycetes is tial to be effective and safe antimicrobials that can be used the presence of polysaccharides. The spectrum of polysac- in poultry feed in order to reduce transmission to humans. charides, flavonoids, melanins, mycelium and fruit of body and other biologically active substances of basidiomycetes is doi:10.1016/j.ijid.2010.02.1683 very wide. The results of the studies of fungi extracts suggest about the great prospects associated with the study of substances from basidiomycetes to create new highly effective antiviral therapeutic preparations on their basis.

doi:10.1016/j.ijid.2010.02.1684 14th International Congress on Infectious Diseases (ICID) Abstracts e89

28.015 Parkinson’s disease. Some encephalitis cases with petechial Multifocal cerebral hemorrhages in H1N1 SOIV influenza lesions in the brain have also been reported. The highly patients: Report of 2 cases pathogenic H5N1 influenza virus has shown neurological damage in both birds and humans. Current medical lit- E. Carvalho Siqueira, L.M. Carvalho valle, A.D.F.Borges, P.S. erature, including some up-to-date publications of H1N1 ∗ Gonçalves da Costa pandemic haven’t shown the occurrence of multifocal hemorrhagic neurological syndromes. The cases here presented Hospital Monte Sinai & Suprema Medical School, Juiz de should aware practitioners for such possibility especially Fora MG, MG, Brazil because many seriously ill influenza patients in ICU have Background: Neurological complications of influenza been kept under sedation so hiding several neurological have been scarcely reported possible under-recognized. The symptoms. full description of clinical forms of the current pandemic influenza is currently underway. Several different neuro- doi:10.1016/j.ijid.2010.02.1685 logical syndromes have been associated with influenza but no cases of multi-focal cerebral hemorrhages have been 28.016 reported so far. The aim of this report is to present 2 cases Development of a consensus microarray method for iden- of multiple focal cerebral hemorrhages in patients with tification of different influenza A viruses influenza H1N1 pandemic. D. Barlic - Maganja 1,∗, A. Fratnik Steyer 2, N. Toplak 3,A. Methods: Clinical, laboratorial and imaging data of 2 Zrimec 4, O. Zorman Rojs 2 cases of influenza and serious neurological symptoms are presented. Cranial CT scan was performed in both cases. 1 University of Primorska, Izola, Slovenia Influenza virus identification in upper respiratory secretion 2 University of Ljubljana, Ljubljana, Slovenia (UPS) was performed by real-timereversetranscriptase- 3 OMEGA Ltd., Ljubljana, Slovenia polymerase-chain-reaction assay. Cerebrospinal fluid (CSF) 4 Institute of Physical Biology Ltd., Ljubljana, Slovenia was analized. No necropsy or brain biopsy were performed Results: Case n◦ 1: 32 years old pregnant woman with Background: Rapid and reliable identification methods flu like symptoms, evolved to severe pneumonia and ARDS are fundamental for the comprehensive characterization requiring mechanical ventilation. She developed comma and of emerging and evolving influenza viruses. A consensus cranial CT scan has shown multiple hemorrhagic foci scat- microarray approach for detection and a panel of specific tered throughout the brain and subaracnoid hemorrhage probes covering 16 hemagglutinin (HA) subtypes of influenza (SAH) (Figure 1). CSF was hemorrhagic. No hemorrhagic type A viruses has been designed. disorder was found and eclampsia was ruled-out. Despite Methods: Nucleotide sequences of all available influenza oseltamivir therapy she eventually died. H1N1 SOIV was iso- A virus subtype combinations, isolated from various species lated from UPS. on different geographic regions were selected from GenBank Case n◦ 2: 51 years old male with flu like symptoms and from influenza virus specific databases (FLU Database, evolved to ARDS and respiratory insufficiency demanding Influenza Research Database). Among them 192 sequences of ICU and mechanical ventilation. He developed status epilep- matrix (M) protein gene and 206 sequences of hemagglutinin ticus. Cranial CT scan showed multifocal hemorrhages. (HA) gene were aligned and arranged, respectively, using Lumbar CSF was hemorrhagic. H1N1 SOIV was isolated from ClustalX and BioEdit programmes. UPS. Despite therapy with oseltamivir he eventually died. Results: For the influenza A virus detection oligonucleotide probes were selected on the virus M gene. 16 different segments of this gene were used for the construction of 37 probes. The probes for simultaneous identification of different subtypes were selected on 6 different parts of the virus HA gene. For each HA subtype at least 10 probes were designed on the 1770 nts long segment 4. Conclusion: Oligonucleotide microarray method was designed for simultaneous detection and subtyping of influenza A viruses. The evaluation of developed approach including all 16 HA subtypes is in progress.

doi:10.1016/j.ijid.2010.02.1686

Figure 1: Cranial CT scan showing multifocal hemorrhage in frontal, parietal, temporal and occipital lobes, as well as SAH and intraventricular hemorrhage Conclusion: Inﬂuenza has imposed an under-recognized burden of central nervous system disease so far. Well known neurological syndromes associated with inﬂuenza virus in humans have been febrile convulsions, acute encephalitis, acute encephalopathy, Reye’s syndrome, Guillain-Barré syndrome, Kleine-Levin syndrome and post encephalitic e90 14th International Congress on Infectious Diseases (ICID) Abstracts

28.017 Local syndrome was presented as Clinic-epidemiologic identification of the first wave of 1) Rhinitis (nose congestion 14, exudative rhinorrhea 15, AH1N1 in adults in Albania sneezing 17) N. Como 1,∗, D. Kraja 2, P. Pipero 3, S. Bino 4, E. Meta 3,N. 2) Pharingitis 18 cases (dryness and sore throat 18, pain of Gjermeni 3, E. Muco 3, A. Kica 3, E. Erindi 4, V. Ostreni 3,R. pharynx 13) Petrela 1, S. Cibuku 3 3) Laryngitis 3 cases with hoarseness and 1 with dyspnea; 4) Catarrhal angina 19 cases; 1 University Hospital Centre ‘‘Mother Theresa’’, Tirana, AL, 5) Tracheitis 17 cases (cough 17, sputum 7, chest pain 10) Albania 6) Bronchitis 13 cases(unproductive cough 13,productive 2 Faculty of Medicine, Tirane, Albania cough 9;chest pain 7,dyspnea 2,bronchial rale 13) 3 HUC, Tirane, Albania 7) Tracheo-bronchitis 9 cases 4 Institute of Public Health, Tirane, Albania 8) Bronchiolitis 5 cases Background: Our goal is the recognition of demonstration clinical-epidemiologic of AH1N1 first wave.This material 14 cases were healthy subjects;7 cases had chronic includes 32 cases of ages 15 — 66 years old,during June- diseases (diabetes mellitus 4,cirrhosis 1, cholagenosis 1,lym- September 2009.The influenza identification is based on phoma 1);1 was 4 months pregnant. criteria of WHO. Complications: Methods: The cases were classified based on chronology Diagnosis Number of cases demonstration, origin, group-age and gender.There were analyzed symptoms with what influenza was represented;it Otitis 1 was conceived its clinical syndrome based on the sub- Myositis 1 ject.There were evidenced and complications. Encephalopathy 2 Results: Epidemiological aspects: Pneumonia 8 Chronological:June 9,July 5,August 17,September 1 case. ARDS 4 cases(2 with multiorganory failure) Imported cases 27(England 12,Greece 7,Italy 6,Macedo- Conclusion: 1. AH1N1 first wave extended June- Septem- nia 1,Malt 1);autochton 5. ber; the maximum reached on August with 53.12% of cases. Based on group-age 2. Cases were imported from 5 countries; majority 37.5% Age in years Number of cases from England. 3. Affected age fluctuated from 15-66 years old; predom- 15-24 10 inated group-age 25-44 years old, 40.62%. 25-44 13 4. The temperature fluctuated from 37.6- 39.4 0C; 6.25% 45-59 6 were subfebrile. 60-66 3 5. There were highlighted 7 clinical syndromes and 6 Where 20 were male and 12 female. cases of complications. Clinical aspects: General syndrome appeared with subfebrile temperature doi:10.1016/j.ijid.2010.02.1687 Temperature Number of Cases 28.018 37.60C - 37.90C 2 Analysis of first cluster outbreak of the pandemic 38.20C- 39.40C 30 influenza (H1N1) in Georgia with hyperpyrexia 0 K. Zakhashvili, P. Imnadze, O. Tarkhan-Mouravi ∗ The fever extended: National Center for Disease Control and Public Health, Tbil- Number of days Number of cases isi, Georgia 118 Background: On 30 July, 2009 a member of a Georgian 29 dance group was confirmed to have influenza A(H1N1). For 33 that time 7 sporadic imported cases of influenza A(H1N1) 41 have been confirmed in Georgia. Group had just returned 51 from touring Western Europe. We investigated transmission Symptomps Number of cases of influenza within the group and their close contacts upon return to Georgia. sweating 32 Methods: WHO case definitions of pandemic influenza general myalgia 13 A(H1N1) virus based on real-time RTPCR confirmation were lower extremitetes myalgia 9 used. We collected information regarding age, symptoms, headache 29 and health practices using a standardized questionnaire. diarrhea 6 Received data have been analyzed in EpiInfo vomiting 7 Results: As of 17 August 2009, we detected 5 confirmed loss of appetite 25 and 9 probable case-patients with influenza A(H1N1) virus weakness 27 (13 of 35 group members, Attack Rate=37%; 1 of 37 in- country contacts, AR=3%). First probable case developed 14th International Congress on Infectious Diseases (ICID) Abstracts e91 symptoms on 20 July, 2009 during the tour. All the subse- of an outbreak of influenza like symptoms (ILS) in a military quent a case have developed symptoms within the possible training center. The Spanish Army Academy in Madrid (Spain) period of a transmission of infection from previous cases. received cadets during the whole year and approximation Age distribution of cases was 10 to 18 years old; none of 30 of 200 recruits monthly for military service distributed in adults (4 group members and 26 in-country contacts) was instruction cycles. The objective of this study is to describe affected. Common symptoms of case-patients were: fever the first outbreak of 2009 influenza A (H1N1) in Spain in a mil- over 380C (70%), cough (35%), sore throat (35%), runny nose itary training center and to analyze the adopted measures (35%) and, headache (29%). 93% of all cases revealed limited to control the virus transmission. hand-washing during the tour and all of them had been in Methods: Epidemiological and clinical data were col- close contact with each other for 5 days while traveling by lected with an epidemiological interview to the patients ferry and bus. No group members or contacts were ever vac- with ILS. During the interview samples of sera and cinated against seasonal influenza. No one received antiviral nasopharyngeal swabs were obtained and later processed treatment. No complications or deaths have occurred.

Epidemiological curve of date of symptoms onset in cluster outbreak of pandemic influenza (H1N1), July-August 2009, Georgia in the Microbiology National Center by real-time reverse Conclusion: First cluster outbreak in Georgia coincided transcriptase-polymerase chain reaction (RT-PCR). with summer pick of pandemic influenza A(H1N1) virus in Results: Among the 1464 staff and students, 106 the Western Europe. Investigations showed that more sus- suspected cases with ILS were studied. Influenza virus ceptible were under 18 years’ old group members and no A/California/7/2009 was isolated in 31 of the 52 analyzed transmission was identified in adults. Poor hygiene and close samples. Clinical and epidemiological characteristics com- contact were the most likely risk factors of transmission patible with 2009 influenza A (H1N1) were present in 76% among the group. Discontinuation of these conditions after (81) of the subjects. Mean age of cases was 22.7 years arrival and moderate severity of the disease may explain (range 18-31 years). Cough (81.5%), fever (72.8%) and rhi- limited in-country transmission, as evidenced by the dif- norrea (76.5%) were the most frequent reported symptoms. ferences between the attack rates among group members Total attack rate (AR) was 12.5%. The students of the third and in-country contacts. These findings suggest that social cycle suffered 52% of the cases (AR of 21%). All symptomatic distancing and appropriate hand hygiene could have an patients were isolated in a separated building (7 days) and important role in reducing transmission of A(H1N1) virus. oseltamivir prescribed. The persons in contact with people of the cycle affected remained under quarantine without doi:10.1016/j.ijid.2010.02.1688 receiving antiviral chemoprophylaxis. The illness was mild in all cases and the symptomatic evolution minor .The out- 28.019 break was declared over the 1st June 2009. Neither history 2009 Influenza A (H1N1) first outbreak in a Spanish mili- of trip out of Spain nor contact with cases out of the military tary training center center was found in our cases. Conclusion: The Spanish Epidemiological Surveillance 1 1,∗ 2 E. Ballester , E. Mayo-Montero , P. Santa Olalla , M.J. was realized of the probable virus circulation without of his- 2 3 Sierra-Moros , A. Fe Marques tory of trips or closed contacts with influenza A confirmed 1 Defense Institute for Preventive Medicine ‘‘Capitán ills. Early detection of cases beneficts the early interven- Médico Ramón y Cajal’’, Madrid, Spain tion and adoption of preventive measures in order to contain 2 Coordination Centre of Sanitarian Alerts and Emergencies outbreaks of diseases like the 2009 influenza A (H1N1). National Health Ministry, Madrid, Spain 3 Infectious Diseases Department; Defense Central Hospital doi:10.1016/j.ijid.2010.02.1689 ‘‘Gómez Ulla’’., Madrid, Spain Background: The Defense Institute for Preventive Medicine and the Coordination Centre of Sanitarian Alerts and Emergencies (CCAES) were notified the 19th May 2009 e92 14th International Congress on Infectious Diseases (ICID) Abstracts

28.020 a case who (1) was diagnosed with influenza-associated Investigation of pandemic influenza A (H1N1) 2009 virus: encephalopathy, (2) was admitted to an intensive care unit Isolation and genetic analysis of brazilian strains (ICU), (3) was intubated or (4) died. We analyzed a total of 120 cases, including 23 deaths, who developed the disease T. Paiva by 6 October 2009. Results: Of the 120 cases, those aged < 20 years Instituto Adolfo Lutz, São Paulo, Brazil accounted for 71.7%. All 11 cases aged 65 and older resulted Background: Since April 2009, human cases of respiratory in death, while the proportion of deaths among cases aged infections originated by novel swine-origin influenza A virus, < 20 years and adults aged < 65 years was smaller (5.2% and designated pandemic A(H1N1)v, have been detected world- 34.8%, respectively). The mean (SD) and median times from wide, causing immediate international concern. In Brazil, onset to hospitalization were 62.8 (40.2) and 48.0 hours, as of 06 October 2009, there have been 14.229 confirmed respectively. The mean (SD) and median times from onset cases of infection and 1.167 deaths. Mortality rates of to death for the 23 fatal cases were 160.4 (116.5) and 0.61/100.000 inhabitantes were observed. 120.0 hours, respectively. The timing of antiviral administra- Methods: The virus samples were obtained from clin- tion did not appear to significantly affect the clinical course ical specimens from patients who came from the states among critically ill patients. of São Paulo, Mato Grosso and Distrito Federal. Virus iso- Of the 120 cases, 57 (47.5%) had at least one underly- lation was performed in MDCK cell cultures. Viral RNA ing medical condition. Of the 86 cases aged < 20 years, 27 was extracted from the infected cells and submitted to (31.4%) had one or more comorbidity, with asthma being the reverse transcription-amplification reactions with primers most common (22.9%). Similarly, of the 34 adult cases, 30 set designed to cover the complete segments of the HA, (88.2%) had comorbidities and chronic respiratory disease NA and MP genes. The amplified products were directed (23.5%) was the most common. sequenced. The complete genes of hemagglutin (HA), neu- Conclusion: First, age below 20 were more frequently raminidase (NA) and matrix (MP) were sequenced. reported as critically ill than adults. As the epidemic pro- Results: Comparative sequence analysis indicated the gresses further, the age-composition of severe cases may presence of point mutations in the HA gene of the change. Second, the clinical courses appeared to have been Brazilian strains when compared to the reference strain rapid after onset. The time from onset to death in Japan A/California/04/H1N1 (2009). These alterations do not was shorter than those reported elsewhere. Third, approxi- change the all five of the known antigenic sites of the HA mately half of the cases were accompanied by at least one protein. The canonical sites for N-linked glycosylation at underlying condition, and this proportion was particularly NxS/T motifs were preserved among strains. Data of the MP high among adults. sequence analysis revealed that the strains of this study carried the S31N mutation that confers cross-resistence to the doi:10.1016/j.ijid.2010.02.1691 adamantine class of anti-influenza drugs. Sequencing of the NA gene showed that the neuraminidase relative drug bind- 28.022 ing pocket represented by H275 was not altered, yielding Clinical, radiological features and outcome in children the strains sensitive to oseltamivir. with confirmed infection by 2009 influenza A H1N1, Conclusion: These results emphasize the contribution of admitted to a reference hospital of Curitiba, Brazillian molecular surveillance, in addition to antigenic characteri- South region zation to monitor the evolutionary pattern of the pandemic H. Giamberardino 1,∗, L.F. Bricks 2, V.H. Costa Jr. 1, P.F.A. A(H1N1)v, in order to vaccine development, and evaluation Boze 1, F.A. Motta 1, A.P.P. Oliveira 3, M. Guedes 1 of antiviral drugs susceptibility. 1 Hospital Pequeno Principe, Curitiba, Brazil doi:10.1016/j.ijid.2010.02.1690 2 Sanofi Pasteur, São Paulo, Brazil 3 Hospital Pequeno Principe, Curitiba, Brazil 28.021 An analysis of critically ill patients with the novel Background: Since 16 July, when pandemic 2009 A H1N1 influenza A (H1N1) virus in Japan virus was considered widespread in Brazil, a substantial number of children with acute respiratory symptoms (ARS) ,∗ K. Wada 1 , H. Nishiura 2, A. Kawana 3 demanded medical services. The impact of this outbreak was significant; especially in Parana, São Paulo and Rio Grande 1 Kitasato University School of Medicine, Sagamihara, Japan do Sul states (South region).We describe clinical and radi- 2 PRESTO, Japan Science and Technology Agency, Saitama, ological characteristics of 32 children attended at Hospital Japan Pequeno Principe,a pediatric reference center. 3 National Defense Medical College, Saitama, Japan Methods: After review medical charts from 133 children Background: Japan identified its first case of novel attended because of ARS, from 24 July till 16 Oct, we influenza A (H1N1) on 9 May 2009, and its incidence has collected data from 32 patients hospitalized for at least increased steadily. As of 26 October, 34 deaths have been 24 hours because of influenza-like illness, and who had rRT- reported. The aim of this study was to summarize the clinical PCR positive test for 2009 A H1N1 influenza virus. findings of critically ill patients in Japan. Results: The median age was 4.05y (range, 3m-14y1m): Methods: Critically ill patients are defined as confirmed 51.61% were<5y,and54.83% males. All patients received or probable cases who meet one of the following conditions: oseltamivir, on average 2.25 days (range 1— 22d) after the 14th International Congress on Infectious Diseases (ICID) Abstracts e93 onset of illness and 87.5% had received antibiotics at the were received by 15 patients (93.7%); 62% received cover- time of hospitalization. The median time of hospitaliza- age with 2 antivirals and 62% received steroids. Treatment tion was 5.75 days (range 3- 22) and 12.9% need intensive for non-ICU patients was 63%. Three pregnant women did care. Rx exam was performed in 22 children and was sug- not receive treatment ICU treatment with Oseltamivir was gestive of bacterial infection in 7 (31.81%). Samples for begun a mean of 2.8 days into hospitalization and in non-ICU blood culture were taken from 11 children (only 1 posi- patients, 3.5 days after hospital admit (p = 0.52). Duration tive for CNS). At least one underlying medical condition was of treatment was 9.8 ± 4.3 days and 5.5 days ± 0.92 ICU and found in 35% of children and the most common was con- non-ICU respectively (p = 0.0005) Secondary bacterial infec- genital heart disease.Two children dead (CFR = 6.25%):both tion was found in 2 ICU patients by mini- BAL. One patient were>2y,hadunderlying conditions (1 cardiac and other with Streptococcus pneumonia, 1 patient with MRSA and pulmonary chronic disease), demanded medical help 5 days Haemophilus Influenzae (12.5%) after the onset of disease and have not been immunized Conclusion: Overall mortality was 9.75%, and 18.75% for against pneumococcal, as recommended by National Pro- the ICU. No pregnancy related deaths. All deaths were in ICU gram of Immunization for at-risk children. patients. A significant increase in length of illness, duration Conclusion: These data suggest that early treatment with of fever and leukocytosis was seen in ICU patients. No dif- oseltamivir and antibiotics can benefit children with ARD and ference was noted in the onset of treatment between the 2 should start early in serious cases and immunocompromised groups but longer treatments in ICU patients were seen.Time children. About 1/3 of children had radiologic condensation of onset of symptoms to ER presentation did not impact out- suggestive of co-infection by S.pneumoniae.The low posi- come. There was no difference in the BMI or age of those in tivity rate of blood culture do not exclude infection by this the ICU vs non-ICU. bacteria, because of antibiotic use and low sensitivity of this test. It is necessary to divulgate recommendations for doi:10.1016/j.ijid.2010.02.1693 immunization against S. pneumoniae, that is offered free of charge for at-risk children in Reference Centers for Immuno- 28.024 biologics, but is underused. Impact of educational measures about influenza A (H1N1) directed to healthcare workers and patients doi:10.1016/j.ijid.2010.02.1692 ∗ C. Freuler , C. Ezcurra, M. Mayer-Wolf, V. Rodríguez, R. 28.023 Durlach Novel influenza A 2009 - A comparison of intensive care Hospital Alemán, Buenos Aires, Argentina unit vs non-intensive care unit patients Background: The aim of this report is to describe C. Boehringer the impact of educational measures during the influenza A(H1N1) pandemic in an acute-care hospital in Buenos Aires. UCSF Fresno, fresno, CA, USA Methods: This is a retrospective descriptive study based Background: Novel 2009 influenza A cases were first on own data and data from the National Health System dur- noted in California in mid April. To our knowledge there ing epidemiological weeks 20 to 30 (17th May-1st August). are no studies to date, which have reviewed duration of ill- Results: Because of the influenza epidemic a crisis com- ness, fever, treatments and outcomes. We reviewed patient mittee was organized under the leadership of the Infectious demographics and clinical characteristics in ICU vs non-ICU Diseases Department and constituted by the heads of the patients. Internal Medicine and Pediatric Departments, the Emer- Methods: From June 2009 to October 2009, 41 patients gency Room Coordinator, and the head of nurses. They were admitted to our 620 bed teaching hospital and 80 bed published a daily report and outlined common guidelines community hospital with confirmed H1N1 by rRT- PCR. 16 about diagnostic and treatment proceedings, prevention patients admitted to ICU- and 25 to non-ICU beds. Data was measures, and overall hospital performance. A call cen- analyzed using multi-logistic regression analysis. ter with specially trained physicians answering the phone Results: 51.2% Hispanic, 19.5% Caucasian, 17.1% Asian decreased patients and community anxiety, advising asymp- and 12.2% African-American. Seventeen males; 24 females, tomatic patients or patients without risk to stay at home. 8 were pregnant. The mean BMI 33.4 ICU vs 32.3 non- Visits to hospital patients were restricted to 2 hours per ICU, p = 0.76. Mean age for ICU was 43.7 vs 39.6 non-ICU, day and suppressed for pregnant women. Alcohol for hand p = 0.46. There were 4 deaths. Fever (>37.8 C) was noted hygiene was offered at hospital entrances. Respiratory in 75% ICU and 72% non-ICU patients (mean 38.5 ± 0.62 vs masks were given to symptomatic patients until physician’s 38.9 ± 0.75 respectively). Duration of fever was 4.5 days evaluation. (±4.8) vs 2.2 (± 2.5) p = 0.028. Of ICU patients 43.8% had Of 1520 employees, 1083 in contact with patients, only leukocytosis (mean 19.6). 3 of 25 (12%) floor patients had two servants became infected, thus reflecting overall com- leukocytosis, mean 8.9 (p = 0.009,[95% CI, 1.062, 1.541])). munity risk. The hospital cares for 47000 members, 439 Mean WBC in pregnancy was 9.11 ± 2.3. Duration of illness (0,93%) were studied because of influenza A(H1N1) suspi- in ICU patients, from onset of symptoms to day of discharge cion, media age 15 years, 48% men. Forty-one required was 19.93 days (SD ± 10.5) vs of 9.4 days (SD ± 4.99) non- admission and 3 died. ICU (p = 0.00013). Mean days on mechanical ventilation were 14.81 (SD ± 12.71). Days to ER presentation for ICU vs non- ICU patients 3.4 ± 3.0 vs 2.72 ± 1.9 (p = 0.236). Antivirals e94 14th International Congress on Infectious Diseases (ICID) Abstracts

Data Suspected Confirmed Deaths Deaths/suspected Deaths/confirmed influenza Influenza influenza influenza

Buenos Aires City 22502 930 (4.13%) 27 0.12% p < 0.01 2.90% p = 0.89 Hospital Alemán 439 48 (10.93%) 3 0.68% 6.25%

There is a statistically significant difference between the number of patients in which we confirmed diagnosis compared with the overall data in the rest of the city. Also the 28.026 mortality rate was similar in both populations if only con- Epidemiological profile of the A (H1N1) pandemic firmed influenza-patients were regarded, but much higher influenza in the state of Sao Paulo, Brazil, for the April- in ours if the suspected patients were taken in account. September 2009 timeframe Conclusion: The suspicion of influenza in our population was much better established leading to a greater diagnosis T.R.M.P. Carvalhanas ∗, A.L.F. Yu, G.D. Freitas, A.C.G. accuracy, certainly due to the impact of the educational Pellini, A.F. Ribeiro, B.L. Liphaus efforts we did. State Secretary of Health of Sao Paulo, Sao Paulo, SP,Brazil doi:10.1016/j.ijid.2010.02.1694 Background: On April 2009, the emergence of a new influenza virus strain set the stage for the first pandemic in 28.025 the 21st century. The speed of global dissemination of the How was the telephone consultation service perceived by new virus has no precedents in recorded history. We have the officers who provided it in Japan during swine-origin analyzed the epidemiological profile of the A/H1N1 pan- influenza A (H1N1) outbreak? A qualitative study demic influenza virus — the reported number of cases and K. Iwata 1,∗, C. Shirai 2 deaths, confirmed by lab tests. The geographical scope of the analysis comprised the state of Sao Paulo, Brazil, during 1 Kobe University, Kobe, Hyogo, Japan the Autumn-Winter season (April to September). 2 Kobe City government, Kobe, Hyoto, Japan Methods: Epidemiological data was obtained from the National System of Acute Notifications (Sinan Influenza on Background: For the preparation of pandemic influenza, line), which aggregates reported cases in a dedicated sys- Japan’s government requested to set up telephone consulta- tem, and are analyzed with the Epi Info/Win and Excel tion service at each prerfectual and city government. During software. Initial definition of suspected cases was similar to the initial period of swine origin influenza A (H1N1) out- that of the flu syndrome (fever, cough — associated or not break in Japan, the telephone consultation service received with headaches, myalgia, and arthralgia). After confirmed a great number of calls. However, the effectiveness of this evidence of transmission, the definition for acute respira- system had not been evaluated. This study reports the result tory syndrome (ARS) — fever, cough and respiratory distress of a qualitative study, which explored officers who pro- was used. Laboratory confirmation tests were processed at vided the telephone consultation system during influenza Adolfo Lutz Institute in São Paulo, using real-time reverse outbreak. transcriptase-polimerase chain reaction (rRT-PCR) in nasal Methods: A qualitative study, using semi-structured inter- or oropharyngeal specimens. views (n = 3), was conducted to the officers of a major city Results: There were 25,082 reported cases till Septem- government in Japan, who provided the service. Theory con- ber 2009, from these, 53% had ARS criteria, 29% influenza struction was conducted with a use of M-GTA and SCQRM like illness. Among the 13,651 cases with ARS, 28% were (structure construction qualitative research method). positive for Influenza A(H1N1) and 4% for seasonal flu. Results: Many difficulties were expressed by the officers The majority of reported and confirmed cases were noti- during the outbreak. The uncertainty of the disease charac- fied in July and August, declining in September. Infants) teristics, rapidly changing situation, fear of bad outcome of 24 months and young adults 20-29 years of age were the patients due to wrong triage, and miscommunications among groups more affected. Case fatality rates were greater in health care workers were among the difficulties extracted. children) 2 years and adults (20-59 y). Cases tested posi- While inefficiency was one of the problems extracted, less- tive for A(H1N1) varied from 20-35% within this period. High ening health care burden by triaging patients was one of risk groups included children) 24 months and young adults, the achievement they felt the telephone service provided. patients with chronic pulmonary disease, smokers, patients Development of a practical manual made their provision of with metabolic disease and pregnant women. service easier. Conclusion: The characteristics and evolution of the Conclusion: Various aspects of the telephone consulta- cases were similar to those occurring in the northern tion service during swine origin influenza A outbreak were hemisphere, with predominant circulation of the pandemic extracted through the interview. Perception of the officers influenza virus. These findings can provide elements to helped to understand the effectiveness and shortcomings define strategies for prevention and control of A (H1N1) of the telephone consultation service, which may lead to outbreak. further improvement of it.

doi:10.1016/j.ijid.2010.02.1696 doi:10.1016/j.ijid.2010.02.1695 14th International Congress on Infectious Diseases (ICID) Abstracts e95

28.027 28.028 H1N1 Pandemic: From imported cases in July 2009 to Factors associated to death in patients with confirmed sustained transmission in school clusters in September, diagnosis for influenza A/H1N1. State of Sao Paulo, Brazil, Uganda, 2009 April to October, 2009 L. Lukwago 1,∗, J. Wamala 2, B. Erima 3, C. Okot 4,B. A. Ribeiro ∗, A.C.G. Pellini, T.R.M.P. Carvalhanas, B.D.L. Bakamutumaho 5, I. Nabukenya 2, J.J. Lutwama 6 Liphaus, A.L.F.L.F. Yu, G.D. Freitas, M.D.C.S.T. Timenetsky 1 Ministry of Health, Uganda, Kampala, Uganda State Secretary of Health of Sao Paulo, Sao Paulo, SP,Brazil 2 Ministry of Health, Kampala, Uganda Background: In April, 2009, a new subtype of influenza 3 Makerere University Walter Reed Project, Kampala, A/H1N1 virus emerged from the American continent, spread- Uganda ing worldwide. Until the end of October,2009, WHO reported 4 World Health Organization, Kampala, Uganda more than 440.000 influenza A/H1N1 laboratory-confirmed 5 Uganda Virus Research Institute, Kampala, Uganda cases, registering more than 5.700 deaths. Studies point out 6 Uganda Virus Research Institute, Entebbe, Uganda that population groups who develop higher severity and mor- Background: In Uganda, since the confirmation of the first tality are: children less than two years of age, young adults, case of Influenza A (H1N1) on July 1, 2009, Influenza-like patients with chronic diseases and pregnant women. illnesses (ILI), were reported in school clusters in September. Methods: An exploratory analysis was performed to The clusters were investigated to confirm ILI and determine identify factors associated with death among confirmed the causative strains. cases of influenza A/H1N1, considering the residents and Methods: Clinical records were reviewed and specimens other people treated in healthcare facilities in SP, from collected for laboratory testing. Epidemiological analysis of EW 16 to 41. Data were collected from the Information data was done for descriptive and analytical reporting. The System of Notifiable Hazards — Influenza Online. Associa- WHO ILI case definition was adapted as any person with tion between remarkable expositions and death caused by fever, cough, headache, runny nose, and sore throat in the influenza A/H1N1 was investigated by unadjusted odds ratio last 3 to 5 days. A total of 543 specimens of throat and estimation, with 95% confidence intervals, employing the nasal swabs from different clusters and individuals were col- EpiInfo software. lected for laboratory testing and epidemiological analysis. Results: In SP, since EW 16, 31.589 influenza A/H1N1 Case based surveillance was administered to all students in suspected cases were reported, from which 5.242 (16,6%) the first school cluster (Kitabi Seminary), with ILI from begin- were confirmed and fulfilled the criteria for Severe Acute ning of September 2009 to assess the clinical and possible Respiratory Disease. Among these, 372 cases resulted in exposure history. Line lists were used to collect demographic death, 3.619 were discharged from hospital and 1.251 are and clinical information from the other clusters. still under investigation. The following variables showed Results: Pandemic influenza A (H1N1) 2009 in was con- association with death caused by influenza A/H1N1: chronic firmed in 13/18 school clusters. The index case in the first cardiopathy OR = 3,00 (IC95% = 2,05-4,40); chronic renal cluster with a sustained H1N1 transmission was a student failure OR = 3,85 (IC95% = 2,02-7,33); immunosuppression who came with the infection from the holiday. In the school OR = 4,93 (IC95% = 3,35—7,25); tobacco abuse OR = 1,52 clusters, the number with ILI symptoms ranged from 50- 430. (IC95% = 1,03-2,26); chronic metabolic disease OR = 6,36 The major signs and symptoms from the first cluster were (IC95% = 4,27—9,48); diarrhea OR = 1,56 (IC95% = 1,16- cough 341/403(84.6%), headache 330/403(81.9%), sneez- 2,10);); residence in the metropolitan area of Greater ing 288/403(71.5%), general body weakness 283/403(70.5%), Sao Paulo in relation to the interior of state OR = 1,37 fever 269/403(66.7%), runny nose 208/403(51.6%), sore (IC95% = 1,11-1,70). Variables which did not present asso- throat 104/403(25.8%), and others 126/403(31.3%). The ciation with death were: lack of previous vaccination attack rate as determined from first cluster by dormitory of against influenza OR = 1,65 (IC95% = 0,93-2,93) or pneumo- residence ranged from 47.1 - 89.1 per 100 population, with coccus OR = 1,22 (IC95% = 0,44-3,39); chronic pneumopathy a mean of 76.2 per 100 population. The nested case control OR = 1,14 (IC95% = 0,80-1,61); haemoglobinopathy OR = 1,74 analysis from the laboratory database revealed a significant (IC95% = 0,60-5,04). association with confirmed cases of H1N1 and having fever Conclusion: Widespread knowledge of influenza A/H1N1 OR 1.68(CI: 1.16-2.45), and cough OR 1.86(CI: 1.2-2.86). epidemiology, its complications and risk factors for death Conclusion: The H1N1 pandemic in Uganda has since the is extremely important to support the implementation of confirmation of the first case, reached high levels of per- strategies to prevent and control this disease in high-risk son to person transmission resulting in clustered epidemics. groups. Comparison of data found in the assessed population Observations from the case control analysis reveal a more with other similar studies is recommended. likelihood of finding an H1N1 positive laboratory result from a patient with fever and cough compared from the other doi:10.1016/j.ijid.2010.02.1698 Influenza-like illnesses. doi:10.1016/j.ijid.2010.02.1697 e96 14th International Congress on Infectious Diseases (ICID) Abstracts

28.029 had more serious evolution, with higher hospitalization and H1N1 Epidemic: Our experience at PGIMER Delhi, India mortality rates. The risks for complications and deaths were higher in children under two years of age, young adults, ∗ A. yadav , T. samra, M. pawar patients of chronic diseases and pregnant women. Methods: Analysis was performed to identify factors Dr. RML Hospital,PGIMER, New Delhi, India associated with death among confirmed cases of influenza Background: Patients infected with the H1N1 strain of A/H1N1 in women during their fertile years (WFY:10-49 years the influenza A virus frequently develop rapidly progressive of age) and included pregnant women, both with rRT-PCR lower respiratory tract disease resulting in respiratory fail- positive for influenza A (H1N1). Data were collected from ure. We describe the clinical characteristics of patients who the national bank for influenza A (H1N1) reporting system, expired in ICU at our hospital in Delhi, India. We did the during the epidemiologic weeks (EW) 16 and 41, 2009. Soft- study to see cause and pattern of death in H1N1. ware employed: Epinfo. Methods: Using guidelines developed by the Indian Results: In this period (EW16- 41), we identified 31,589 health ministry, all individuals with flu-like symptoms were suspicious cases of influenza A (H1N1); from these, 9,350 screened by a physician into three management categories- (29.6%) were confirmed, 27% (N = 2,548) in WFY and 26% Category A (out-patient treatment and home isolation), (n = 668) in pregnant women. The case fatality rate in preg- Category B (hospital isolation ward) and Category C (inten- nant women was 7.5% (N = 50). The proportion of gestation sive care units) based on clinical presentation. Of the 236 in this group is 26%,higher proportion wnen compared with patients with confirmed H1N1 evaluated between 8th August population. The first pregnant who died was registered in to 27th October 2009 at our facility, 26 patients expired. the EW 26 and the last one, in EW 39, most of cases were Data was collected from the hospital records for patients registered during WE 28 and 29. Risk factors associated with H1N1, who expired in the ICU. Influenza A (H1N1) virus were: chronic diseases: cardiopathies OR 2,5 IC95%1,2-5,3; infection was confirmed in specimens using TaqMan real- immunosuppression OR 2,7 IC95% = 1,5-5,0; metabolic dis- time reverse transcriptase-polymerase-chain-reaction (CDC eases OR 4,9 OC95% 2,5-9,7 and renal diseases OR 3,2 Protocol). IC95% 1,2-8,5. Among the women during their fertile years, Results: Median age was 29 years (Range: 12 - 74); >80% pregnancy was not associated to the deaths OR 0,9 IC95% of patients were < 40 years. Three (11.5%) were diabetic, 2 0,7-1,3. In pregnant women there was an association to (7. 7%) pregnant, 5(19.2%) hypertensive, 2(7. 7%) had preex- death with the second and third trimester of pregnancy OR isting respiratory disease and 14 (53.9%) had no pre-existing 4,3 IC95% = 1,3-14,1. medical conditions. 24 (92.3%) had primary viral pneumoni- Conclusion: These results confirmed that pregnant tis and 2 (7.7%) had exacerbation of structural respiratory women should be included in at-risk dor more severe dis- disease. 14 (53.9%) developed acute respiratory distress ease. For death, the risk is more important after second syndrome (ARDS), 4(15.4%) developed multi organ dysfunc- trimester. It is essential to alert people and doctors that tion syndrome (MODS), 3 (11.5%) developed acute renal pregnant women should have better control of healthy con- failure (ARF), 2(7.7%) developed myocarditis/Congestive ditions, and start immediately antiviral if they develop heart failure (CHF) and 3(11.5%) developed disseminated symptoms of influenza like illness. This group should also intravascular coagulopathy (DIC).All 26 required mechanical be prioritized for influenza vaccination ventilation. Oseltamivir administration delay ranged from 3 to 10 days after illness onset, 52.78% received high-dose doi:10.1016/j.ijid.2010.02.1700 (300 mg/day) treatment, and treatment duration ranged from 1 to 10 days (mean 3.0 ± 2.5days). 28.031 Conclusion: Over a 12 week period, H1N1 virus infec- The impact of the ‘‘novel’’ influenza A (N1H1) pandemic tion caused ICU deaths in 26 adult patients with a high case in Norway, as monitored by recorded fatal cases - end of fatality rate of 26/236 (11.0%). Deaths resulted from organ October 2009 failures including ARDS, MODS, ARF, DIC and CHF. Clinicians V. Hasseltvedt should be aware of the severe organ complications of H1N1, particularly in pregnant and previously healthy young adults Sykehuset Innlandet Trust, Lillehammer, Norway Background: This paper deals the with impact of the doi:10.1016/j.ijid.2010.02.1699 pandemic of ‘‘novel’’ influenza A (N1H1), in Norway, as 28.030 documented by experiences from the end of April 2009 to Deaths in women during fertile years and pregnant women the end of October 2009, as monitored by recorded fatal as confirmed for pandemic influenza A (H1N1) in the state cases, during the six months up to October 25, 2009. From of São Paulo the 1980 s the excess mortality from ‘‘seasonal flu’’ has been estimated ranging from 1000 to 1500 cases during ∗ A. Ribeiro , G.D. Freitas, A.C.G. Pellini, T.R.M.P. the time span of the outbreak. The duration of ‘‘seasonal Carvalhanas, A.L.F. Yu, B.D.L. Liphaus, M.D.C.S.T. flu’’, caused by influenza virus A has been estimated to be Timenetsky approximately 10 weeks. The Norwegian projections given by The Directorate of Health, on April 27, 2009 (source- State Secretary of Health of Sao Paulo, Sao Paulo, SP,Brazil URL: dagsavisen.no) gave a scenario of: up to a possible 13 Background: Since 16 July, the new influenza virus A 000 deaths - and up to 1.2 million infections — caused by (H1N1) was considered widespread in Brazil. Some groups ‘‘novel’’ influenza virus A (H1N1). 14th International Congress on Infectious Diseases (ICID) Abstracts e97

Methods: Data on Norway’s preparedness and surveil- 50% worried about contracting H1N1 flu. 58% would like to lance - available from bodies and sites (URLs) comprise receive H1N1 shot and 25% won’t mostly due to safety con- some of the following, The Norwegian Public Health Institute cern of vaccination (45%). 17% haven’t made their decision (fhi.no), The Directorate of Health (helsedirektoratet.no) — yet. including the general information given at The Norwegian Table1 Where people get their information? Governmental Official site - (pandemi.no). The projections and scenarios given by these governmental bodies have been compared with data from Norwegian sources — as well as from - promedmail.org and WHO data, as of October 25, 2009 - from who.int/csr. Results: From the end of April 2009 to the end October 25, 2009 13 deaths were recorded. Many of these individuals had predisposing illnesses/ conditions, which may have contributed to a fatal outcome. The known impact has been 13 recorded deaths, so far, - not 13 000 deaths - i.e. one thousandth — in contrast to the worst-case scenario. Conclusion: The documentation above highlights uncertainties concerning projections made in an early epi- Conclusion: Most people in Taiwan have good aware- demic/pandemic phase. It also might give reasons for ness and right perception to this novel influenza, the media caution — when extrapolating small data sets — in order to played a critical role for the public awareness. The worri- give short/intermediate term projections, to health profes- some about the epidemic on autumn and winter commonly sionals, as well as to the public in general. existed and drove the residents doing something such as stockpiling the face masks. 37% complained of the exagger- ations of the media reports of H1N1. Striking the balance of doi:10.1016/j.ijid.2010.02.1701 awareness and the panic of the public is the challenge for 28.032 the public communication of the H1N1. A survey in Taiwan 2009 for the public perception and Table 2 Important attitude analysis of demographic the willingness to be vaccinated of pandemic influenza A variables (H1N1) Worrying Worrying Willing H1N1 would them- to accept ∗ W.-S. Jhao , T.-H. Wang, L.-L. Ho, H.-P.Huang, C.-M. Chen, be more selves H1N1 flu Y.-P. Chou, M.-C. Peng serious may get vaccine Taiwan CDC, Taipei, Taiwan, R.O.C during fall H1N1 flu and winter Background: Taiwan established H1N1 Central Epidemic ** * * Command Center on April 27, 2009 while swine flu out- Gender Male 52% 50% 64% break developed in Mexico. The first wave communication (n = 542) was focusing on border quarantine and travel alert. The sec- Female 61% 57% 53% ond wave communication drifted to self prevention and the (n = 581) ** treatment after the first death on July 30. Until October 26, Age Less than 29 62% 58% 58% there are 423 H1N1 hospitalized cases and 26 deaths with (n = 246) fatality rate round 0.11‰. Older than 55% 52% 58% Methods: Telephone survey targeting people aged 18 and 29 (n = 877) *** older knowing H1N1 flu sampling by the Computer Assisted Education Under than 58% 53% 59% Telephone Interview (CATI) was conducted during October university 1-3 2009, Questionnaires were developed under the theoret- (n = 624) ical framework of the KAP model. After excluding 50 cases Up than 55% 54% 56% of respondents who haven’t heard of H1N1 flu, 1,123 valid university interviews have been successfully collected at 95% confi- (n = 479) ± dence level with sampling error is 2.99%. *: p < 0.05 **: p < 0.01 ***: p < 0.001 Results: Our survey explored that the perceptions of the respondents’ to H1N1 flu such as the transmission routes, doi:10.1016/j.ijid.2010.02.1702 treatment and vaccine for prevention have all reached to 70%. The perception of the preventive measures such as hands-washing, seeing doctor immediately after the symptoms develop reached to above 90%. The main channel of H1N1 information was TV (95%), followed by newspaper (34%) and internet (18%). 95% of the respondents have prepared some materials for H1N1evention such as face mask(85%), thermometer (78%), or handkerchief or tissue paper (77%). Almost 60% worried that the H1N1 outbreak will be more serious during fall and winter in Taiwan. More than e98 14th International Congress on Infectious Diseases (ICID) Abstracts

28.033 28.034 The outcomes of H1N1 09 screening at the 17th World Epidemiology of severe pediatric patients with novel Transplant Games influenza A (H1N1) in Korea G. Thompson 1,∗, M. Schmittmann 2, C. Hahne 2 S. Soo Youn 1,∗, J.H. Kim 1, H.S. Kim 1, Y.A.Kang 1, H.G. Lee 1, J.S. Kim 1, W.K. Kim 2 1 Campbelltown Hospital, Campbelltown, NSW, Australia 2 Aspen Medical, Deakin, NSW, Australia 1 Korea Centers for Disease Control and Prevention, seoul, Korea, Republic of Background: The 17th World Transplant Games occurred 2 Inje University College of Medicine, Seoul, Korea, Republic on the Gold Coast, Australia August 22 to 30, 2009, at the of end of the winter season in the southern hemisphere. Due to concerns related to the virus and after 4 countries withdrew Background: Since the first outbreak of novel influenza altogether, a mandatory screening process and influenza A (H1N1) in May 2009, the virus has been spread through- clinic was instituted to assist in the health and safety of out local communities. More than 4,000 diagnosed cases the participants. This review outlines the procedure and are being reported daily as of November 2009. One of the outcomes of this process. major infection routes is the educational institutions, so Methods: Screening consisted of a medical questionnaire children and teenagers have high risk of viral exposure. and tympanic temperature scan, conducted by 4 nurses Korea Centers for Disease Control and Prevention (KCDC) and 2 doctors. Positive symptoms and/or a temperature is operating nationwide monitoring system for severe hos- >37.5 C (99.5.F) were referred for physician assessment. The pitalization cases. The objective of this study is to highlight BinaxNOW test kit (Inverness Medical, Maine USA) was used demographics, infection risk factors and clinical courses. for the rapid diagnosis of influenza A. Screening attendance Methods: Influenza A (H1N1) patients who were hospital- was cross referenced with the registration database, and ized in ICU or had pneumonia in needs of intubation were individual team managers helped reinforce screening com- categorized as severe pediatric patients. Between June and pliance and isolation processes. October,total of 22 cases under the age of 18 were identified Results: A total of 2125 individuals presented for screen- as severe patients. After the medical chart review, we had ing over a 2.5 day period, arriving from over 45 countries. an interview with the doctor in charge. All the patients were Only 8 registered athletes and supporters failed to attend laboratory-confirmed influenza A (H1N1) virus infection by for screening however 29.4% of the volunteer group failed to means of real-time PCR. Based on the Advisory Commit- attend screening and 7.5% of volunteers did not register for tee on Immunization Practices, the patients with high-risk the Games altogether. Only 0.5% of attendees required fur- medical conditions were defined as having higher risk for ther medical evaluation. Of these, 68 people were deemed influenza complications. to have had a mild viral illness of either respiratory or gas- Results: Among the reported 22 severe cases, 15 were trointestinal origin. 31 people were swabbed nasally and male and 7 were female. Ages ranged from 2 months to all returned a negative result with the BinaxNOW Rapid 18 years old (median 7, standard deviation 5.4). Fourteen Influenza test, 7 were clinically deemed non infectious, 14 patients (63%) had high-risk medical conditions such as 1) were placed in home isolation for 48 hours, treated con- age less than 59 months (6 cases), 2) chronic respiratory dis- servatively and medically reassessed, 9 were prescribed ease (3 asthma cases), 3) neuro-developmental disorder (3 influenza prophylaxis and 7 convention centre staff were cases), 4) congenital heart disease (1 case) and 5) leukemia instructed to take a medical leave of absence until symp- (1 case). Total of 7 patients have expired. Patients took toms resolved. Separate to this process, just fewer than anti-viral agent (Tamiflu®) average 2 days after onset. Thir- 10% of participants were prescribed influenza prophylaxis teen patients received ventilator care, 7 did not and 2 were by their regular physicians. This practice varied by country unsure. Viral pneumonia was the most common complica- and by registration status. tion (17 cases, 77%) and 3 patients exacerbated into acute Conclusion: The screening process was limited by time respiratory distress syndrome. Initial symptoms were fever constraints and volunteer compliance. No documented cases and cough (18 cases, 81% each). There were 11 leukocyto- of H1N1 09 were identified during the Games; however 25 sis, 3 leucopenia and 3 thrombocytopenia cases on complete conservatively treated upper respiratory viral illnesses were blood count. managed in the clinic. Conclusion: Half of patients with high-risk medical conditions have expired. Considering current situations, we need doi:10.1016/j.ijid.2010.02.1703 to maintain high-risk medical conditions category and to have continuous tracking for severe pediatric patients with influenza A (H1N1).

doi:10.1016/j.ijid.2010.02.1704 14th International Congress on Infectious Diseases (ICID) Abstracts e99

28.035 28.036 Epidemiologic characteristics of deaths associated with The effect of influenza-like illness symptoms and labo- 2009 pandemic influenza A (H1N1) virus infection in ratory confirmed influenza A on hand hygiene and other Korea health habits among US University students H.S. Kim 1,∗, J.H. Kim 2, S.Y. Shin 2, Y.A. Kang 1, H.G. Lee 1, V. Perez ∗, S. Galea, J. Kalbfleisch, A.S. Monto, A.E. Aiello J.S. Kim 1, B. Cho 3 University of Michigan School of Public Health, Ann Arbor, 1 Korea Centers for Disease Control and Prevention, seoul, MI, USA Korea, Republic of Background: Although hand hygiene and other non- 2 Korea Centers for Disease Control and Prevention, Seoul, pharmaceutical interventions have been used for mitigating Korea, Republic of influenza, the effect of influenza illness on adherence with 3 Seoul National University Hospital, Seoul, Korea, Republic these measures is unknown. of Methods: Data analyzed came from a cluster randomized Background: The 2009 pandemic influenza A(H1N1) virus intervention trial held at the University during the 2007-2008 has emerged to cause the first pandemic of the 21st century. flu season. Immediate and sustained effects on hand hygiene Clinical and epidemiologic features of fatal cases associ- and reduction in social contacts from clinically verified ILI ated with 2009 influenza A(H1N1) infection is a important and seasonal influenza A were examined using lagged regres- information to manage the disease. sion to estimate beta ($) coefficients and 95% confidence Methods: Nationwide enhanced public health surveil- intervals. Separate analyses were conducted for compar- lance of Korea residents who were died with laboratory ing (1) clinically verified ILI cases, non-clinically verified ILI evidence of pandemic 2009 influenza A(H1N1) infection cases, and healthy ILI-free controls (no reported ILI either reported to the Korea Centers for Disease Control and Pre- clinically or on surveys); and (2) influenza A cases, clinically vention between August 15 and November 05, 2009. verified or survey reported ILI cases not positive or tested Results: During the study period there were 51 cases of for influenza, and healthy ILI-free controls. Clinical ILI and death due to pandemic 2009 influenza A(H1N1) infection influenza cases were further dichotomized by ILI symptom reported in Korea. Among the 51 cases, the median age severity (ss) based on their mean value. was 55 years (range, 2 months-83 years); 27(52.9%) were Results: During the week of illness verification, clinically male and 24(47.1%) were female. The median time form verified ILI cases reported washing hands less than partic- symptom onset to diagnosis was 3days(range: 1-16days) and ipants with non-clinically verified ILI and healthy controls from symptom onset to death was 6days. Antiviral drugs (i.e. nonclinical ILI cases) ($=-1.04, p=0.03; high ss cases vs. were administerd to 42patients(82.4%). 24patients(57.1%) low ss/non-clinical ILI cases: $=-1.55, p=0.02; low ss cases of them start antiviral medication before diagnosis and vs. high ss/non-clinical ILI cases: $=-0.52, p=0.56). Clinical others start antiviral medications as soon as the influenza ILI cases also reported using hand sanitizer more, spending confirmed. 42 patients(82.4%) had risk factors for sea- less time handwashing, and spending fewer hours in their sonal influenza complications such as 1) age less than own residence hall rooms during the week of illness verifi- 59months were 4 patients, 2) age more than 65years cation (all p>0.05). Comparing influenza A cases to ILI only were 22 patients(19 cases of these had chronic medi- cases and controls (i.e. non-flu cases) during the week of cal conditions), 3) chronic medical conditions were 16 viral confirmation, flu cases reported spending fewer hours patients(malignant tumor, DM, chronic lung disease and in their own residence hall rooms ($=-2.56, p=0.01; high chronic renal disease).46 patients(90.2%) of those had pul- ss cases vs. low ss/non-flu cases: $=-3.52, p=0.03; low ss monary complication like pneumonia or acute respiratory cases vs. high ss/non-flu cases: $=-1.60, p=0.56). However, distress syndrome. Evidence of coinfection was found in flu cases reportedly had better hand hygiene than non-flu specimens from 19.6%(10/51) patients, including 6 caused cases (all p>0.05). No sustained effects were observed. by bacteria and 2 caused by funfus. Conclusion: Although adherence to non-pharmaceutical Conclusion: Fatal cases from 2009 influenza A(H1N1) in interventions varied by clinical ILI and seasonal influenza Korea occurred in high-risk patients and was associated with A occurrence, the temporal changes were not statistically viral pneumonia and severe acute respiratory distress syn- significant. Emphasis on the importance of complying with drome. Considering current situation, we need to manage non-pharmaceutical recommendations such as hand hygiene high-risk patients actively. and voluntary reduction in social contacts is needed to potentially mitigate disease spread among university stu- doi:10.1016/j.ijid.2010.02.1705 dents on campus.

doi:10.1016/j.ijid.2010.02.1706 e100 14th International Congress on Infectious Diseases (ICID) Abstracts

28.037 disabled for confirmed influenza outbreaks. We described The progressive expansion of the Novel A (H1N1) v epi- the epidemiological findings of an outbreak with a case of demic in the EpiSouth region (Mediterranean and Balkans) oseltamivir resistant infection detected. Methods: We calculated the effectiveness of sea- ,∗ F. Ait Belghiti 1 , N. El Omeiri 1, J. Gueguen 1, A. Rachas 1, sonal influenza vaccination 2008-2009 which comprised M. Gastellu-Etchegorry 1, S. Declich 2, M.-G. Dente 2,P. A/Brisbane/59/2007 (H1N1)-like virus, A/Brisbane/10/2007 Barboza 1 (H3N2)-like virus and B/Florida/4/2006-like virus in protection against pandemic influenza A (H1N1) 2009, and 1 Institut de Veille Sanitaire (InVS), Saint Maurice, France the effectiveness of oseltamivir chemoprophylaxis. Thirty- 2 Istituto Superiore di Sanita, Rome, Italy four respiratory specimens (15 nasopharyngeal aspirates, Background: EpiSouth is a network covering 26 Mediter- 15 nasopharyngeal swabs and 4 throat swabs) were taken ranean and Balkan countries. Since April 2009, all continents from 34 residents for realtime RT-PCR testing for pandemic have been progressively affected by the A(H1N1)v influenza influenza A (H1N1) 2009. All of the 21 positive samples were pandemic. further tested for antiviral resistance. Methods: In the scope of the project, EpiSouth countries Results: Seasonal influenza vaccination did not confer shared, on a voluntary basis, information regarding their protection against pandemic influenza A (H1N1) virus (OR confirmed cases, case definitions and cases management 2.23, 0.70 to 7.00; p>0.05), but oseltamivir prophylaxis was strategies. Data concerning confirmed cases were analysed found to be effective in preventing disease (OR 0.31, 0.10 to on a weekly basis. 0.98; p<0.05). Overall compliance with oseltamivir chemo- Results: The first confirmed case was reported on the prophylaxis was satisfactory (94.5%). Two staff members 27th of April in Spain. As of 06 July 2009, 2,577 con- who were offered oseltamivir reported early discontinuation firmed cases were reported by 24/26 countries. The most due to side effects while two others did not start the med- affected country was Spain (776 cases) followed by Israel ication at all. Oseltamivir resistance in influenza A (H1N1) (681) and France (330). The pandemic spread within the four virus infection was detected in one of the residents who had EpiSouth sub-regions was slightly different: the number of been given oseltamivir prophylaxis for 6 days. There was no cases started to increase markedly first among EpiSouth EU evidence of spread of the resistant strain in the outbreak. countries (week 19), followed by Middle-East (week 23), and Conclusion: Oseltamivir chemoprophylaxis was effec- finally North Africa and Balkans (Week 27). tive in reducing the transmission of pandemic influenza These different dynamics can be partly explained by the A (H1N1) virus infection in long-term care facilities dur- historical or socio-economical links existing between coun- ing outbreak. Clinicians, microbiologists and public health tries. The more rapidly affected EpiSouth countries (e.g. physicians should be alerted to the possibility of emer- Spain, Israel or France) are those with close links (e.g. gence of oseltamivir-resistant viruses in patients who have numerous direct daily flights with the Americas) while coun- received chemoprophylaxis. tries with less direct or frequent connections could delay longer the implementation of a local cycle of transmis- doi:10.1016/j.ijid.2010.02.1708 sion. Later,population movements within EpiSouth countries also contributed to a further pandemic spread (e.g. cases 28.039 exported from France to Algeria, Slovenia and Tunisia and Evaluation of direct immunofluorescent assay (DFA) and from Spain to Lebanon and Serbia). The third phase was rapid antigen test (RAT) for diagnosis of new pandemic linked to relations with neighbouring areas e.g. Saudi Arabia influenza A H1N1 2009 (FLU AH1N1) during first wave in exported cases to several EpiSouth countries. Santiago, Chile Conclusion: While all countries were faced with the same C. Vizcaya 1,∗, M. Ferrés 2, C. Perret 3, C. Martinez 4,P. difficulties regarding implementation of control measures, Godoy 4, A.M. Contreras 4, P. Ferrer 4, T. Azocar 4 the ongoing information exchange between countries has proven its importance. 1 Clinical Hospital of Catholic University, Santiago, Chile 2 Catholic University, Santiago, Chile doi:10.1016/j.ijid.2010.02.1707 3 Pontificia Universidad Catolica de Chile, Santiago, Chile 4 Infectious diseases and Molecular Laboratory, Catholic 28.038 University, Santiago, Chile An outbreak of influenza A pandemic (H1N1) 2009 in a residential home for the disabled in Hong Kong and detection Background: Since May 17th 2009 (epidemiological week of the first local case of oseltamivir-resistant infection 20th), the new strain of influenza A H1N1 was detected in respiratory samples of symptomatic patients in Santiago, ∗ W.H.A. leung , L.T.T. LOH Chile. The circulation of the virus lasted 11 weeks, with a peak between weeks 25-27th. The objective of our study was Centre for Health Protection, Hong Kong, China to evaluate the performance of influenza tests for diagnosis Background: In Hong Kong, outbreaks of pandemic of FLU AH1N1. influenza A (H1N1) virus infection occurred in institutions Methods: Nasopharyngeal swabs were taken from in and since June 2009. The Centre for Health Protection (CHP) outpatients with influenza like illness (ILI), between June of the Department of Health carried out epidemiological 1st and July 19th of 2009 (weeks 23-29th) and the results of investigation and provided oseltamivir chemoprophylaxis for DFA and RAT were compared using RT-PCR FLU AH1N1 (Light residents of residential home for the physically and mentally mix Kit Influenza A virus M2 and Light Mix Kit FLU A swine 14th International Congress on Infectious Diseases (ICID) Abstracts e101

H1Ò of TIB MOLBIOL) as gold standard. We analyzed sensitiv- days after the WHO declared the pandemic.Methods: We ity, specificity, positive predictive value (PPV) and negative retrospectively compared the clinical and radiological find- predictive value (NPV) of DFA (D3 Ultra 8 DFA Respiratory ings between the 2 groups of adult patients tested positive & Identification Kit ä de Diagnostic Hybrid) and RAT (Quick- or negative for H1N1 RT– PCR assay (nasal swab). VeuÒ of Biomerieux). Results were compared by age group Results: A total of 73 adults were hospitalized with pre- and over three different periods of the outbreak: increasing, sumptive diagnosis of Influenza AH1N1, from June 14th to peak and decreasing. October 18th 2009. Tests were positive for 21 patients and Results: 510 patients had RT-PCR for FLU AH1N1 with negative for 52. The mean age was 43 years (range 16-85), simultaneous DFA, 385 with RAT and 48 with both tests. Aver- male/female ratio: 13/8 in the positive results group and 56 age age with DFA was 25,8 years (1 month-108 years, 53% years (range 17- 92) male/female ratio: 29/23 in the nega- females) and with RAT 32,9 years (2 months-108 years, 51% tive. There were no significant differences in age (p: 0.14) females), (p <0,0001). Comparing periods of the outbreak, and sex (p: 0.29). Among the 21 positive cases 15 (71%) had DFA sensitivity was 58%, 77% and 81% in ascending, peak and preexisting medical conditions, obesity being the most fre- descending period, respectively (p <0,001) and specificity quent 6 (28%). Among the 52 negative adults 38 (73%) had was 90%, 83% and 91% respectively (p>0,05). Evaluating RAT, preexisting medical conditions, HTA being the most frequent sensitivity was 41%, 61% and 67% (p<0,001) and specificity 9 (17%). The following symptoms were present at admission was 87%, 96% y 92% (p> 0,05) in different periods. in both groups (positive/negative): fever 95%/ 83%, myalgia DFA and RAT for diagnosis of FLU AH1N1 76%/ 35%, coughing 67%/ 65% and shortness of breath 38%/ 31%. DFA RAT DFA+RAT Among the 21 positive cases, both CT scan and chest X Sensitivity 75* 59 60 ray were obtained in 15, 5 patients only had chest X rays. Specificity 87* 94 94 There was only 1 patient showing normal images. Of the PPV 80 88 82 52 negative cases, 42 had both CT scan and chest X-ray, 4 NPV 84 74* 84 had only chest X-ray and 6 had no diagnostic images. Only 3 patients showed normal images. Sensitivity and Specificity of DFA and RAT in different age Table 1. Radiological findings groups Radiological Pattern n positive A n negative P-value <1 1-4 5-14 15-54 ≥ 55 H1N1(%) A H1N1(%) year years years years years Interstitial 7/20 (35) 11/43 (25) (p: 0.21) DFA sensitivity 77 72 87* 71 35* Bilateral 16/20 (80) 26/43 (61) (p: 0.27) DFA specificity 94 87 74* 87 92 Pleural Effusion 5/20 (25) 11/43 (24) (p: 0.61) RAT sensitivity 66 54 60 62 45* Lymphadenopathy 11/14 (79) 34/40 (85) (p: 0.42) RAT specificity 83 95 94 92 96 Peripheral localization 4/20 (20) 12/43 (28) (p: 0.36) * Significantly different, p<0.001 Conclusion: DFA had better sensitivity than RAT for diag- Conclusion: No significant differences were found in age nosis of FLU A H1N1. Sensitivity varies with age and periods and clinical presentation at admission, although mean age of the outbreak; it is worse in ≥55 years old patients and at was inferior and myalgia was more frequent in the confirmed the beginning of the outbreak. Using both tests simultane- A H1N1 group. There were no significant differences in radi- ously doesn’t improve sensitivity. It’s important to consider ological findings, which could be attributed to the small size the age of patients and the relative period of the wave to of our study population. decide the exam to perform. doi:10.1016/j.ijid.2010.02.1710 doi:10.1016/j.ijid.2010.02.1709 28.041 28.040 Epidemiologic and clinical finding of A H1N1 2009 pan- Influenza A (H1N1) pandemic in Argentina. Experience in demic influenza in the Dominican Republic two private general hospitals during the outbreak (June M. Thormann 1,∗, R. Pimentel 2, C. Then 2, C. Perez 3 2009) 1 Salvador B. Gautier Hospital, Santo Domingo, D.N., ,∗ G. Vidiella 1 , P. Titanti 2, V. Cruzat 3, E. Parino 4,H. Dominican Republic Quinteros 4, G. Diaz Colodrero 4, M. Curone 4, I. Moine 5,G. 2 Direccion General de Epidemiologia, Santo Domingo, Kohan 1, J.C. Gallo 4, A. Moreno 4, P. Gallego 2 Dominican Republic 3 1 Maternidad Suizo Argentina y Sanatorio Agote, Buenos Salvador B. Gautier Hospítal, Santo Domingo, Dominican Aires, Argentina Republic 2 FUNCEI, Buenos Aires, Argentina Background: The influenza virus belongs to Orthomyx- 3 Sanatorio Fleni, Buenos Aires, Argentina oviridae family and is classified into three types of virus A, 4 Maternidad Suizo Argentina, Buenos Aires, Argentina B and C. These viruses have two major surface glycopro- 5 Sanatorio Agote, Buenos Aires, Argentina tein: hemaglutinin (H) and neuraminidase (A) which helps Background: On June 14th 2009 the first confirmed case the ranking of multiple subtypes. One of the most impor- of Influenza AH1N1 was hospitalized in our institution, four tant characteristics is their ability to mutation and antigenic variation. Influenza A has been linked to catastrophic pan- e102 14th International Congress on Infectious Diseases (ICID) Abstracts demic. The last of these is called Swine flue (influenza A Our objetive was value the adherence, security and effi- H1N1), which since its inception has caused great alarm, ciency of the prolonged prophylaxis against AH1N1 Influenza high morbidity and mortality especially in pregnant women. with oseltamivir in an oncohematologic patients cohort. This is a sample of the features of the disease in Dominican Methods: From July to September 2009, a prospective Republic. study was performed from a cohort of 45 oncohematologic Dominican Republic is a tropical country located in patients above 19 years old, that received a 75 mg daily dose the Caribbean that receive substantial annual number of of oseltamivir during 30 days. Then, by an anonymous survey, tourists, which makes influenza outbreaks throughout the age was consulted, as well as sex, oncohematologic pathol- year: both seasonal peaks in the northern and southern ogy, treatment performance, adverse effects that patients hemisphere. presented, doses that were used, whether and why medica- Methods: The Epidemiology National Program starts a tion was interrupted, concomitant medication and whether surveillance since the epidemic arise at level 5, at epidemi- the patient had to consult the doctor during that period of ological week 16. time. Diagnosis confirmation was made with rt- PCR for A H1N1 Results: Nor Influenza Syndromes were registered in the to all symptomatic respiratory cases. cohort, neither Influenza cases during the administration of Results: Until the 40th epidemiology week, we have such prophylaxis. Medium age was 54 years (range 19-87), 22 2,664 suspicious cases, 997 (37%) hospitalized, 441 con- females and 23 males. Basal diseases were Lymphomas in 42, firmed cases, from this 191 (45%) hospitalized, and 22 (5%) 2% of the cases; Acute Leukemias in 24%; Multiple Myeloma death, 76 (17%) cases were pregnant women with 16% mor- in 17, 8%; Hodgkin disease in 11,1% and Myelodysplasia in tality. 6,7%. Clinical manifestations were: fever (94%), cough (89%), From 45 patients, 24 (53, 3%) presented adverse effects, nasal congestion (76%), headache (71%), muscle pain (67%), 60% with digestive symptoms, 18% neurologic and 15% sore throat (60%), dyspnoea (45%), nausea (25%), rales (21%), fatigue. vomiting (18%) and diarrhoea (11%). In 34 patients (75, 5%) a 100% adherence was achieved. Pregnancy was one of the more important risk factor From those patients that did not finish the treatment, 5 associated with mortality. said that it was because they had a digestive intolerance, Necropsy findings where: edema, hemorrhage and necro- 3 did not give their reasons and another one because he/she sis in lung tissues, frequently associate with intravascular began late. thrombosis. No serious adverse effects requiring hospitalization were High mortality was cause due a delay in search of medi- objectived. cal attention and no suspected diagnosis from health cares There were 32 patients that were already receiving other personel. medication during antiviral prophylaxis, and only 6 patients Conclusion: It must be increased the Primary Care Ser- had to consult their doctor during such period of time. vices to obtain an early diagnosis of the disease, and began Conclusion: Daily prophylaxis efficiency with oseltamivir the antiviral treatment in high risk populations, when this was successful in 100% of the cases. The adherence to pathology is suspected, mostly in pregnant women. oseltamivir was partial (75,5%) mainly because of digestive intolerance. No serious adverse effects were detected. doi:10.1016/j.ijid.2010.02.1711 doi:10.1016/j.ijid.2010.02.1712 28.042 Prolonged prophylaxis for A H1N1 Influenza pandemic in 28.043 Oncohematologic patients - Adherence, security and effi- Homologous and heterologous immune responses to ciency naturally-acquired influenza virus infection S.J. Ramirez Borga 1,∗, A.S. Firpo 2, L. Lopez 3, J.J. Napal 3, L. Lau ∗, V.J. Fang, K.H. Chan, E. Ma, G.M. Leung, M. Peiris, M.V. Prates 3, S. Yantorno 3, A. Enrico 3, J. Milone 3 B.J. Cowling 1 Hospital Italiano de La Plata, La Plata, Buenos Aires, The University of Hong Kong, Hong Kong, China Argentina Background: Humoral antibody responses, typically mea- 2 Hospital Italiano La Plata, La Plata, Buenos Aires, sured by hemagglutination inhibition (HAI) and viral Argentina neutralization, are common measures of immunity to 3 Hospital Italiano La Plata, La Plata, Argentina influenza virus infection. An antibody titer of greater than Background: Since 1 May to 31 October 2009, 1,241,612 1:40 is thought to correlate to around 50% protection to cases of a kind of Influenza disease were notified in Argen- infection, while a 4-fold rise in antibody titers between two tine. 24,504 virologic samples were processed, confirming times is evidence of infection during that interval. Infec- that 10,248 were cases of AH1N1 Influenza, there were tion from a specific strain of influenza can elicit an antibody 12,471 cases that required hospitalization and 600 confirmed response against other strains of influenza, which may cor- deaths. relate with protection. Oncohematologic patients were in the high risk group to Methods: Subjects presenting with influenza like illness this infection. As a preventive strategy a prolonged prophy- (ILI) were recruited from general outpatient clinics through- laxis with oseltamivir was administered during 30 days. out Hong Kong. Those subjects who tested positive for influenza by a rapid diagnostic test, and their household 14th International Congress on Infectious Diseases (ICID) Abstracts e103 members, were followed up with home visits to determine ness from Mbulu district with laboratory confirmed influenza secondary infections in the household. Serum samples taken A (H1N1) virus or who is epidemiologically linked to a con- at baseline and convalescence were tested for HAI specific firmed case. Cases were actively searched and identified; to pandemic H1N1, seasonal H1N1 and seasonal H3N2. Nasal specimens were collected and sent to the National Influenza and throat swabs (NTS) were collected from each individual Centre in Dar es Salaam for rt-PCR confirmatory testing for and tested by RTPCR to confirm active infections. Influenza A (H1N1). Data analysis was done using Epi info Results: There were 18 pandemic H1N1, 5 seasonal H1N1, 3.5.1 and 24 seasonal H3N2 virus positive cases confirmed by Results: The index case was a student of the school and RT-PCR. Among those positive for influenza virus, 39 were from September 16, through October 5, a total of 99 were adults (‘‘16 years) and 8 were children. The proportion of confirmed with Influenza A H1N1. The mean age of cases was individuals with a homologous antibody titer of ≥1:40 rose 16 years (SD=8.4); 78% of patients were less than 20 years. from 17%, 20% and 4% to 78%, 100% and 38% after infection Twenty two percent were identified from the community with the pandemic H1N1, seasonal H1N1 and seasonal H3N2 following a graduation activity at the school on Septem- viruses respectively. Heterologous responses were strongest ber 26, 2009. The most common presenting symptoms were between pandemic H1N1 and seasonal H1N1. In individuals fever (90%), cough (46%), headache (40%), and Joint pains with RT-PCR confirmed seasonal H1N1 infection, the pro- (30%). Significant transmission occurred in the class and dor- portion with an antibody titer ‘‘1:40 for pandemic H1N1 mitory where the first case was identified (attack rate = increased from 20% to 40%. In the opposite direction, the 23.8%)..Being present in a graduation gathering was found to proportion of those confirmed with pandemic H1N1 with an be a risk factor for developing the disease at the community antibody titer ≥1:40 for seasonal H1N1 increased from 33% level (OR=1.4, 95%CI= 1.2—6.0). to 44%. Low levels of cross-strain HAI titer rise to ≥1:40 were Conclusion: Following the outbreaks and the subsequent detected in other variations. community spread, Tanzanian FELTP residents and MoHSW Conclusion: We identified low baseline immunity prior were co-opted to investigate, control and prevent future to naturally-acquired infection with seasonal or pandemic spread. The epidemic was subsequently controlled and strains of influenza in the 2009 summer season in Hong Kong. surveillance reinforced. Early identification and institution- This suggests that a proportion of those infected with either alization of control measures are vital tools in shifting seasonal H1N1 or H3N2 viruses could gain protection against epidemic curves to the left. the novel pandemic H1N1 strain and vice-versa. doi:10.1016/j.ijid.2010.02.1714 doi:10.1016/j.ijid.2010.02.1713 28.045 28.044 Co-infection between the pandemic influenza virus A The role of schools as social networks in transmission of H1N1 and seasonal influenza A virus in a patient present- Influenza A (H1N1 2009): The Mbulu District, Northern ing severe acute respiratory disease Tanzania, November 2009 experience A. Feltrin 1, K. Augusto 1, V. Isper 1, J. Delamain 1, B. Kemp 2, E. Mwakapeje 1,∗, J. Mghamba 1, E. Nyale 2, M.A. mohamed 1, A.R.R. Freitas 2, M. Pacola 3, R. Angerami 4,∗ V. Makundi 3, O. Oleribe 1, P. Mmbuji 4 1 Hospital Madre Theodora, Campinas, SP, Brazil 1 Tanzanian Field Epidemiology and Laboratory Training Pro- 2 Epidemiological Surveillance Coordination of Campinas, gram (TFELTP), Dar Es Salaam, Tanzania, United Republic Campinas, SP, Brazil of 3 Epidemiological Surveillance Group, Regional Division of 2 School of Public Health Muhimbili University of Health Health VII,State Department of Health of São Paulo, Camp- and Allied Sciences, DAR ES SALAAM, CA, Tanzania, United inas, SP, Brazil Republic of 4 State University of Campinas, Campinas, SP, Brazil 3 Ministry of health and social welfare, 22, Tanzania, United Background: With the pandemic circulation of the new Republic of influenza A/H1N1 virus in 2009, became mandatory to imple- 4 Tanzanian Ministry of Health and Social Welfare, Dar Es ment the national preparedness plan to improve both health Salaam, Tanzania, United Republic of care and laboratory settings activities. However, it is also Background: Novel influenza A H1N1 virus is the latest important a continuous surveillance is essential to promote emerging viral disease with a pandemic phase 6 status. Since a better comprehension of mechanisms of transmission, viral July 4th when the first case was confirmed in Tanzania, there virulence, and treatment efficacy. The aim of this study is have been several sporadic cases across several regions. A to describe the clinical, laboratorial, and epidemiological cluster of cases were identified at a school in Mbulu dis- aspects of a fatal case of severe acute respiratory disease trict on September 16th 2009, Northern Tanzania. Within (SARD) with simultaneous identification of both pandemic a week, 94 cases were confirmed (72 in the school and 22 and seasonal influenza A virus. within the community). This prompted immediate outbreak Methods: Retrospective and descriptive study based on investigation, risk factor analysis and establishment of con- information collected in medical records and notification file trol measures. We describe the steps taken to curtail this about a patient hospitalized in Campinas, State of São Paulo, health event in Tanzania. during the first influenza A/H1N1 epidemic period in Brazil. Methods: An unmatched case control study was done. A Results: A white female patient, 25 years old, with case was defined as any person with acute respiratory ill- antecedent of obesity and diabetes, was admitted in e104 14th International Congress on Infectious Diseases (ICID) Abstracts

July/2009 with 2 days history of fever, cough, sore 20% of cases had gastrointestinal symptoms; and approxi- throat, myalgia, and malaise. On admission, chest X-ray mately 40% had other symptoms such as body pain, myalgia showed bilateral, diffuse, and intersticial-alveolar opac- and/or headache. The age groups most affected by pan- ities. Despite the started treatment with oseltamivir, demic influenza were those aged 0-14 years and 20-49 years. ceftriaxone, and azithromycin, she presented with tachyp- The least affected age group was those aged >60 years. noea, tachycardia, cyanosis, and hypoxemia in the day-3 The second wave of pandemic influenza appears to have of disease. In day-4, her respiratory pattern progressed to peaked in the English and Dutch Caribbean. severe respiratory distress, lung hemorrhage, and shock; Conclusion: The Caribbean Community responded well to invasive ventilatory support and vasoactive drugs were intro- a rapidly changing pandemic influenza situation. The major duced. Her outcome was death in the 8-day of disease. lessons learnt during this pandemic were the importance of: The specific RT-PCR performed by Instituto Adolfo Lutz — continuous communication at all levels; efficient and timely a public health laboratory reference for laboratorial diag- surveillance with collaborative clinical, epidemiological and nostic of pandemic influenza virus in Brazil — identified laboratory input; and adequate intersectoral planning, with seasonal influenza virus in respiratory secretion and pan- evaluation and adaptation to meet the changing needs of demic A/H1N1 pandemic virus in lung specimen collected the disease situation. post morten. With another wave expected early in 2010, countries will Conclusion: In the present case, it is not possible to need to continue to be adequately prepared to deal with the postulate the real impact of simultaneous infection pre- expected increase in influenza cases. dicting the poor clinical evolution. However, it reinforces the importance of a continuous and sensitive epidemiolog- doi:10.1016/j.ijid.2010.02.1716 ical and laboratorial surveillance of respiratory syndromes, during epidemic and interepidemic period, as a strategy to 28.047 detect early changes in the epidemiological pattern and to Enhanced influenza survey: Khartoum state survey in know what respiratory virus are circulating, including pos- selected paediatric hospitals sible emerging new influenza virus strains eventually more S. Mustafa 1,∗, M.S. Karsani 2, A.A. Badri 3, M. Mangory 3,R. virulent or antiviral resistant. Elagib 3, A.S. Abd Elfadeel 4 doi:10.1016/j.ijid.2010.02.1715 1 National Public Health Laboratory, Khartoum, Khartoum, Sudan 28.046 2 National Public Health Laboratoy, Khartoum, Khartoum, Response to pandemic influenza in the English and Dutch Sudan Caribbean 3 National Public Health Laboratory, Khartoum, Sudan 4 ∗ National Public Health Laboratory, Khartoum, Sudan E. Boisson , B. Irons Background: On July 2009, the first influenza A (H1N1) Caribbean Epidemiology Centre (CAREC), Pan American virus laboratory confirmed cases were reported in Sudan. Health Organization (PAHO/WHO), Port of Spain, Trinidad It was brought by a family coming from the UK. The situa- and Tobago tion continued static, except for another three cases coming Background: In June 2009, the first cases of pandemic from abroad. Two months later specifically after the return influenza occurred in the English Caribbean, just prior to of pilgrims from omra (visit to holy Muslim places in Saudi the WHO declaration of pandemic level 6. Since then the Arabia); we started to detect clusters of H1N1 within the virus has spread rapidly throughout the sub-region. community with no history of travelling abroad or contact Methods: In response to the pandemic, at the sub- with abroad comer. An increase acute respiratory diseases regional level: alerts, updates and guidelines were incidence in Khartoum state hospitals above the base line developed and distributed; a Situation Room was activated was also reported. The National Public Health Laboratory with two 24/7 emergency phone lines; a multidisciplinary conducted a survey aiming to determine the burden of H1N1 Flu Team was formed; the laboratory testing algorithm for virus incidence among Sudanese children with acute respi- influenza was revised; there was a rapid increase in test- ratory illness attending emergency clinics in four pediatrics ing capacity; specimen collection kits, laboratory supplies hospitals in Khartoum state. and reagents were sent to countries; and prepaid courier Methods: Pre-survey orientation about influenza pan- accounts were set-up for shipment of specimens. Countries demic and expected bacterial pneumonia was held. Training revised and implemented their pandemic influenza plans. of personnel in specimen collection and preservation. From Results: As of November 18, 2009, there were 1,334 5th to 21st of November 2009, a total of 115 nasopharyn- laboratory cases of pandemic (H1N1), including 298 hospi- geal swabs were collected from children selected according talized cases and 18 deaths identified in 20 of 21 English to the WHO criteria of case definition of influenza- and Dutch Caribbean countries [Table 1]. Of the 18 deaths; like illness. Specimens were sent to the National Public 10 had underlying medical conditions, 9 were obese and Health Laboratory for real-time reverse-transcriptase— 3 were pregnant. Pandemic (H1N1) is the predominant polymerase-chain-reaction confirmatory testing for H1N1. circulating influenza virus type, with seasonal influenza Results: H1N1 was confirmed in 51 patients (44.4%), viruses (H1N1, H3N2 and influenza B) also circulating, but at another 5 patients were flu A (untypable) positive. Male to much lower levels. Most (> 85%) influenza cases had symp- female ratio 26:25. 4 patients were under one year of age, toms of upper respiratory tract infections; approximately 10 patients were within the range from 1-5 years and 24 14th International Congress on Infectious Diseases (ICID) Abstracts e105 patients above 5 years of age. The signs and symptoms of the rate. Combinatorial uncertainty analysis can be useful for disease were mild and rarely required more than 24 hours assessing the impacts of policies when decisions must be hospitalization. One case of fatality was reported. made in an environment of uncertainty. Conclusion: H1N1 outbreak (>40%) among Sudanese children have been confirmed with predominance of incidence doi:10.1016/j.ijid.2010.02.1718 in school aged children (above 5 years). 28.049 doi:10.1016/j.ijid.2010.02.1717 Providing guidance during the swine flu outbreak in 2009: An evaluation study of the National Resource for Infection 28.048 Control (NRIC) Assessing H1N1 (2009) mitigation strategies under epi- S. Wiseman 1,∗, P. Kostkova 2, E. de Quincey 2, G. Jawaheer 2 demiologic and programmatic uncertainty 1 ,∗ Department of Health UK and City University, London, M. Zivkovic Gojovic 1 , B. Sander 2, D. Fisman 3, M. Krahn 3, United Kingdom C. Bauch 4 2 City University, London, United Kingdom 1 York University, Toronto, ON, Canada Background: Over 40 000 professionals monthly access 2 Toronto Health Economics and Technology Assessment Col- the evidence provided by the National Resource for Infec- laborative, Toronto, ON, Canada tion Control (NRIC, www.nric.org.uk) - a digital library for 3 University of Toronto, Toronto, ON, Canada infection prevention and control, was launched in May 2005. 4 University of Guelph, Guelph, ON, Canada The project funded by the Department of Health (UK) is Background: Decision-makers faced substantial uncer- endorsed by NeLI (www.neli.org.uk) and its success has been tainties during the H1N1 (2009) pandemic. Uncertainties in its unique ability to provide the best available evidence were both epidemiologic (e.g. unknowns about likely attack published within the last 5 years (where possible) on inves- rate and severity) as well as programmatic (e.g., unknowns tigation, management, prevention, control and treatment about when vaccines would be available). Simulation mod- of, healthcare associated infection, and infectious diseases. els can be used to assess the effectiveness of mitigation The user base is coming from the UK, US and many other strategies, but model projections may change according to non-English speaking countries. The key added value is the assumptions about epidemiologic and programmatic vari- quality appraisal of posted documents conducted in collab- ables. oration with major professional societies. Methods: We developed a simulation model of a pan- Methods: During the swine flu outbreak from April until demic (H1N1) 2009 outbreak in a medium-sized Canadian August 2009, we conducted a wide evaluation of user city using demographic and epidemiologic influenza pan- searches and needs and access of key resources to better demic data. Simulated individuals were allocated into understand user concerns. homes, schools, workplaces and communities, and the We conducted a number of evaluation searches that will contact patterns and resulting spread of influenza were be presented on at this conference. Most importantly, page modeled. We projected the attack rate under different views for resources related to swine flu peaked in late combinations of vaccination, school closure, antiviral drug August, as illustrated on Figure 1. strategies, and ‘‘trigger’’ thresholds and under various Results: Further, important revelation was investigation levels of pre-existing immunity. To assess the impact of epi- of the swine flu searches along the timeline of the outbreak demiologic and program uncertainty, we used combinatorial clearly demonstrating the raise and increase of the keyword uncertainty analysis in which all possible scenarios combi- ‘‘pandemic’’ (graph in red) after 11th June 2009 and the nations are simulated, and the results stratified according keyword ‘‘influenza’’ (graph in green) after 23rd July 2009 to questions of interest. This permitted us to identify the while the keyword ‘‘pandemic flu’’ (graph in blue) initially general features of public health response programs that popular decreased. Figure 2 illustrates the popularity of the resulted in the lowest attack rates. three most frequent keywords. Results: Delays in vaccination of 30 days or more reduced Direct access to influenza resources on NRIC was also the effectiveness of vaccination in lowering the attack rate. encouraged by the placement of a dedicated link on the However, pre-existing immunity in 15% or more of the popu- Home Page (green line on Figure 2). Furhter timelines, traf- lation kept the attack rates low, even if the whole population fic and information needs analysis revealed an increase in was not vaccinated or vaccination was delayed. School clo- interest in evidence around pandemic influenza. sure was effective in reducing the attack rate, especially if Conclusion: Having learning these lessons we have applied early in the outbreak, but this is not necessary if vac- updated the NRIC Home page in October 2009 and are in cine is available early or if pre-existing immunity is strong. the process of collecting more results for the autumn sec- These results are robust under the combinatorial uncertainty ond wave. A comparative study of this unique evaluation analysis. For a baseline scenario of 5% pre-existing immunity and user navigation behaviour, user demographics as well as and no school closure, the attack rates under scenarios of searches from popular search engines will be presented at (i) no vaccination, vaccination of 30% beginning (ii) 30 days the conference. or (iii) 60 days after the outbreak were (i) 21.7%, (ii) 7.6%, and (iii) 12.5% respectively. doi:10.1016/j.ijid.2010.02.1719 Conclusion: Early action, especially rapid vaccine deployment, is disproportionately effective in reducing the attack e106 14th International Congress on Infectious Diseases (ICID) Abstracts

28.050 ditions. The identification of seasonal influenza virus strains Severe acute respiratory disease caused by pandemic in SARD patients reinforces the potential impact of sea- influenza A H1N1 virus. A case series of hospitalized sonal influenza on morbidity and mortality annually and the patients in Southeastern Brazil during the 2009 epidemic importance of a continuous epidemiological and laboratorial surveillance of respiratory syndromes. A. Feltrin 1, K. Augusto 1, J. Carvalho 2, J. Vitone 3, A. Silva 4, J. Morelli 5, F. Toniatti 2, M. Reis 6, C. Silva 7, B. Kemp 8, doi:10.1016/j.ijid.2010.02.1720 A.R.R. Freitas 8, M. Pacola 9, R. Angerami 10,∗ 28.051 1 Hospital Madre Theodora, Campinas, SP, Brazil Is the 2009 influenza A (H1N1) virus uncovering health 2 Santa Casa de Valinhos, Valinhos, SP, Brazil disparities in Miami? 3 Hospital Galileo, Valinhos, SP, Brazil ,∗ 4 Hospital Samaritano, Campinas, SP, Brazil F. Leguen 1 , A. LLau 2, G. Zhang 1, E. O’Connell 2 5 Santa Casa de Vinhedo, Vinhedo, SP, Brazil 1 Miami-Dade County Health Department, 33126, FL, USA 6 Epidemiological Surveillance Coordination of Vinhedo, 2 Miami-Dade County Health Department, Miami, FL, USA Vinhedo, SP, Brazil 7 Epidemiological Surveillance Coordination of Valinhos, Background: Since last April 2009 when the first cases of Valinhos, SP, Brazil 2009 H1N1 influenza were diagnosed in the United States, 8 Epidemiological Surveillance Coordination of Campinas, the Miami-Dade County has been the hardest hit by this Campinas, SP, Brazil disease among Florida counties. This outbreak has also 9 Epidemiological Surveillance Group, Regional Division of uncovered large disparities in the outcome of this disease Health VII, State Department of Health of São Paulo, Camp- among ethnic and racial groups in our community. Sixty-two inas, SP, Brazil percent of the 2,400,000 Miami-Dade County residents are 10 State University of Campinas, Campinas, SP, Brazil of Hispanic origin, eighteen percent are Black Non-Hispanic, and White Non-Hispanic respectively. Among County resi- Background: During the pandemic influenza A H1N1 dents, twentyeight percent have no health insurance, and (FluAH1N1) period in 2009, it was observed a significant seventeen percent live below the poverty level. number of suspected cases presenting severe acute respira- Methods: Information was retrieved from the enhanced tory disease (SARD). In this context, all health care settings public health surveillance database of Miami-Dade County have adapted their structure — including infection control residents who were hospitalized or died due to laboratory- strategies, emergency and intensive care unities organiza- confirmed 2009 H1N1 influenza infection reported to the tion, treatment protocols — to increase their capacity of Miami-Dade County Health Department between April 26th pandemic response. The main objective of this study is to and November 30th, 2009. describe the main clinical and epidemiological features of Results: During this period, a total of 32 patients died, a case serie of severe acute respiratory disease caused by and 423 were admitted at Miami-Dade hospitals due to this pandemic FluAH1n1 in a metropolitan region. disease. The hospitalization rate among Black Non-Hispanic Methods: Retrospective and descriptive study based on residents (26.7 per 100,000) was more than three times information of medical records and epidemiological files of higher than the one observed among White Non-Hispanics SARD hospitalized cases caused FluAH1N1 in 5 hospitals in (7.3 per 100,000). Black Non-Hispanic residents (1.9 per the metropolitan region of Campinas, São Paulo State, dur- 100,000) were more than twice likely to die due to this ing the first epidemic period in Brazil. disease than Non-Hispanic Whites (0.7 per 100,000). Miami- Results: Between July/6 and October/30 there were Dade had more pronounced disparities among racial/ethnic evaluated 254 cases of SARD; of them, 49 have been con- groups than the ones observed in other areas of the State of firmed as FluAH1N1 infection (19.3%) and 14 (5,5%) as Florida. seasonal influenza strain. Of the 49 confirmed FluAH1N1 Conclusion: The current 2009 H1N1 influenza outbreak cases, 28 were female (57.1%) and the median age was 26 has hit more severely the minority population in Miami- years (range: 0-75 years). The median time from onset of Dade, underscoring the need to address the social and illness and hospital admission was 2 days (range, 1 to 5). environmental factors leading to increasing health dispar- Nine cases (18.3%) were admitted in intensive care unity ities observed on this community. and 5 (10.2%) required mechanical ventilation. The most important clinical features were fever and cough(98%), dys- doi:10.1016/j.ijid.2010.02.1721 pnoea (77.5%), and malaise (83.6%). X-ray abnormalities were present in 75.5% of patients; leucocytes count was 28.052 elevated in 5 (10.2%) and reduced in 6 (12.2%) patients. Comparative evaluation of ARDS patients with and without Pre-existing conditions were observed in 28 patients (55.1%); H1N1 infection at a tertiary care referral center chronic respiratory disease (51.8%) and obesity (22.2%) were ∗ the most frequent underlying medical conditions. There T. Samra , M. Pawar, A. Yadav were 4 deaths associated with FluAH1N1 (lethality 8.1%), Dr.RML Hospital,PGIMER, New Delhi, India one of them with simultaneous seasonal influenza strain virus infection. Background: The recent emergence of H1N1 as pandemic Conclusion: As observed in other case series, it has been has raised concerns in its critical care management. The observed a higher frequency of SARD in female gender, management in our ICU is primarily based on guidelines of younger adults, and in patients with underlying medical con- sepsis and ARDS. So we compare our experience of Acute 14th International Congress on Infectious Diseases (ICID) Abstracts e107 lung Injury patients referred to our centre with and without ductive sector or insurers, depending on the time of license H1N1 infection. and various forms of recruitment. In the literature there are Methods: All patients admitted to our centre over a different models that show the impact generated by this period of 3 months were studied. Patients with Acute lung measure in different populations but not in our population. Injury and ARDS and clinical suspicion of H1N1 were shifted Methods: Our study was a simulation of discret events to the ICU specifically assigned for management of such with the Arena Professional Edition Software Version 11, patients. The demographic profile, presenting features, out- starting from the existence of a first case infected with the come and parameters of oxygenation and ventilation were virus, taking as susceptible population the total population recorded and compared. of Bogota, to compare 3 strategies of social distancing in Results: The clinical features were comparable in the two workers with wages: 1. Only hygiene measures in the work groups — H1N1 and nonH1N1 group, at the time of presen- site (washing hands and mask); 2. Unable to work for 3 days; tation in our centre. A total of 40 patients were shifted to and 3. Unable to work for 7 days. We calculated the costs our ICU with the clinical suspicion of H1N1 infection and of productivity lost with each of the strategies through the having respiratory compromise requiring ventilatory sup- approach of human capital. port. Out of these 26 patients were tested positive for H1N1 Results: The most cost-effective strategy for our pop- and rest were negative. The mean age was 32.8 and 31.8 ulation was to give incapacity during three days. For this years and male: female ratio of 16: 10 and 6:8 in patients strategy we calculated a total of 1,862,331 of infected with and without H1N1 infection respectively. 12 patients in patients and a mortality rate of 1.0%, the lost of produc- H1N1 group and 3 patients in nonH1N1 group had associated tivity calculated was 6 days, and the cost was 155 dollars comorbidities. The mean duration of symptom prior to need patient. of ventilator support was 6.4 and 5.9 days respectively in Conclusion: The strategy of social distancing more cost- the two groups. The mean PaO2 at the time of ICU admis- effective in preventing the spread of the virus influenza A sion was 48.6 and 52.7 mm Hg in the two groups respectively. H1N1 in the Colombian population is unable to work for 3 The The H1N1 group had 100% mortality while it was 71.4% days. in nonH1N1 group. The mean duration of stay in ICU was 3.4 and 5.5 days respectively in two groups. The acute renal doi:10.1016/j.ijid.2010.02.1723 failure was seen in 8 patients in H1N1 group as compared to none in nonH1N1 group. 42% and 36% of the patients required Malaria & Blood-borne Parasites (Poster Presenta- inotropic support in the two groups respectively. tion) Conclusion: The H1N1 positive patients has more florid and severe course with high mortality as compared to 29.001 nonH1N1 patients with similar demographic profile, ini- A study of acute myocardial infarction in a hospital cohort tial clinical symptoms and respiratory compromise requiring of malaria: 4 years retrospective analysis ventilatory support. K. Jain 1,∗, D.C.M. 2 doi:10.1016/j.ijid.2010.02.1722 1 JSS Medical college and hospital, Mysore, Karnataka, India 2 28.053 Kasturba Medical college, mangalore, mangalore, Kar- nataka, India Comparison between three not pharmacological strategies aimed to prevent the dissemination of the A/H1N1 Background: Malaria, a protozoal disease, caused by influenza virus in Colombia genus plasmodium, is prevalent in about 100 countries worldwide & is a major cause of morbidity & mortality 1 2 3,∗ 4 C. Alvarez , J.A. Cortes , M. Sossa , G. Aristizabal ,C. especially in sub Saharan Africa, Southeast Asia & Latin- 5 Rodriguez America. Myocardial infarction has not been recognized as a 1 Pontificia Universidad Javeriana, Bogota, Colombia complication of malaria though there have been reports of 2 Universidad Nacional de Colombia, BOGOTA, Colombia myocardial involvement in experimental studies and in post- 3 Unisanitas, Bogota, Colombia mortem findings. The objective of the present study was to 4 SecretariaDistrita de Salud, Bogota, Colombia analyze the association of acute myocardial infarction (AMI) 5 Clinica Colsanitas, Bogota, Colombia in malaria patients Methods: Retrospective observational study of 38,919 in- Background: Influenza by the new A H1N1/09 virus is patients of Dr. TMA Pai Rotary Hospital was done from the an emerging disease characterized by high transmissibility, year 1995 to 1998. Analysis had been started from 1995 as rapid capacity to spread, high pandemic potential and seri- malaria resurged in Mangalore city from 1995 onwards. A ousness of its complications, particularly in population with year wise categorizations of patients were done & occur- risk factors already established. The countries have been rence of AMI among patients with malaria was compared preparing for the impact of mitigation in case of appear- with the occurrence of AMI among all other in-patients ance of a new pandemic through the adoption of different for each year & cumulatively. Diagnosis of malaria cases strategies of which the social distancing is one of the most had been established by QBC test. Diagnosis of myocardial used strategies. Social distancing strategies have lasted in infarction had been established by following standard ECG an arbitrary manner between 7 and 21 days, and have a changes and cardiac biomarkers profile. After tabulation, p potential impact on the spread of the epidemic virus and at value has determined by applying standard Gaussian test. p the same time an economic impact on individuals, the pro- value <0.05 was considered to be significant. e108 14th International Congress on Infectious Diseases (ICID) Abstracts

Results: AMI was found in 2.47%(9/365), 1.29%(6/465), Conclusion: Almost all severe malaria patients treated 0.96%(4/418), 1.06%(3/283) of malaria patients in the year in Samarinda are males (91.5%) in productive ages (20 — 1995, 1996, 1997, 1998 respectively and 0.87%(96/11005), 40 years). Jaundice, cerebral malaria and acute renal fail- 0.87%(97/11113), 0.87%(75/8646), 0.71%(47/6624) of non- ure are the most common complications found. Mortality malarial in-patients during the corresponding period. The is related to the number of complications found, whereas occurrence of AMI gradually decreased in malaria patients as patients with 3 or more complications have very high mortal- the years progressed - from 2.47% in 1995, when Mangalore ity rate (above 70%). Overall mortality rate of severe malaria experienced a resurgence of malaria, to 1.06% in 1998. cases is 17.0%. Conclusion: Compilation of 4-year data has shown a higher occurrence of AMI among all malaria patients (1.44%) doi:10.1016/j.ijid.2010.02.1725 compared to AMI among all in-patients other than due to malaria (0.82%), (p<0.05). These findings suggest that AMI 29.003 should be regarded as an important clinical complication of Performance of four rapid diagnostic tests for diagnosis of malaria. This is of importance since some of the anti malarial falciparum and non-falciparum malaria in endemic areas drugs also depress cardiovascular function. of Gondar region, Northern Ethiopia A.K. Gelaglie doi:10.1016/j.ijid.2010.02.1724 Addis Ababa University, Medical Faculty, Addis Ababa, 29.002 Ethiopia Severe malaria in East Kalimantan, Indonesia Background: Malaria remains a major public health prob- ,∗ C. gunawan 1 , P.D. Nasution 2, A.R. Magdaleni 2 lem in Ethiopia, despite decades of a sustained national control program. One of the major obstacles to this control 1 Indonesian Malaria Expert Committee/ Mulawarman Uni- program is the lack of accurate and rapid diagnostic service versity School of Medicine/ A. Wahab Sjahranie General in most resource poor settings where malaria is endemic. Hospital, Samarinda, Indonesia Very recently, efforts have been made to develop and imple- 2 Mulawarman University School of Medicine, samarinda, ment various formats of malaria RDTs. Indonesia Methods: In view of this, the performance of the Background: Malaria is endemic in many provinces in OptiMAL-IT, Paracheck-Pf, CareStartTM malaria pLDH 4 line Indonesia, especially in Eastern Region, where 35% of popu- test and CareStartTM malaria pLDH/HRP II combo test were lation live in areas with risk of getting infected by malaria. investigated in comparison with microscopic examination of Mortality of severe malaria reported in Indonesia is 10 — thick and thin blood film in malaria endemic areas of Gondar 30%. Abdul Wahab Sjahranie General Hospital, Samarinda is region. In order to evaluate these assays, the sensitivity, the top referral hospital in East Kalimantan Province that specificity, PPV and NPV values of each RDT were calculated manage many severe malaria patients sent from some dis- taking microscopy results as the gold standard in a total of tricts around Samarinda.Objectives: To know the features of 588 febrile patients. severe malaria patients treated at Abdul Wahab Sjahranie Results: Paracheck-Pf was the most sensitive (100%) General Hospital Samarinda. assay for the diagnosis of P. falciparum in comparison with Methods: An observational study was performed on OptiMAL-IT (98.1%), CareStartTM malaria pLDH 4 line test severe malaria patients treated at the Department of Inter- (98.1%) and CareStartTM malaria pLDH/HRP II combo test nal Medicine of Abdul Wahab Sjahranie General Hospital, (96.2%). However, OptiMAL-IT was the most specific (99.1%) Samarinda during 2 years (January 2007 — December 2008). as compared to Paracheck-Pf (97.9%), CareStartTM malaria Severe malaria was diagnosed based on WHO criteria (pos- pLDH/HRP II combo test (96.4%) and CareStartTM malaria itive microscopic examination of Plasmodium falciparum pLDH 4 line test (93.8%) for falciparum malaria diagnosis. For with one or more complications). Anti malarial drug given the diagnosis of P.vivax, both CareStartTM assays had better was quinine infusion 10 mg/ kg BW/ 8 hours for at least sensitivity (94.4% for CareStartTM malaria pLDH 4 line test 48 hours, and then continued with sulfate quinine tablet if and 94.2% for CareStartTMTMTM malaria pLDH/HRP II combo patients could take oral medicines until 7th day. test (97.9%). malaria pLDH/HRP II combo test) as compared Results: There were 47 severe malaria patients treated to OptiMAL-IT 88.2%. But OptiMAL-IT gave the higher speci- in this hospital during 2 years, consisting of 43 males (91.5%) ficity (99.8%) than CareStart malaria pLDH 4 line test (98.1%) and 4 females (8.5%). All patients worked or lived in the for- and CareStart est areas out of Samarinda. Patients ages’ were 13 - 63 years, Conclusion: Although microscopy remains the gold most of them were 20 — 40 years (57.5%). The most com- standard for malaria diagnosis, OptiMALIT, Paracheck- mon complications found were jaundice (72.3%), cerebral Pf, CareStartTM malaria pLDH/HRP II combo test and malaria (40.4%), acute renal failure (31.9%), while severe CareStartTM malaria pLDH 4 line test may prove a useful anemia was only 6.4%. Most patients had 1 complication screening for malaria control in Ethiopia where microscopic (63.8%), while patients with 2 complications were 21.3%, examination is not in place. Finally, further studies on RDT and patients with 3 or more complications were 14.9%. Mor- performance is recommended to be undertaken in multisite tality of patients with 1 complication, 2 complications, 3 or study fields, in monitoring drug therapy and with respect to more complications were 6.7%, 10.0%, 71.4%, respectively. molecular analysis. Overall mortality rate was 17.0%. doi:10.1016/j.ijid.2010.02.1726 14th International Congress on Infectious Diseases (ICID) Abstracts e109

29.004 Results: During 2 year study period (May 2006- June 2008) Clinical presentation and outcome of severe falciparum 41 patients with Severe Malaria were admitted in differ- malaria in Eastern Nepal ent ICUs of Kasturba Hospital, of whom6 were females and 35 were males.11 patients succumbed to their illness and S.K. Sharma 1, B. Khanal 1, D. Manandhar 2, S. Rijal 1 30 survived. There was no significant difference in age and parasite index in patients who survived and succumbed to 1 BP Koirala Institute of Health Sciences, Dharan, Nepal illness. Clinical parameters like tachycardia, hypotension 2 Nepal Medical college, Kathmandu, Nepal and hypoxia were significantly seen in patients who suc- Background: Malaria is endemic in 65 out of 75 districts of cumbed to illness. Neurological obtundation was seen in Nepal and > 70% of the total population are at risk of the dis- all 11 dead patients at presentation is another independent ease. The clinical presentations of severe and complicated variable predictive of severe malaria Among lab parameters malaria vary. thrombocytopenia, raised BUN, Creatinine, low blood sug- Methods: Clinical profile, biochemical parameters and ars were significant predictive factors for mortality. Most outcome in 138 adult patients of malaria requiring hospital patients 10 out of 11 had lung involvement with ARDS admission in BP Koirala Institute of Health Sciences hospital, required ventilation. Mean APACHE III scoring among alive a tertiary care hospital in eastern Nepal during April 2002 to patients was 50.94 ± 17.25 and among dead patients was April 2005 were studied. 100.18 ± 26.86.The scores were compared by using Indepen- Results: Mean age of the patients was 33 ± 16 yrs with dent T test and the scores were highly statistically significant majority (n = 88) being in age group of 15 to 34 years. (p < 0.005) 67% of the patients were from terai belt (southern plain Conclusion: area). Mean duration of febrile illness was 13 ± 9 days at the time of presentation and 54% patients had recent his- 1. APACHE III is very good prognostic marker in predicting tory of travel to India. Hepatic dysfunction (39%), anemia mortality in severe malaria (30%), hypotension (18%), metabolic acidosis (16%), convul- 2. Among individual clinical parameters tachycardia, sion (11%), hypoglycemia (8%) and 22% (n = 30) had acute hypotension, hypoxia oliguria, altered sensorium were renal failure according to WHO criteria. Three or more associated with significant mortality complication was present in 32%. Apart from antimalarial 3. Among lab parameters raised BUN, Serum creatinine, therapy, dialysis support and mechanical ventilation was Hypoglycemia thrombocytopenia and chest X ray shad- provided to 22 and 25 patients respectively. All the patients ows (ARDS) predict independently high mortality and ≥ who died (23%) had 3 complications. need for ICU monitoring and aggressive treatment. Conclusion: Death from complicated malaria is high. Delayed in diagnosis leading to multiple complications might doi:10.1016/j.ijid.2010.02.1728 have contributed to high mortality. 29.006 doi:10.1016/j.ijid.2010.02.1727 Poor impact of the primary health care (PHC) on malaria 29.005 control in rural communities of Southeast Nigeria APACHE III score as a prognostic marker in severe malaria O. Odikamnoro in a tertiary care hospital from south India Ebonyi State University, Abakaliki, Ebonyi, Nigeria K. Nataraj 1,∗, M. Prabhu 2, M. Sangar 2, B. Ramachandran 2 Background: Malaria is a disease of poverty and low socio- 1 NRS Medical College, Kolkata, West Bengal, India economic status and these conditions abound in developing 2 KMC Manipal, Manipal, Karnataka, India countries. This means that the successful implementation of malaria control programmes requires a certain level of Background: Malaria is a most common parasitic infec- basic health services. In countries where malaria is a serious tion with transmission in 103 countries affecting > 1 billion impediment to socio-economic progress, emphasis should be people and causing between 1 and 3 million deaths each on malaria control rather tan eradication. This will reduce year. Falciparum malaria causing severe malaria is one of the the burden of the disease and pave the way for the speed- commonest infections with high mortality in India in spite of ing up of socio-economic development which may in the long potent chemotherapy. APACHE III is the most recent version run contribute to a future eradication of malaria. The resur- of the scoring system developed by Knaus and colleagues. gence of malaria is a global phenomenon. Most studies on So far no studies are available using APACHE III in severe malaria have dealt with clinical, laboratorial and entomo- malaria in Indian setting logical aspects. Few studies have dealt with human factors. Aims: Prospective clinical study of APACHE III score as a Methods: 2400 volunteers from all age- groups from predictor of mortality in patients with severe Malaria. selected endemic rural communities of southeast Nigeria Methods: 41 patients with diagnosis of severe Malaria were screened for malaria parasitaemia from June 2008 to admitted in Kasturba Hospital Manipal, tertiary care hospi- August 2009, using the thin and thick smear microscopy. tal during the period of May 2006 to June 2008 Statstics:SPSS Following this, 16 close-ended questionnaire items were 15.3 was used to perform statistics, depending on the nor- generated and administered on 600 adults, mainly heads malcy of distribution curve and skew deviation mean or of households to assess their knowledge, attitudes,and median was compared using Independent T test or Non para- practices on the various aspects of malaria transmission, metric t test such as Mann Whitney’s were used respectively. management and control, thus evaluate the impact of the e110 14th International Congress on Infectious Diseases (ICID) Abstracts

Primary Health Care on malaria control in the study areas. 29.008 Results: The results showed the following percentage Improving estimates of malaria intervention coverage infection in the varous age-groups: 0-11 months (24%); from household surveys using GPS data 1year-2years (43%); 2-4 years (80%); 5-9 years (74%); 10-14 ,∗ years (71%); 15 years and above (68%). A total of 1440 per- C. Burgert 1 , S.E. Bradley 2, F. Arnold 2, E. Eckert 2 sons were positive for Plasmodium falciparum parasitaemia, 1 Blue Raster, LLC, Arlington, VA, USA representing an average infection of 60%. In the question- 2 ICF Macro, Calverton, MD, USA naires, 93% of the respondents did not associate malaria with mosquito bite; 60% were not carrying out any form of vector Background: Standard indicators of malaria prevention control; only 7% had adequate knowledge of the manage- interventions, such as ownership and use of insecticide- ment of fever, and 15% had any knowledge of government treated mosquito nets (ITNs), are restricted to the action towards the control of malaria. population at risk of getting malaria. Household survey Conclusion: The study revealed poor implementation of measurements of those indicators, however, are typically the Primary Health Care as it concerns malaria control at the reported at the national level, including areas with little peripheral level. The remoteness of some rural communities or no malaria transmission. Moreover, many surveys are not and lack of easy accessibility makes it difficult for health conducted during the high malaria transmission season. For progrmmes to get to the grassroot. There is the need to these reasons, estimates of coverage by malaria interven- train a large number of Village-Based Health Volunteers, who tions are often biased downward. This paper quantifies the should step up community mobilizaion and health education effect of these biases by examining two coverage measures campaigns. Parents should know how to prevent and manage for universal coverage: 1) household possession of at least malaria fever in their children. one ITN (HP1+) and 2) at least one ITN for every two usual residents (HP1/2), by doi:10.1016/j.ijid.2010.02.1729 A) Using GPS data to correlate these measures with levels 29.007 of malaria endemicity and seasonality, and Malaria parasitemia in surgical patients in University of B) Recalculating coverage estimates based on the popula- Calabar Teaching Hospital, Nigeria tion at risk, taking into account the timing of the survey and endemicity in the area. N. Usoro ∗, E.E. Anwan, I.O. Uchejuru, O.J. Bam University of Calabar Teaching Hospital, Calabar, Cross Methods: Data come from 15 recent sub-Saharan Demo- River State, Nigeria graphic and Health Surveys (DHS) or Malaria Indicator Surveys (MIS). GPS location of household cluster is linked Background: Malaria is endemic in Nigeria. Surgical with Malaria Atlas Project maps to evaluate the malaria patients in our environment are predisposed to perioper- transmission zone and season. ative anemia and postoperative pyrexia due to malaria. We Results: The percentage of HP1+ households varies from carried out a prospective study of malaria parasitemia in 3.4% in Ethiopia to 53.3% in Zambia, and the percentage of surgical patients to evaluate the need for routine malaria HP1/2 households varies from 0.4% in Ethiopia to 18% in Zam- parasite (MP) test for surgical patients in an endemic area. bia. If the estimates are restricted to households located in Methods: Fifty adult elective surgical patients were endemic areas, coverage is considerably higher. For exam- tested preoperatively for MP by Giemsa staining of thick ple, HP1/2 universal coverage is 6% nationwide in Namibia, blood smear. Pre-operative hematocrit was also recorded but ranges from 2% in areas with no malaria to 11% in highly and patients were followed up for postoperative pyrexia. endemic areas (with parasitemia >40%). Rates of ITN use Results: Forty-four patients (88%) were positive for MP. also differ substantially: in Uganda, 11% of the population Twenty-one of these (47.7%) were anemic with mean hemat- in highly endemic areas interviewed during the malaria sea- ocrit of 33.3%. None of the 6 patients who were MP negative son slept under ITNs, compared to only 3% in areas with no was anemic (mean hematocrit 42%). Thirty-six patients had malaria. surgery and 20 of these had postoperative pyrexia for which Conclusion: Estimates of ITN ownership and use based 15 required antimalarial medication for resolution. All 15 on household surveys are strongly affected by the location had tested positive for MP. of survey clusters and the month of the interview. Taking Conclusion: There is significant malaria parasitemia these factors into account is recommended to improve the among surgical patients in our environment. This contributes monitoring of progress toward achieving national goals and to the perioperative anemia and postoperative pyrexia and to inform in-country programmatic decision-making. therefore the morbidity of our surgical patients. Routine preoperative MP test would facilitate prompt diagnosis and doi:10.1016/j.ijid.2010.02.1731 treatment of malaria, anemia, and postoperative pyrexia in this group of patients, thus reducing morbidity. doi:10.1016/j.ijid.2010.02.1730 14th International Congress on Infectious Diseases (ICID) Abstracts e111

29.009 29.010 Assessment of chloroquine resistance of Plasmodium in Blood microfilarial-stage specific gene expression profile patients attending malaria clinic in a government gen- of Brugia malayi eral hospital, Kurnool; Strategies to prevent chloroquine S. Nuchprayoon 1,∗, S. Sungpradit 2, A.E. Jedlicka 3,J. resistance Bailey 3, A.L. Scott 3 N. Mullaguri 1 Chulalongkorn University, 10330, Thailand Kurnool Medical College, 518002, India 2 Mahidol University, 10300, Thailand 3 Johns Hopkins University, Baltimore, MD, USA Background: Prevalence of chloroquine resistant malaria is on a rise and our area is one of the declared endemic zones Background: Lymphatic filariasis, a mosquito-borne dis- for malaria. Recent mortality trends of the disease have ease, is mainly caused by the nematodes Wuchereria increased considerably seeking immediate modification in bancrofti and Brugia malayi. The adult worms reside in the the treatment guidelines to decrease the complications and lymphatic vessels where they cause damage and the female thus the mortality of the disease. We have attributed the release an abundance of offsprings (microfilariae; Mf) into present condition to the chloroquine resistance, the drug the host’s circulatory system. The Mf stage is associated with which is used to treat the disease in this area for so long. disease transmission, complex disease pathology, and host Even the effective surveillance system fails in decreasing immunomodulation. Potential targets from the Mf stage for the mortality figures by following the prescribed treatment drug and vaccine development were investigated in order to guidelines. Hence, we have undertaken this project to assess reduce Mf density, improve disease morbidity, and prevent the drug resistance and to state new treatment guidelines in disease transmission. the areas where chloroquine resistant malaria is rampant. Methods: The Filarial Nematode Oligonucleotide Array- Methods: 250 patients are taken as sample in this project. Version 2 (BmV2array) slides comprising 18,153 oligonu- After diagnosing them as Malaria by peripheral smear and cleotide elements in duplicate that represent expressed IgM antibody detection tests, the patients are prescribed genes and predicted ORFs from B. malayi, Onchocerca volvu- chloroquine tablets as per the treatment guidelines in this lus, Wuchereria bancrofti, and Wolbachia, were used to region for 3 days closely watching them for complications. investigate gene expression changes in triplicate. 300,000 B. The number of patients cured of the disease are noted and malayi Mf cultured in vitro to identify potential therapeutic the number of uncured cases are assessed for the continu- targets. ation of symptoms. The percentage of cured to uncured is Results: By 48 hours, significant increase of Mf gene calculated and this serves as an evaluation tool for chloro- expression was found in succinate dehydrogenase, malate quine resistance. The Uncured subjects are prescribes Tablet dehydrogenase, NADH dehydrogenase, and cytochrome, Artesunate for 3 days. which are important in glycolysis/gluconeogenesis, cit- Results: 106 patients are not cured after Standard chloro- rate cycle, ubiquinone biosynthesis, and oxidative phos- quine treatment and prescribed Artesunate treatment. phorylation, respectively. Furthermore, expression of 144 patients are cured after the chloroquine treatment. immunomodulatory genes (e.g., macrophage inhibitory fac- % of cured patients = 57.6% tor,transforming growth factor beta, serpin, and glutathione % of uncured patients = 42.4% peroxidase), cathepsin-like cysteine protease, microfilar- The ratio of Uncured to Cured = 0.736 ial sheath protein, motility genes (e.g., actin, myosin, the ratio >0.5 tropomyosin, tubulin, and calmodulin), and ribosomal RNA Full details will be submitted in the conference. were also found upregulated. Conclusion: As the Ratio of Cured to Uncured is greater Conclusion: Microarray analysis is a valuable screening than 0.5 in this area, We want to intervene in the modifi- tool for identifying stage specific B. malayi Mf genes and cations of the standard treatment guidelines by introducing related metabolic pathways. The roles of these genes as Artesunate instead of Chloroquine for the Patients suffer- a target for developing novel antifilarial drugs or vaccines ing from Malaria in Our region. Any Endemic region with the should be verified. ratio of Uncured to cured >O.5 should modify the treatment guidelines to decrease the complication rates and thus the doi:10.1016/j.ijid.2010.02.1733 mortality caused by this disease. For the regions with the ratio less than 0.5, Co-prescription of Artesunate is advised 29.011 instead of relying only on Chloroquine. Nitric oxide synthase immunity in the malaria non-vector Anopheles culicifacies species B: a putative transmission doi:10.1016/j.ijid.2010.02.1732 blocking Plasmodium vivax immune responsive mechanism for refractoriness A. Sharma ∗, S. Vijay, M. Rawat, K. Raghavendra National Institute of Malaria Research, New Delhi, India Background: Innate immune-related anti-parasite defenses mounted by Anopheles may suppress the growth of Plasmodium in mosquitoes. Nitric oxide (NO) produced by the action of an inducible NO synthase (NOS) and its e112 14th International Congress on Infectious Diseases (ICID) Abstracts gene elements kill malaria parasite in vitro and may be evidence also suggests that An. belenrae is a potential vec- central to the anti-parasitic arsenal of this mosquito. tor. Preliminary studies indicate that, although An. pullus, Methods: In the present study, we have identified and An. kleini, and An. belenrae are found throughout Korea, characterized the expression of Anopheles culicifacies nitric population densities are highest near the DMZ and possibly oxide synthase (AcNOS) in non refractory (species A) and accounting for the high rates of transmission in this area. refractory (species B) in order to elucidate a plausible Methods: More than 5,000 larvae were collected from mechanism of refractoriness in terms of NOS physiolo- selected habitats near Warrior Base (approximately 3 Km gies. Understanding the difference between vector and south of the DMZ), labeled, placed in 100% ethanol, and non-vector mosquitoes can facilitate development of novel shipped to the Walter Reed Biosystematics Unit where they malaria control strategies were identified by PCR to species. Additionally, >7,000 Results: The specific activity of AcNOS and circulating adult anopheline mosquitoes were collected by light traps, levels of nitrite/nitrate in mid-guts and haemolymph, end Mosquito Magnets, and resting collections at selected sites products of NO synthesis, were found to be significantly in northern Gyeonggi and Gangwon Provinces (1-30 Km south higher in the refractory species B as compared to non- of the DMZ). The head and thorax of individual specimens refractory species A soon after invasion of the midgut by were identified to species by PCR and sporozoites, and Plasmodium vivax at the beginning and during the course malaria infected mosquitoes identified by single step and of blood feeding. Dietary feeding of a NOS inhibitor, L-NAME semi-nested multiplex-PCR. significantly decreased AcNOS enzyme activity and increased Results: Larvae were identified to species from selected the parasite numbers (oocysts) in infected mosquitoes, habitats and include Anopheles sinensis s.s., An. pullus, An. confirming that An. culicifaces species B limits Plasmod- kleini, An. belenrae, An. lesteri, and An. sineroides. Rice ium development via a NO mechanism. Amplification of paddies were the predominant habitat sampled. From adult the AcNOS gene fragment (200 bp) and sequence analysis collections, Plasmodium vivax was identified in An. belen- show the highest level of homology to other characterized rae, An. kleini, An. pullus, and An. sinensis s.s. We discuss inducible NOS genes. Increased levels of mRNAs (encoding the potential role of these vector species in maintaining iNOS) were observed at 7 days and 9-14 days after ingestion malaria in the ROK. of an infected blood meal using semiquantitative RT-PCR Conclusion: The identification of potential malaria analyses in the refractory species. Nitric oxide synthase vectors, their role in malaria transmission, and their dis- (NOS) gene elements inhibitory to growth of malaria parasite tributions, including population density, are important in in vitro and An. culicifaces NOS gene (AcNOS) is transcrip- understanding the dynamics of transmission and epidemi- tionally activated by the malaria parasite Plasmodium vivax ology of human cases in the ROK. Studies to determine the in refractory mosquitoes distributions of Anopheles spp. and their relative population Conclusion: Our studies have revealed that AcNOS may densities over their range are needed. be used as an additional effector gene to block the development of the malaria parasite in An. culicifaces mosquitoes. doi:10.1016/j.ijid.2010.02.1735 Our studies are important for understanding of innate immune-related anti-parasite defenses of the mosquito, 29.013 parasite-vector interactions and may relate to/elucidate the Cardiac function and haemodynamics in African children mechanism of refractoriness and fight against the disease. with severe malaria S. Yacoub 1,∗, H.-J. Lang 2, M. shebbe 3, M. Twimba 3,E. doi:10.1016/j.ijid.2010.02.1734 Ohuma 3, R. Tulloh 4, K. Maitland 3 29.012 1 Imperial College, W12 0NN, United Kingdom Malaria vector studies in the Republic of Korea: Vector 2 Imperial college, London, United Kingdom parasite rates and habitat distribution 3 Kenya Medical Research Institute- Wellcome Trust Pro- gramme, Kilifi, Kenya T. Klein 1, H.-C. Kim 2, L.M. Rueda 3, D.H. Foley 3,C.Li3, 4 Bristol Royal Hospital for Children, University Hospitals R.C. Wilkerson 3 Bristol NHS Foundation Trust, Bristol, United Kingdom 1 65th Medical Brigade, Seoul, Korea Background: Mortality from severe malaria remains unac- 2 Republic of, 168th Multifunctional Medical Battalion, ceptably high in sub-Saharan Africa. Several markers of Seoul, Korea cardiovascular compromise and metabolic acidosis corre- 3 Republic of Walter Reed Army Institute of Research, Suit- late with mortality. The role of cardiac dysfunction in the land, MD, USA pathogenesis of severe childhood malaria remains unknown. Background: In 1993, vivax malaria reemerged along the In this study we aimed to investigate cardiac function demilitarized zone (DMZ) of the Republic of Korea (ROK) and haemodynamic status of children admitted with severe and rapidly increased to more than 4,000 cases by 2000. malaria, assessing changes over time and response to fluid Although it was presumed that malaria would rapidly spread resuscitation. throughout Korea, malaria transmission remained concen- Methods: Setting:High Dependency Unit, Kilifi District trated near the DMZ. In 2005, two new species of Anopheles Hospital, Kenya. We examined thirty children admitted mosquitoes were identified, with studies indicating that with severe malaria using portable echocardiography to Anopheles pullus and An. kleini were likely the primary vec- assess their cardiac function and haemodynamic status on tors, while An. sinensis s.s., was a secondary vector. New admission (day 0), day 1, and discharge. We compared 14th International Congress on Infectious Diseases (ICID) Abstracts e113 haemodynamic parameters in two study groups: children 29.014 presenting with metabolic acidosis (base deficit > 8) and Transfusion-associated Babesia infections: Reports children without acidosis. Acidotic patients received fluid received by the FDA 1997 to 2008 resuscitation with either Dextran 70 or Hetastarch at admis- ∗ sion. D. Gubernot , K.C. Lee, G.B. Conley, L.G. Holness, S. Results: Several markers of haemodynamic compromise O’Callaghan, S. Cannon, E. Cowan, H. Nakhasi, R.P. Wise were noted on admission including severe tachycardia, Food and Drug Administration, Rockville, MD, USA low stroke volume index (SVI) and high inferior vena cava collapsibility index (IVCCI) that improved with subse- Background: Babesiosis is a known transfusion- quent readings (fig 1). Overall, cardiac function assessed transmitted disease risk and there is no FDA-licensed by ejection fraction (63.1% ± 5.2 vs. 71.9% ± 2.8 P=<0.001) test for donor screening. Approximately 80 transfusion- and left myocardial performance index (LMPI) (0.32 ± 0.16 transmitted cases have been reported 1979 through 2008. vs. 0.25 ± 0.08 P = 0.03) was mildly abnormal on admis- This research evaluated the Babesia-related transfusion sion compared to discharge. Acidotic patients had worse events reported to the Food and Drug Administration (FDA) haemodynamic indicators, with significantly higher IVCCI with particular focus on numbers and characteristics of on day 0 than non-acidotic patients (52.1 ± 21 .9 vs. transfusion-related babesiosis fatality reports. 37.7 ± 15.4 P = 0.03); plus lower SVIs and worse cardiac func- Methods: Data were collected from FDA’s Blood Col- tion with higher LMPI (0.38 ± 0.18 vs. 0.26 ± 0.11 P = 0.05). lection and Transfusion Fatality Reporting and Biological SVI increased post first fluid bolus in 80% of acidotic chil- Product Deviation Reports (BPDRs) surveillance systems. dren, from an average of 36.7 ml/m2 (95% CI: 30.9- 42.5) to 41.5 ml/m2 (95%CI: 37.19- 45.8, P = 0.007).

Inferior Vena Cava collapsibility Index in severe malaria by acidosis over time Results: From 2005 through 2008, the FDA received 10 Conclusion: Children with severe malaria have evidence transfusion-related babesiosis fatality reports after only one of intravascular volume depletion and associated mild car- prior report in 1998. Recipients presented with symptoms diac dysfunction which are more marked in those with 2.5 to 9 weeks after transfusion of implicated red blood metabolic acidosis. By optimizing cardiac output, this might cell units. In recent years, FDA has also seen an increase aid microvascular flow and tissue perfusion with the aim in Babesia-related BPDRs involving donors with post dona- of impacting on the metabolic derangement and associated tion illness and reports of potential transfusion-transmitted high mortality in these children. disease. Most reports submitted to the FDA implicate B. microti. doi:10.1016/j.ijid.2010.02.1736 Conclusion: The reports received by the FDA indicate Babesia infection may be a rare but increasing risk to the blood supply. Without a licensed screening test to prevent these transmissions, enhanced clinician awareness of the possibility of babesiosis in febrile, recent transfusion recipients may facilitate prompt diagnosis, improved prognosis, and more timely investigations to interdict infected units. Prompt reporting of babesiosis donor and transfusion- e114 14th International Congress on Infectious Diseases (ICID) Abstracts related events assists the FDA in assessing the scope of this 29.016 risk and developing appropriate public health control mea- Artemisinin combination therapies: Public and private sures. market and policy surveys in Burundi and Sierra Leone Disclaimer: The findings and conclusions in this abstract ,∗ have not been formally disseminated by the Food and Drug J. Amuasi 1 , Y. Karikari 1, I. Boakye 1, S. Blay 1,L. Administration and should not be construed to represent any Nsabiyumva 2, A. Jambai 3, G. Diap 4 Agency determination or policy. 1 Komfo Anokye Teaching Hospital, KUMASI, Ghana 2 National Malaria Control Program, BUJUMBURA, Burundi doi:10.1016/j.ijid.2010.02.1737 3 Ministry of Health, FREETOWN, Sierra leone 29.015 4 Drugs for Neglected Diseases Initiative, Geneva, Switzer- land Clinical and epidemiological study of patients with malaria treated at the hospital central de Las Fuerzas Armadas in Background: Access to Artemisinin-based Combination Dominican Republic Therapies (ACTs) is still limited in Africa, even though ACTs are recommended by the WHO since 2002. In order to bet- C. Rodriguez-Taveras, L.C. Socias, C. Blanco, J.R. Reyes ∗, ter understand the situation where access has traditionally J.M. Puello been limited, policy analyses and market surveys on anti- Hospital Central de Las Fuerzas Armadas, Santo Domingo, malarial availability and accessibility have been conducted Dominican Republic in selected countries where the ACT, artesunate and amodi- aquine (AS + AQ), has been adopted as first line. Background: As a tropical country, Dominican Republic Methods: The analyses described here were conducted is a malaria endemic area and although it has reduced its in the public and private sectors of Burundi and Sierra incidence, continues to be in the differential diagnosis of Leone using internationally standardized methodologies. febrile illnesses. Data were obtained by reviewing publications; interviewing Methods: This is a retrospective study to assess the relevant health stakeholders; and visiting hospitals, health epidemiological and clinical characteristics of patients diag- centres, pharmacies, and drug sale outlets. nosed with Malaria admitted from January 2008 to November Results: Patients are not accessing ACTs due to systemic 2009, at the hospital, a tertiary-care center, and regional barriers varying between countries. In Burundi, quinine was reference, that serves to the military population, relatives the most common over-the-counter antimalarial found in all of these and the civilian population as social action. Inclu- sectors despite not being first line and being more expensive sion criteria were suspected diagnosis of Malaria at the time than ACTs. Chloroquine (CQ), which has been banned from of admission and confirmed by the presence of asexual forms importation, was not found. Public sector cost of AS + AQ in thin blood smears or thick made at the time of initial (0.16 USD) was found to be 1/5 the cost in the private sector evaluation. (p = 0.00021). In Sierra Leone, no antimalarial importation Results: Of 93 febrile patients admitted with suspected policy exists, the average cost of AS + AQ was approximately malaria, this diagnosis was confirmed in 13 (13.9%), 11 three times the cost of CQ. Although antimalarials like (84.6%) were men. The mean age found was 32 Years (range AS + AQ are not expected to be sold in the public sector, 15-62). While 46.1% were found within Santo Domingo and AS + AQ was found in three public sector outlets at a higher Distrito Nacional, the distribution by region was: South cost (1.88 USD) than either the mission/NGO cost or the (7.7%), North (7.7%), the border region (38.5%). All were private-sector cost (p < 0.0001). symptomatic at diagnosis. The typical clinical presentation Conclusion: Having on-the-ground data best informs the observed in most cases: fever (98.4%), headache (85.6%), malaria community - including the partnership who made chills (46.6%), myalgia (34.5%) and jaundice (10.9%). All the fixed-dose AS/AQ available in 2007 - on how to overcome were managed within the hospital, required standard of access barriers to the widespread adoption and proper use of this military institution. All cases were autochthonous and ACTs. In Burundi, the paucity and cost of ACTs in the private P. falciparum were the only parasite found in all the sector must be addressed. In Sierra Leone, a specific anti- patients, responding satisfactory to chloroquine and pri- malarial importation policy could allow for uniformity and maquine treatment. Death occurred in 1 (7.7%). The average improve adherence to nationally recommended standards. time between the start of clinical setting and the diagnosis was 6.5 days for patients who were transfer from other parts doi:10.1016/j.ijid.2010.02.1739 of the country and 2.8 days (p < 0.05) for those who came seeking medical care directly in the hospital. Conclusion: Attention should be given to febrile patients, and test to investigate malaria must be included as a routine, regardless of the provenance, but especially those living in the border region with Haiti, the interval between the clinical setting and the diagnosis has a prognosis value. The P. falciparum is the unique species prevalent in Domini- can Republic, and chloroquine and primaquine continues to be therapeutic option of choice. doi:10.1016/j.ijid.2010.02.1738 14th International Congress on Infectious Diseases (ICID) Abstracts e115

29.017 29.018 Role of ultrasonography in malaria pregnancy Treatment failure of Artemether-lumefantrine in Falci- parum Malaria in Brazilian Amazon area M. Brock 1,∗, F.E.M. Espinosa 2, J.R.D.T. Leao 3 M. Quiroga 1, A. Lara 1, M. Mascheretti 2,∗, P. Abati 1,M. 1 University of Amazon State (UEA), Manaus, AM, Brazil Boulos 3 2 Fundação de Medicina Tropical do Amazonas, Manaus, Brazil 1 Tropical Medical Center, an accord between the Infectious 3 Universidade do Estado do Amazonas - Fundação de Medic- Diseases Department Hospital das Clínicas University of Sao ina Tropical do Amazonas, Manaus, AM, Brazil Paulo School of Medicine and the Health Department of Santarém, Pará, Brazil., Santarem, Brazil Background: Malaria acquired during pregnancy is one of 2 Centro de Vigilância Epidemiológica CVE/CCD/Secretaria the major causes of poor maternal and birth outcomes in de Estado de Saúde de São Paulo, Sao Paulo, Brazil tropical areas endemic for this disease. Malaria during preg- 3 University of Sao Paulo, Sao Paulo01246, Brazil nancy induces deterioration of placental function, resulting in transient fetal hypoxia and can induces grouth restric- Background: According to Pan-American Health Organi- tion. Ultrassound assessment of intrauterine growth, fetal zation (PAHO) around 11 million of Brazilians live in regions and Placental abnormalities is often used as a important under moderate risk of malaria transmission and 1.5 million clinical tool to identify these patological findings. under high risk. The Ministry of Health in Brazil registered Methods: Fetal biometric mesurements, placental and 314,678 malaria cases (Pf: 46,093, Pv: 265,530, Pf + Pv: amniotic fluid evaluation were obtained and thereafter at 2,975, P.m: 78, Po: 2) all over the country in 2008, 99.5% 4 week intervals from pregnant women enrolled in a longi- of them in Amazonian area. Para state was responsible for tudinal study. 69,212 cases in 2008 (Pf: 10,746, Pv: 57,686, Pv + Pf: 753, The study population comprised 162 singleton gestations P.m:27) Artemisinin combination therapies have been estab- with ultrasound derived gestational age in the first trimester. lish as first choice treatment for falciparum malaria as an Estimated fetal biometric parameters and weight were cal- effective public health of Brazilian Ministry of Health since culated at each ultrasound examination using the Hadlock 2008. algorithm. Placental thickness were estimated using Lub- Methods: Descriptive study. The goal of this study is to schenco data and amniotic fluid was avaliated based in describe the epidemiological and clinical profile of treat- Phelan study. ment failure of Artemether-lumefantrine in two cases of Were included on these study pregnant womens with any Falciparum Malaria in Santarem, Para state, Brazil in 2009. Malaria infection in treatment. Cases were admitted at the Municipal Hospital of Santarem, Were excluded of thete study pregnant womens without case records were retrospectively reviewed. treatment, with any patology that can afect fetal growth, Results: Case 1: male, 52 years old, gold miner worker and multiple gestations. in Para state, admitted in August, 2009 with symptoms of Results: Fetal growth restriction occured in 7 patients fever, headache, nausea, vomit and fatigue. Clinical mani- (4%). Placental thickness was increased in 4 patients (2,4%) festation as anemia and painful hepatomegaly was observed. and decreased in 1(1,2%), 3 pacients had oligodramnious. 1 Peripheral blood smear was positive for malaria P. falci- fetus (1,2%) had bilateral cleft lip detected by ultrasound parum and P. vivax. Patient received specific treatment scan. with Artemetherlumefantrine and primaquine with no side Conclusion: These datas are against the normal popula- effects and clinical improvement. The cure control blood tions datas were the incidence of fetal growth restriction is smear on day 3 was negative. On day 12 microscopy revealed 3% and fetus malformation 1-2%. This study shows that in a P. falciparum parasitemia. well treated population, the fetal growth can be the same Case 2: male, 43 years old, gold miner worker in Para as the population without Malaria. The ultrasonograophy is a state, admitted in October, 2009 with symptoms of fever, good method of fetal, placenta and amniotic fluid evaluation headache, malaise and fatigue. Clinical manifestation as and should be used to folow patologic pregnancy. mucocutaneous pallor and hepatomegaly was observed. Peripheral blood smear was positive for malaria P. falci- doi:10.1016/j.ijid.2010.02.1740 parum (8,000 trophozoito/mm+). Patient received specific treatment with Artemetherlumefantrine with no side effects and clinical improvement. Seventeen days after the malaria diagnosis re-started symptoms of fever, headache and diarrhea, peripheral blood smear was positive for P. falciparum (9,000 trophozoito/mm+). Both cases were successfully re treated with fixed combination of artemether-lumefantrine. Conclusion: Treatment failure with artemisinin combination therapies has been sporadically reported. Further studies are necessary to investigated artemisinin resistance.

doi:10.1016/j.ijid.2010.02.1741 e116 14th International Congress on Infectious Diseases (ICID) Abstracts

Mycology, Fungal Infections and Antifungal Drugs 30.002 (Poster Presentation) Influence of gender, age, previous hospitalization and 30.001 hospital stay on Candida-colonization of patients in a non- surgical ICU Candida species in the lower respiratory tract of healthy ,∗ individuals A. Gloeckner 1 , P. Abel 2 H.J. Salzer 1,∗, R.B. Raggam 2, I. Zollner-Schwetz 1,M. 1 BDH-Klinik Greifswald, Greifswald, Germany Hoenigl 1, T. Valentin 1, R. Krause 1 2 University of Greifswald, Greifswald, Germany 1 Medical University of Graz, Graz, Austria Background: The incidence of systemic fungal infections 2 University Hospital Graz, Graz, Austria is increasing and their mortality remains high despite all advances in therapy. Accurate diagnostic measures are still Background: Candida species (spp.) are frequently iso- difficult to obtain and evaluate in order to determine the lated from respiratory tract secretions such as endotracheal need for antifungal treatment. Moreover, Candida species aspirates (EA) in patients with pulmonary infiltrates. Since differ substantially in their antimycotic susceptibility. Thus the prevalence of Candida spp. in the lower respiratory knowledge of species to be expected is crucial for not miss- tract is unknown in healthy individuals the pathogenetic ing the diagnosis and making the right decision how to treat. relevance of Candida spp. in the lower respiratory tract is Methods: In a prospective study over 30 month we anal- difficult to assess. ysed samples from 411 patients (160 women and 251 men, Methods: A total of 71 healthy individuals without clini- mean age 63.6 years, mean APACHE-II-Score 20.8) admit- cal, laboratory or radiological evidence of respiratory tract ◦ ted to our ICU. Swabs from nostril, throat and anus and infections (temperature >38 C, elevated CRP >8 mg/dl, specimens of tracheal secretions and urine were taken and leukocytosis >11400, elevated neutrophiles) or any other cultured on CHROM- or CandID- Agar at 36 ◦C. The hospital- lung diseases (e.g. COPD, asthma bronchiale, sarcoidosis, ization history of the patients was investigated. interstitial lung disease, malignant diseases of the lung) Results: Positive results were found in 43% of all undergoing general anaesthesia due to elective surgery 1868 investigated samples. Concerning the distribution of were enrolled. Exclusion criteria included antifungal ther- species, we found Candida albicans in 69%, Candida glabrata apy within 8 weeks and antimicrobial therapy within 4 weeks in 35% and Candida tropicalis in 8% of all positive specimens. prior to study inclusion (with the exception of antimicrobial The colonization index was higher in women than in men surgical prophylaxis), immunosuppressive therapy, active (mean 0.47 vs. 0.39, p < 0.01) with no significant influence haematooncological diseases and HIV positivity. The pres- of age. This difference was due to a higher rate of colo- ence of Candida spp. in the lower respiratory tract was nization of anus and urine in women (both p < 0.001). The investigated in EA samples cultivated on Candida CHROMa- species distribution showed no difference between sexes, gar. The Candida colonies were differentiated as C. albicans, but the rate of nonalbicans species rises significantly with C. glabrata, C. krusei, C. tropicalis or others according age (in females p < 0.05, in males p < 0.01). A hospital stay to the color of colonies and by API Aux test. For bacte- longer than 7 days before admission to the ICU was linked rial growth EA samples were further cultivated on selective with a higher rate of colonization (52% vs. 38%) but not with agars. Bacterial cultures are counted and identified by rou- a significant change in species distribution. Patients who had tine microbiological procedures. In addition, oral swabs been hospitalized within two years before the current hospi- were obtained and cultured on Candida CHROMagar. tal admission, showed a higher rate of colonization (42% vs. Results: A total of 88 microorganisms were isolated from 36%) and a higher proportion of non-albicans species (48% 41 of the 71 EA samples containing 1 yeast (C. krusei), vs. 34%). 62 gram-positive and 25 gram-negative bacterial species Conclusion: 1. Women are more frequently colonized including the indigenous oral flora. In 30 EA samples nei- with yeasts than men, particularly in urine and anal swabs. ther bacteria nor fungi were cultured. A total of 24 Candida 2. With advancing age, the proportion of non-albicans spp. were isolated from 21 of the 71 oral swabs containing species detected is increasing. 3. A longer duration of hos- 18 C. albicans, 2 C. glabrata and 1 C. krusei isolates. In addi- pital stay is associated with a higher colonization rate. 4. tion, C. krusei isolated from both EA sample and oral cavity Repeated hospitalizations are linked with a higher rate of was originated within the same patient. non-albicans species. Conclusion: The colonization of the lower respiratory tract with Candida spp. in healthy individuals seems to be doi:10.1016/j.ijid.2010.02.1743 uncommon, despite a relative frequent Candida spp. colonization of the oral cavity. 30.003 Mixed fungal colonization in non-surgical intensive care doi:10.1016/j.ijid.2010.02.1742 patients A. Gloeckner 1,∗, P. Abel 2, K. Zimmermann 2 1 BDH-Klinik Greifswald, Greifswald, Germany 2 University of Greifswald, Greifswald, Germany Background: Knowledge of risk factors is important for properly applying and evaluating diagnostic tests to derive 14th International Congress on Infectious Diseases (ICID) Abstracts e117 therapeutic conclusions. Colonization with fungi has been Results: While 64,20% (64.9%) were C. albicans, 7,5% identified as an independent risk factor for invasive myco- (7.8%) were C. glabrata ahead of C. tropicalis with 4,7 sis. In addition to colonization with a single species, the (4.6%), while in 1,74% C. krusei was detected. 384 isolates combination of different fungal species may be of interest. were obtained from two hemato-oncology units with C. albi- Methods: In a prospective study we analyzed samples cans 52, 3% (80.5%) ahead of C. glabrata 8,1% (7.8%), C. taken from 411 patients after admission to our ICU. Swabs tropicalis 5,4% (4.7%) and C. krusei (1.9%). A total of 148 from nostril, throat and anus and specimens of tracheal isolates were detected from blood cultures. C. albicans was secretions and urine were taken and cultured on CHROM- found to be less common in candidemia 57,5% (58.9%), but Agar. dominated far ahead of C. glabrata 17,1% (20.9%), C. trop- Results: Positive results were found in 798 (42.7%) of icalis 6,8% (7.0%), C. parapsilosis 4,8% (5.4%) and C. krusei all 1868 samples. Of these, 618 were positive for a single 2,7% (3.1%). 28.6% of candidemia eps was by C glabrata in species, 158 for two species, and 22 for three species. Con- cancer pts in 2008 an 09. cerning distribution of species, we found Candida albicans Conclusion: Although a shift towards C. non albicans has in 69.3%, Candida glabrata in 34.8% and Candida tropi- been described elsewhere, our study indicated C. albicans calis in 8.1% of all positive specimens. In 90 cases, cultures remains the leading species. No further shift to C. glabrata grew Candida albicans together with Candida glabrata,in23 and C. tropicalis has been observed within the last 4 years. cases, Candida albicans together with Candida tropicalis,in If candida is found, C. glabrata is detected about 2.3-fold 12 cases, Candida albicans together with Candida glabrata more often and accounts for 17% of candidemia eps, with and Candida tropicalis. Most frequently, a mixed coloniza- an even 3.8-fold higher risk in cancer pts. Echinocandins, tion was detected from throat swabs (74 mixed, out of 281 newer azoles and lipid AmB therefore seem to be justified positive cultures, 26.3%), followed by tracheal secretions for upfront candidemia Rx, in particular cancer and those (35 mixed, out of 153 positive cultures, 22.9%) and anal pts with an unstable clinical condition. swabs (48 mixed, out of 235 positive cultures, 20.4%). In contrast, a mixed colonization was significantly less frequent in doi:10.1016/j.ijid.2010.02.1745 nasal swabs (18 mixed, out of 136 positive cultures, 13.2%) and in urine (5 mixed, out of 56 positive cultures, 8.9%). 30.005 Conclusion: A large proportion of samples showed growth Anti-Saccharomyces cerevisiae (ASCA) antibody levels in of yeasts. Out of culturally positive, in 22.6% were found a subgroup of patients with ulcerative colitis, Crohn’s dis- more than one species. Colonization with more than one ease, GI Behcet, and GI tuberculosis: Correlations with species was found to be significantly more frequent in disease duration, activity, and extension throat, trachea and anus compared to nose and urine. M. Aslan 1,∗, B. Kocazeybek 1, A. Celik 2, Y. Erzin 3,I. Hatemi 2, G. Hatemi 2, H. Yazici 2 doi:10.1016/j.ijid.2010.02.1744 1 Istanbul University Cerrahpasa Faculty of Medicine, 30.004 Turkey, Turkey Recent trends of Candida epidemiology in cancer and non- 2 Istanbul University Cerrahpasa Faculty of Medicine, Istan- cancer patients bul, Turkey 3 ,∗ Yeditepe University Medical Faculty, Istanbul, Turkey M. Karthaus 1 , R. Biedenkopf 1, M. Hentrich 2, X. Schiel 2,I. Schuth 3, G. Schwarzkopf-Steinhauser 4 Background: Clinical utility of serological markers in inflammatory bowel disease (IBD) diagnosis and differen- 1 Klinikum Neuperlach/Tumorzentrum München Süd, tiating is controversial. Recently ASCA has been found to Munich, Germany have some correlation with the complication and recurrent 2 Klinikum Harlaching, Munich, Germany surgery rate Our aim was to seek for correlations between 3 KKS&C, Coblenz, Germany ASCA levels and disease duration, extension, activity, CRP 4 Klinikum München, Munich, Germany levels, and use of immmunosupressive therapy Background: In recent years a shift towards candida non Methods: A total of 41 consecutive patients (16 UC, albicans has been reported from candidemia trials. A species 20CD, 3 GI BD, and 2 GI Tb; 34 women, 7 male) were ana- shift in candidemia is important, since newer guidelines lyzed regarding ASCA IgG levels with anti-ASCA IgG ELISA kit favor upfront echinocandins containing an economic bur- (Euroimmune, Lübeck, Germany), the cut-off value being den. This has to be balanced with medical needs. Trends 15 U/ml. Disease activity was assessed using SEO for UC and of epidemiology outside of controlledl trials are therefore CDAI for CD, GI BD, and GI Tb patients, respectively. Addi- of particular interest. tionally, a simplified endoscopic extension score was used We analyzed all candida isolates from five Munich teach- by dividing the colon into six equal units and accepting ileal ing hospitals (3500 beds). The objective was to compare all involvement as an additional unit in an ordinal manner. SPSS candida isolates and all candidemia eps in 2008 and 09 with 15 for Windows is used for data collection and are expressed the previous 2ys (data in brackets). as means, with SD of the mean calculated when appropriate. Methods: Between 01/08 and 10/09 a total of 15258 can- Correlations were sought using Pearson’s and Spearman’s dida isolates were detected. No routine azole prophylaxis correlation coefficient and multivariate analysis was per- was given beside high risk cancer pts.There was no hint for formed by using a stepwise regression model. p < 0.05 was a seasonal cluster during the study periods. regarded as significance. e118 14th International Congress on Infectious Diseases (ICID) Abstracts

Results: The mean age (±SD) of patients was patients-4.8% (p = 0.000). The prevalence of ASCA in BD 37.31 ± 10.65 years, 83% of them being female, and patients-15.4% disclosed a significant difference compared 14 out of 41 (34%) patients were in an active phase of to CD patients (p = 0.014), but the prevalence of ASCA in TBC the disease. ASCA IgG levels significantly were correlated patients showed no significant difference compared to CD or with sypmtom duration x disease extension score factorial BD patients. (r = 0.481, p = 0.001), disease duration x disease extension Table 1: Prevalence of pANCA and ASCA in different sub- score factorial (r = 0.468, p = 0.002), and SES-CD (r = 0.480, groups.Marked values(p < .05) p = 0.001). No correlations were noted between ASCA pANCA(+) ASCA(+) age male(%) and CRP levels and clinical activity. On age-sex adjusted IBS (n = 130) 1(0.8%) 4(3.07%) 40.84(SD 12.69)* 42.3(a) HC (n = 165) 1(0.6%) 7(4.2%) 35.07(SD 10.49)*;** 40(b) stepwise regression analysis, sypmtom duration, disease UC (n = 102) 43 (42.2%) 11(10.8%) 40.72(SD 13.44)** 50(c) duration, disease extension, and SES-CD entered into CD (n = 63) 3 (4.8%) 34(54%) 37.56(SD 12.65) 38.1(d) the model, disease extension score was found to be the GI-BD (n = 13) 0 2(15.4%) 32.11(SD 8.89) 61(e) Celiac Disease (n = 10) 0 4(40%) 36.77(SD 7.94) 0(a;b;c;d;e;f) only independent predictor of ASCA IgG levels (R2 = 0.1, GI-TBC (n = 10) 1(10%) 3(30%) (SD 9.96) 70(f) p = 0.044). Conclusion: Although the aetiopathogenesis of inflam- Conclusion: Our results confirm that in clinical practice matory bowel disease remains unsolved, a serologic ASCA is not specific enough to be a useful tool in differential anti-microbial response exists one of them being ASCA. Dis- diagnosis of any specific inflammation. However, it may have ease and symptom duration, disease extension but clinical some value in screening of normal population for any bowel activity have significant correlations with ASCA levels point- inflammation. pANCA may have a better clinical value in the ing out to the importance of sustained immunological stimuli discrimination of UC from other intestinal inflammations. as a triggering process. These results might provide new insights into the mechanisms of epithelial responses to anti- doi:10.1016/j.ijid.2010.02.1747 gens and ideas for therapies. 30.007 Comparative studies on the in-vitro activity of pen- doi:10.1016/j.ijid.2010.02.1746 tamycin against non-albicans Candida species and 30.006 Saccharomyces cerevisiae in 161 clinical isolates Clinical utility of perinuclear antineutrophil cytoplasmic C. Winnips 1,∗, W. Buzina 2, B. Dupont 3 antibodies and anti-Saccharomyces Cerevisiae antibodies 1 for discriminating specific intestinal inflammations Lumavita AG, Basel, Switzerland 2 Institute of Hygiene, Microbiology and Environmental 1,∗ 1 2 3 B. Kocazeybek , M. Aslan , Y. Erzin , A. Celik ,I. Medicine, Medical University of Graz, Graz, Austria 3 3 3 Hatemi , G. Hatemi , H. Yazici 3 Service de Maladies Infectieuses et Tropicales, Hôpital 1 Istanbul University Cerrahpasa Faculty of Medicine, Necker-Enfant Malades, Paris, France Turkey, Turkey Background: Pentamycin is a broad-spectrum polyene 2 Yeditepe University Medical Faculty, Istanbul, Turkey macrolide and the available intravaginal formulation 3 Istanbul University Cerrahpasa Faculty of Medicine, Istan- (FemiFect®, 3 mg vaginal tablets, Lumavita AG, Basel, bul, Turkey Switzerland) is effective in the treatment of vaginal tri- Background: The role of perinuclear antineutrophil chomoniasis, candidiasis sustained by Candida albicans and cytoplasmic antibodies (pANCA) and anti-Saccharomyces mixed infections (Clin. Ter. 92: 137-142, 1980; Internet Jour- cerevisiae antibodies (ASCA) assessment in inflammatory nal of Gynecology and Obstetrics 11(1), 2009). Because bowel disease (IBD) diagnosis and differentiating is still yeasts other than C. albicans are frequently isolated in imprecise and controversial. recurrent or mixed forms of vaginal mycoses, it is impor- Methods: The aim of the study was to determine the tant to assess the activity of pentamycin against these accuracy of pANCA and ASCA in patients with specific intesti- species, which also exhibit reduced susceptibility to conven- nal inflammations, namely UC, CD, GI Behcet (GI-BD), GI tional antimycotic drugs. Therefore, the objective of this tuberculosis (GI-TBC) which are under the same inflam- study was to compare the in-vitro activity of pentamycin matory bowel registry, compared to tree control groups; with that of nystatin, amphotericin B, and fluconazole namely, Celiac disease, irritable bowel syndrome (IBS) against strains of nonalbicans candidal species and strains of patients and healthy controls (HC). A total of 493 subjects Saccharomyces cerevisiae isolated from medical samples. (102 with UC, 63 with CD, 13 with GI BD, 10 with GI Tb, 130 Methods: Two collections of clinical isolates included in with IBS, 10 with Celiac disease, and 165 HC) firstly admitted total 40 strains of C. glabrata, 41 strains of C. parapsilo- to our weekly IBD outpatient practice of a tertiary referral sis, 30 strains of C. tropicalis, 30 strains of C. krusei and center were analyzed regarding pANCA and ASCA Ig A-G via 20 strains of S. cerevisiae. In-vitro susceptibility testing was immunofluorescent assay (IFA) with commercially available performed using the broth microdilution method developed IFA kits (Euroimmune, Lübeck, Germany). by the Clinical and Laboratory Standards Institute (CLSI), Results: The prevalence of any pANCA or ASCA positiv- document M27-A2. The minimal inhibitory concentration ity and age and sex of patients are summarized in Table 1. (MIC) of each tested drug was read visually after 24 hours In UC patients the prevalence of pANCA was 42.2%, which and 48 hours of incubation. was significantly higher than in CD-4.8% (p = 0.000). ASCA Results: The MIC at which 90% of strains of each yeast was found significantly more often in CD-54% than in UC species were inhibited (MIC90) after 48 hours of incubation 14th International Congress on Infectious Diseases (ICID) Abstracts e119 was 1-4 ␮g/ml for pentamycin, 1-2 ␮g/ml for nystatin, 0.5- mon symptoms observed (93.2%). Amphotricin B was used 1 ␮g/ml for amphotericin B and 1-32 ␮g/ml for fluconazole. in patients with Aspergillus and Candida Keratitis, but for Some strains of C. glabrata and S. cerevisiae, and most Fusarium and other molds keratitis, Natamycin was used strains of C. krusei were categorized as susceptible-dose for 6 to 12 weeks. In one patient with Fusarium Keratitis, dependent or resistant to fluconazole, according to the CLSI medical therapy was failed and therapeutic penetrating document (MIC > 8 ␮g/ml). At concentrations)4 ␮g/ml, pen- keratoplasty was performed. Six months follow up showed tamycin inhibited completely the growth of 100% of strains that prognosis was good in all of the patients. of all species tested, including those strains less susceptible Conclusion: In relation to the last decade, the incidence to fluconazole (MIC range: 16-32 ␮g/ml). of Mycotic Keratitis is increased in Mashhad. Keratitis due to Conclusion: Pentamycin exhibited potent in-vitro fungi- the molds is more prevalent than yeast keratitis. Entrance cidal activity against the yeasts that are frequently isolated of foreign body (Plant particles) is the most common predis- in recurrent forms of vaginal mycoses and mixed infections, posing factor. However, it needs long term therapy but the like C. glabrata and S. cerevisiae (J. Clin. Microbiol. 43: prognosis is good. 2155-62, 2005; Mycoses 49: 471-5, 2006). Pentamycin was also highly active against the strains of non-albicans candidal doi:10.1016/j.ijid.2010.02.1749 species that were susceptible-dose dependent or resistant to fluconazole. 30.009 Assessment of a novel region of the 28S rRNA operon for doi:10.1016/j.ijid.2010.02.1748 identification of clinically significant Mucormycota ∗ 30.008 U. Kesavachandran , S. Hurst, L. Gade, A. Balajee Mycotic keratitis in Mashhad, Iran: Predisposing factors, Centers for Disease Control and Prevention, Atlanta, GA, etiologic agents & clinical manifestation USA ,∗ S. Fata 1 , A. Derakhshan 2, A. Boloorian 3, M. Sedaghat 1, Background: Mucormycosis is a frequently lethal invasive H. Khakshoor 2, F. Berenji 1, M.J. Najafzadeh 4, M. Afzal infection in high risk individuals including transplant recip- aghee 1, M. Meshkat 5, A. FATA 1 ients and diabetic individuals. Members of these taxa are difficult to identify by traditional methods in the clinical 1 Mashhad University of Medical Sciences, Mashhad, Iran, microbiology laboratory and in vitro differences in antifun- Islamic Republic of gal susceptibility within the genera have been noted. Today, 2 Mashhad University of Medical Sciences, Mashhad, Iran, comparative sequences based methods are considered the Islamic Republic of gold standards for rapid, accurate and objective species 3 AZAD UNIVERSITY OF MASHHAD, MASHHAD, Iran, Islamic identification of fungi. Although the rRNA regions includ- Republic of ing the 18S, ITS, 5.8S and D1-D2 hypervariable region of 4 University of Amsterdam, Amsterdam, Netherlands the 28S have been evaluated as targets, none have proven 5 Isalmic Azad University, Mashhad Branch, Mashhad, Iran, to be useful as a ‘‘universal’’ locus for broad fungal iden- Islamic Republic of tification. Recently, fredricks et al., analyzed a hitherto Background: Mycotic Keratitis is a suppurative, usually unexplored region of the 28S rRNA gene for species iden- ulcerative, and sight threatening infection of cornea that tification of a wide range of fungal genera. In the present sometimes lead to loss of vision. The peak of incidence study, we explored the utility of this target region for is observed in the tropical and subtropical regions. To specific and discriminatory identification of Mucormycota investigate the etiological agent, predisposing factors and genera. treatment follow up of mycotic keratitis; this study was Methods: A total of 100 isolates representing 10 differ- undertaken over a period of 2 years in Mashhad. ent medically important genera of Mucormycota from the Methods: In this prospective, cross sectional study, culture collections of the Centers for Disease Control and among 466 individuals suffering from keratitis,65 patients, Prevention (CDC), Atlanta, GA, and the National Center for highly suspected to mycotic keratitis were examined by Agricultural Utilization Research, U.S. Department of Agri- direct fresh smear (KOH 10%) and culture in Mycology Media. culture, Peoria, IL were used in this study. Genomic DNA The results were analyzed by SPSS method. was extracted using Qiagen kit and PCR amplification and Results: Among 65 clinically suspected individuals, the sequencing of the extended 28S rRNA was performed as pre- results of direct smear and culture of 44 patients were pos- viously described. Sequences were aligned using Clustal W itive. 21 patients were male (47.1%) and 24 were female and distance matrices were generated using the Biolomics (52.3%). The patients were between 8 to 84 years old. More software. than 40% of them were farmers. Trauma was the most com- Results: PCR products were generated for all the isolates mon predisposing factors in more than 47% cases due to tested and amplicon size differences were detected among vegetable material. the genera. Accordingly, large regions of insertion/deletion Molds and Yeasts were isolated from 86.4% and 13.6% of were observed when the sequences were aligned. Distance the samples respectively. matrices and phylogenetic analyses revealed appreciable Fusarium spp. were the most frequent isolates nucleotide differences among the genera tested. (44.4%).Others included Aspergillus spp. (21.8%), Acre- Conclusion: In summary, the novel 28S r RNA region eval- monium spp. (8.3%), Penicillium spp. (5.6%) and Candida uated in this study was readily amenable to PCR/sequencing albicans (13.9%).Tearing and redness were the most com- and revealed genus specific nucleotide differences, thus e120 14th International Congress on Infectious Diseases (ICID) Abstracts holding promise as a target for discriminatory genus iden- Disease-topographic:dermal-16 tification of Mucormycota. Topography Number of cases axillary 1 doi:10.1016/j.ijid.2010.02.1750 submamare 2 30.010 inguinal 3 gluteal 3 Recurrent/resistant fungal infections in females intradigital 4 1,∗ 2 3 3 3 N. Como , D. Kraja , N. Gjermeni , M. Qato , A. Kica ,K. Disease-topographic:vulvovaginale -26 Duraku 3 Topography Number of cases 1 University Hospital Centre ‘‘Mother Theresa’’, Tirana, AL, anal-perianal 2 Albania onicomycosis 2 2 Faculty of Medicine, Tirane, Albania Etiologic:Candida albicans -33 cases 3 HUC, Tirane, Albania Candida glabriatra -5 cases Background: Recognition of epidemiologi- Trichophyton-6 cases cal,etiological,topographical and treatment aspects. Criptoccocus Laurens-1 case. In this study are included 45 cases,18-35 yearsold, during Therapeutic:According to mycogram,the clinical the years 1999—2008 with recurrent (at least 4 episodes response and the subject quality. of fungal infections in a year)/resistant (which doesn’t -In (19) resistant cases we have: respond to antifungal therapy) fungal infections. Methods: We have analyzed the group-ages,the origin and a) repeated the therapeutic cycle(in 11 cases) the immunity state of the patients.We have determined the b) extended the local treatment(10 cases), etiology,topographic variant of the fungal infections and the c) associated the systemic treatment(16 cases), real sensibility against antifungal drugs (Ketoconazol, Intra- d) changed the antifungal drugs(13 cases). conazol,Fluconazol,Clotrimazol). Results: Epidemiologic: We have done diagnose reconfirmation(2 cases from 8 has Group-ages Number of cases resulted misdiagnosed). 3 from 5 cases with candida glabriata were resistand 18-21 1 against azole. 22-25 8 -In (26) recurrent cases we have applied the treatment 26-30 11 with (Fluconazol 100 mg(p.o)or supp.Cotrimazol 500 mg 1 31-35 25 time/week until 6 month) Where 28 were citizien, and 17 were peasants. In 14 cases, after the treatment of recurrent The immune state: episodes(fluconazol 100—200 mg/day/7—14 days) we have improved the management of immunecompromised a) immunocompetent-30 cases disease of subjects in 13 cases. b) immune-compromised-15 cases Conclusion: The recurrent/resistant fungal infections are encountered more frequently in group-ages 31-35 years- Diagnosis Number of cases old,54% of all cases. 33% were immune-compromised; HIV 4 colagenosis 4 67% were immune-competent (women). Diabetes Mellitus 2 6% of all cases were named as idiopathic,the long-term Lymphoma 1 treatment resulted ineffective. Visceral Leishmania 1 Vulvo-vaginal fungal infections were predominated in Hypogamaglobulinemi 1 57.7% of cases. Thyrotoxicosis 1 The most frequent etiologic cause was Candida albi- Chronic hepatitis 1 cans(73.3%). The resistant fungal infections were 42.2% of all cases; Disease-topographic:Oro-pharyngeal fungal infection-42 recurrent 57.7%. cases The treatment in the resistant forms has resulted effec- Topography Number of cases tive in 84.2% and ineffective in 15.7%;in the recurrent forms keilitis 6 73.1% effective and 26.9% ineffective. glositis 9 pharyngitis 5 doi:10.1016/j.ijid.2010.02.1751 pharynx—esophagitis 4 14th International Congress on Infectious Diseases (ICID) Abstracts e121

30.011 microbiology. Diagnosis and effective treatment is often Recurrent vulvovaginal candidiasis- where does Candida delayed in resource-constrained settings, because clinical albicans persist? features could be confused with disseminated tuberculosis, and specialized services are limited. To our knowledge, this ∗ F. Beikert , M.T. Le, A. Clad is the first reported case series of HIV infected patients with DH in Africa. University of Freiburg, Freiburg, Germany Methods: We report retrospective descriptive data on a Background: 5-8% of all women of childbearing age suf- series of HIV and DH co-infected patients attending an aca- fer from recurrent vulvovaginal candidiasis (RVVC). In most demic hospital between September 2003 and December 2008 cases, recurrences are caused by identical Candida strains in the Western Cape region. suggesting a site of C. albicans persistence in female geni- Clinical and laboratory characteristics of all diagnosed talia. The purpose of this study was (1) to investigate where DH were analysed with the statistical package SPSS 15.0. C. albicans persists despite prolonged oral therapy, (2) to Results: During the study period, 11 cases of DH were determine the clinical symptoms and signs related to C. diagnosed: the majority of cases occurred in men (82%). albicans positive vulvar cultures and (3) to evaluate a new All DH patients presented with skin lesions in addi- therapeutic approach in women with positive interlabial cul- tion to other symptoms of which 6 had fever (55%), 9 tures. had constitutional symptoms (weakness, night sweats and Methods: A total of 469 women with recurrent vul- weight loss) (82%), 6 had epistaxis (55%), 5 had respira- vovaginal complaints were examined by colposcopy and tory symptoms (45%), and 4 had gastrointestinal complaints microscopy of vaginal smears was performed. Swabs were (36%). obtained from both vagina and interlabial sulcus of the The mean CD4 lymphocyte count was 43 cells/␮l (IQR: external vulva and cultured for fungal growth. Women 4-107). The mean CRP level was 166 mg/dl (IQR: 27-306), with positive C. albicans cultures from the external vulva the LDH was 887 U/l (IQR: 158-3220). Pancytopenia was received 100 mg of oral fluconazole daily for 20 days and top- diagnosed in 3 patients. ical ciclopiroxolamin cream applied in the interlabial sulcus Diagnosis was made in all patients by positive and perianally for 4 weeks. Follow-up visits were at 3, 6, 9 histopathology results (100%); only 3 patients had a micro- and 12 months. biologically confirmed culture result (27%). The mean Results: Of 469 women with chronic vulvovaginal com- time-interval between first symptoms and treatment was plaints, 139 patients (30%) had positive C. albicans cultures. 148 days (IQR: 80-305). Of these 139 patients, 70% had both C. albicans positive vul- Three patients developed paradoxical IRIS features var and vaginal cultures, 24% had positive cultures from the (27%) and three patients unmasking DH after initiation of vagina only and 6% from the interlabial sulcus only. Pruri- antiretroviral treatment (ART) (27%). One patient died of tus (OR 5.4; 95% CI 2.0 - 14.9), signs of vulvar edema (OR DH (9%), due to delayed diagnosis and treatment, after two 3,8; 95%CI 1.0-16.8) and fissures (OR 2.4; 95%CI 1.0-5.8) days of intravenous amphotericin. correlated with positive vulvar cultures. Conclusion: In a tuberculosis high endemic region, where Recurrence rates for the combined treatment were 27% many AIDS patients with a very low CD4 count are seen in at 6 months and 34% at 12 months. antiretroviral clinics, the follow-up of patients is complex, Conclusion: Our results point at the stratum corneum of mostly due to TB related infections. the moist interlabial sulcus rather than the non-keratinizing A high index of suspicion for DH is necessary to detect vaginal epithelium as the site of C. albicans persistence and specific clinical characteristics on time. Patients who source of endogenous re-infection in patients with recur- present with constitutional symptoms and skin lesions should rent vulvovaginal candidiasis. Based on this hypothesis and be checked for DH through pathology and/or microbiology. A analogous with the treatment of nail mycosis, we used a presenting epistaxis, and a relative high CRP should increase combination of the fungistatic fluconazole and fungicidal the likelihood of the diagnosis of DH. ciclopiroxolamin cream. This new approach showed promising results. doi:10.1016/j.ijid.2010.02.1753 30.013 doi:10.1016/j.ijid.2010.02.1752 Breakthrough Rhizopus spp. in an immunocompromised 30.012 patient receiving caspofungin. Case Report and review Delayed diagnosis of disseminated Histoplasmosis cap- N. Dunkel ∗, J. Ambrosioni, Y. Chalandon, J. Passweg, J. sulatum var. capsulatum infection in AIDS patients in a garbino tuberculosis high endemic country ,∗ University Hospital of Geneva, Geneva, Switzerland P. soentjens 1 , I. Eshun-Wilson 2, J. Taljaard 3 Background: Invasive zygomycosis is a rare opportunis- 1 Military Hospital Brussels, Brussels, Belgium tic fungal disease, with high morbidity and mortality rates 2 Tygerberg Academic Hospital, CapeTown, South Africa that affects predominantly immunosuppressed patients. An 3 Tygerberg academic Hospital, Cape Town, South Africa increase incidence is observed with the widespread use of Background: Histoplasmosis is an low endemic myco- newer antifungal drugs, such as voriconazol and caspofun- sis in some parts of South Africa. The final diagnosis of gin. We report a case of breakthrough invasive zygomycosis disseminated histoplasmosis (DH) requires pathology and in a stem cell transplant recipient on sequential voricona- e122 14th International Congress on Infectious Diseases (ICID) Abstracts zole and caspofungin treatment, and we review the previous bodies. Granuloma formation can be interpreted as a host published cases. defense mechanism to destroy or contain Pb and avoid its Methods: Analysis of a clinical case with zygomycosis dissemination. breakthrough infection and review of previous published Methods: We infected susceptible (S) and resistant cases. (R) mice with Pb to study the granulomas. We analysed Results: To date, seven cases of immunocompromised the architecture of the granulomas and associated with patient with breakthrough zygomycosis infection receiving presence of morphologically preserved or destroyed Pb, caspofungin were published (Table 1) deposition of some extracellular matrix (ECM) components In September 2007, a 51 year old female patient was (collagen fibers types I, II, IV, osteopontin, laminin, bigly- admitted for myelodysplastic syndrome RAEB-T, diagnosed can, decorin), presence of relevant cytokines to granuloma a year before. A related allogenic hematopoietic stem cells formation (/-IFN, TGF-$, TNF-&) and of matrix metallopro- transplant (HSCT) (HLA 9/10) was performed. On October teinases (MMP). 12th, the patient developed an hepatic GVHD, treated by Results: We detected all the above mentioned elements prednisone. The clinical evolution was good and the patient in the lesions. The thick fibers of collagen type I, (R > S) was discharged of the hospital on October 29th on pred- may be associated with Pb infection containment; the thin nisone, cyclosporine, penicillin V, valaciclovir, voriconazole, reticular fibers of collagen type III may promote the microen- co-trimoxazole and folinic acid. These treatments were vironment for Pb-cell-ECM interactions; the marker of newly stopped 6 weeks later. formed vessels collagen type IV may promote Pb dissemi- On January 3rd, the patient was readmitted presenting a nation and favor the influx of inflammatory cells and the febrile state and aqueous diarrhea. proteoglycans biglycan and decorin, (R > S) may promote An acute digestive GVHD was diagnosed and large spec- fungal containment. The cytokines TNF-& and /-IFN, this trum antimicrobial treatment was initiated. Voriconazole later more observed in R mice may promote macrophage was switched to caspofungin on January 16th, due to liver activation, enhancing Pb killing by these cells and the tests enzymes alteration control fungal dissemination; TGF-$, (S > R) may promote After 1 week of treatment, a thoracic CT scan was per- deactivation and inhibition of Pb killing by macrophages, formed and revealed signs of pulmonary infection. Nasal favoring fungal dissemination and osteopontin may favor swab and bronchoalveolar lavage cultures grew with Rhi- infection at its onset (S > R) and promote protection later zopus spp. The patient experienced an important clinical (R > S). MMP-9 was detected in both S and R mice with active worsening. Considering the severity of infectious and hema- infection, eventually being involved in fungal dissemination. tologic prognosis as well as the lack of clinical response, the Conclusion: The fate of PCM infection locally depends physician according with the family decided to stop aggres- of the combined effects of ECM components, which can be sive therapy. The patients died 10 days later. limiting or permissive to Pb dissemination, and those of The autopsy finding showed that the death was due to a cytokines, which can either activate or inactivate phago- disseminated angioinvasive mycotic infection. cytic cells, leading to Pb lysis or survival. Conclusion: As reported with voriconazole, prolonged caspofungin treatment may be a risk factor for invasive doi:10.1016/j.ijid.2010.02.1755 zygomycosis infection in immunocompromised patients. This disease must be always considered in immunocompromised 30.015 patient receiving caspofungin therapy. Fibrosis treatment in experimental Paracoccidioides brasiliensis infection doi:10.1016/j.ijid.2010.02.1754 ,∗ E. Burger 1 , A.S. Nishikaku 2, J.V. Alves 2, C.R.P. Pizzo 2, 30.014 R.F.S. Molina 2 Granulomatous lesions in experimental Paracoccidioides 1 Universidade Federal do Espirito Santo and Universidade brasiliensis infection de Sao Paulo, Sao Mateus and Sao Paulo, Espirito Santo and ,∗ Sao Paulo, Brazil E. Burger 1 , R.F.S. Molina 2, J.V. Alves 2, C.R.P. Pizzo 2, A.S. 2 Universidade de São Paulo, Sao Paulo, Sao Paulo, Brazil Nishikaku 2 Background: Paracoccidioidomycosis (PCM) is a deep 1 Universidade Federal do Espirito Santo; Universidade de mycosis that presents frequent and incapacitating sequelae Sao Paulo, Sao Mateus e Sao Paulo, Espirito Santo e Sao due to the development of numerous fibrotic granulomatous Paulo, Brazil lesions even after mycological cure, rendering the quality of 2 Universidade de São Paulo, Sao Paulo, Sao Paulo, Brazil life of the patients extremely poor. Background: Paracoccidioidomycosis (PCM) is a systemic After characterization of the granulomas developed by mycosis, caused by the fungus Paracoccidioides brasiliensis susceptible (S) and resistant (R) mice infected Paracoccid- (Pb), that affects healthy individuals living in rural areas in ioides brasiliensis (Pb), we evaluated the effect of drugs Latin America. There are many clinical forms of the disease; that interfere with fibrosis. We treated S mice with drugs severe forms are characterized by the presence of numer- that interfere with fibrosis: we used the cytokine ␥-IFN ous disseminated granulomatous lesions, anergy in cellular because, in addition to its known effect as macrophage acti- immunity and high levels of specific antibodies, in con- vator, it presents direct antifibrotic activity; Tetracycline trast, mild forms have few localized granulomatous lesions, due to its inhibitory effect on extracellular matrix (ECM) syn- preserved cellular immunity and low levels of specific anti- thesis in addition to its antibacterial effect and the specific 14th International Congress on Infectious Diseases (ICID) Abstracts e123

COX-2 inhibitors Lumiracoxib and Celecoxib, because these hospitalization, and costs associated with adverse events. anti-inflammatory drugs increase the expression of collagens Medical costs were extracted from 7 ICUs of 3 major cities types III and IV. and drug costs were taken from a standard colombian cost- Methods: We evaluated in situ the presence of some ing source. The incremental cost per successfully treated granuloma components such as collagen as well as of its patient was calculated and the one way sensitivity analysis degradation product hydroxiprline. We also determined the was performed. local presence of relevant cytokines to granuloma formation Results: Patients treated with ANI experienced the higher and maintainance (TNF-␣, TGB-␤, ␥ - IFN, GM-CSF and IL-12) outcomes (13.7 LYs)followed by AMB (12.1 LYs)and CAS (11.7 and also of NO, Pb with preserved or altered morphology and LYs). Mean cost per patient was lower with AMB (US$4,131) the overall architecture of the granulomas. followed by ANI (US$6,001) and CAS (US$6,444). Based on Results: The best indicators of control of PCM as ICERs, ANI was the dominant therapy compared to CAS and expressed by successful local Pb lysis were the presence of ANI was cost-effective compared to AMB (ICER US$1.228). compact granulomas, delimited by a continuous deposit of Conclusion: Anidulafungin represents the cost-effective collagen type 1 arranged in concentric orientation required treatment of choice when compared to caspofungin and to contain the fungi, and the production of high concen- amphotericin B for the invasive candidiasis in Non- tration of cytokines IL-12 and ␥-IFN as well as of NO. The neutropenic patients in Colombia. concentration of collagen metabolite per se was not an indicator of Pb containment or dissemination. doi:10.1016/j.ijid.2010.02.1757 Conclusion: Based on these parameters, we can conclude that therapy with ␥-IFN and /or Tetracycline seems 30.017 promising, reducing the fungal load, increasing the produc- Myocardial infarction caused by aspergillus embolization tion of NO and of the stimulatory cytokines ␥-IFN and IL-12, in a patient with cirrhosis decreasing that of the inhibitory cytokine TGB-␤ and altering A. Shahzad 1,∗, B. Nseir 2 the granulomas architecture towards a compact structure in order to provide Pb containment without excessive fibrosis. 1 Ochsner Medica; Center, Kenner, LA, USA 2 Ochsner Clinic Foundation, New Orleans, LA, USA doi:10.1016/j.ijid.2010.02.1756 Background: Patient presented with ST elevation MI and 30.016 died secondary to multiorgan failure. Autopsy revealed Cost-effectiveness analysis of the therapy for the invasive angioinvasive aspergillosis involving several organs. Candidiasis in Colombia Methods: Case: A 47-year-old African American male with past medical history of alcoholinduced cirrhosis presented ,∗ F.J. Molina 1 , J.A. Cortes 2, H.A. Caceres 3, R. Soto 4, E.V. with acute midsternal pain of 5 hours duration. Respiratory Lemos Luengas 5 distress developed and mechanical ventilation was required for airways protection. 1 Clinica Bolivariana, Medellin, Colombia Results: Initial work up showed markedly elevated car- 2 Universidad Nacional de Colombia, BOGOTA, Colombia diac enzymes with CPK 14000 U/L, elevated AST 800 3 Universitat Pompeu Fabra, BOGOTA, Colombia U/L, ALT 210 U/L, total bilirubin 8 mg/dL, direct biliru- 4 Centro Medico Imbanaco, CALI, Colombia bin 7 mg/dL, and ST segment elevation on inferior EKG 5 Fundacion para el Desarrollo y Apoyo en Salud Interna- leads. Patient underwent emergent left heart catheteriza- cional (FUDASAI), Bogota, Colombia tion which revealed patent coronary arteries. Subsequently Background: Candidiasis is a nosocomial infection associ- multiorgan failure resulted in decompensated shock and ated to considerable mortality and high economic impact. patient received several vasopressors. Blood, spinal fluid, The echinocandins are a new class of therapeutic medica- urine and sputum cultures showed no growth. Patient had tions that have shown to be effective in treating candidemia negative serology for HIV, acute viral hepatitis, syphilis, and other forms of invasive candidiasis; however, cost of dengue fever, tularemia, herpes virus 1&2, CMV, EBV, amphotericin B dose is lower. Hypothesis: Is anidulafun- leptospirosis, Q fever, Lyme disease, brucellosis, and gin (ANI) costeffective compared to caspofungin (CAS), and ehrlichiosis. Patient experienced intractable ventricular fib- amphotericin B (AMB) in the treatment of invasive candidia- rillation which resulted in death after a 13-day hospital sis in non-neutropenic patients hospitalized in Intensive Care stay. Autopsy report confirmed disseminated angioinvasive Units (ICU) when the fluconazole is not a choice, from a aspergillosis involving heart, lungs, bowel, thyroid, kidneys third-party payer perspective. and spleen in addition to complete occlusion of the poste- Methods: A decision tree was designed to assess the rior descending artery with a fungal thrombus and multiple cost-effectiveness of the three medications and this was fungal vegetations. validated by 2 critical care specialists and 2 infectologist. Conclusion: Discussion: Aspergillus organisms are ubiq- The model simulated costs and effectiveness in a 14-week- uitous and exposure to their conidia must be a frequent period. Effectiveness measure was the rate of survival and event. However, disease due to tissue invasion is uncommon the main outcome was saved Life Years (LYs). Clinical effi- and occurs primarily in the setting of immunosuppression. cacy and node probabilities were obtained from a published Risk factors for invasive aspergillosis include prolonged and meta-analysis that was identified by systematic literature severe neutropenia, organ transplantation, AIDS and corti- review. This study estimated the direct costs associated with costeroid use. invasive candidiasis treatment including antifungal drugs, e124 14th International Congress on Infectious Diseases (ICID) Abstracts

Infection of virtually any organ can occur, but most com- Linear regression analysis found no evidence of a statistical monly kidney, liver,spleen, and CNS are involved. Aspergillus significant correlation between HIV-1 plasma viral load and is second only to Candida as a cause of fungal endocarditis. CCP concentrations (r = 0.1522; p = 0.4676). Patients typically present with fever and embolic phe- Conclusion: In opposition to in vitro findings, HIV-1 nomena. Blood cultures are rarely positive. Prognosis of plasma viral load has no correlation with CCP concentra- Aspergillus endocarditis is poor. Even with combined medical tions. To the best of our knowledge, this is the first study and surgical therapy, the mortality approaches 100 percent. to assess if there is a relationship between the levels of an Septic embolization has been occasionally reported as a rea- opportunistic pathogen in blood and HIV-1 viral load in a real son for cerebral, myocardial and pulmonary infarctions. Our life clinical setting. report represents rare case of myocardial infarction as a part of aspergillus septic emboli in the setting of hepatic cirrho- doi:10.1016/j.ijid.2010.02.1759 sis as etiology of the immunocompromised state. Autopsy; however could not identify the original infected source. 30.019 Risk factors for candidemia-related mortality in a Neona- doi:10.1016/j.ijid.2010.02.1758 tal Intensive Care Unit (NICU) ∗ 30.018 C.I. Echave , M.L. Praino, M.L. Vozza, C. Manso, M. Russman, C. Enfedaque, A. Martinez Burkett, A. Procopio, Correlation between HIV-1 viral load and cryptococcal N. Rivas, E.L. Lopez capsular polysaccharide concentration: Evaluation in a clinical setting Hospital de Ninos˜ Ricardo Gutiérrez, Buenos Aires, ∗ Argentina D. Cecchini , A.M. Canizal,˜ H. Rojas, A. Arechavala, R. Negroni, M.B. Bouzas, J. Benetucci Background: Candidemia is related to significant morbidity and mortality, specially in infants at the NICU. The aim Hospital Muniz,˜ Buenos Aires, Argentina of this study was to identify the risk factors for mortality Background: In vitro studies demonstrated that a clini- among these patients cally relevant concentration of cryptococcal polysaccharide Methods: We retrospectively studied all the patients with enhanced HIV-1 production in peripheral mononuclear positive blood cultures for Candida spp. treated in NICU cells (Pettoello-Mantovani M, et al. Enhancement of HIV- between, January 2003 and December 2008, at the Hospital 1 infection by the capsular polysaccharide of Cryptococcus de Ninos˜ ‘‘Ricardo Gutierrez’’ in Buenos Aires, Argentina. neoformans. Lancet 1992, 339:21-23). However, the corre- We analyzed the clinical baseline characteristics and risk lation between cryptococcal capsular polysaccharide (CCP) factors for mortality: persistence of positive blood cultures, concentrations and HIV-1 viral load has never been assessed days to central venous catheter (CVC) removal, underly- in a clinical setting. Considering the immunomodulatory ing diseases, secondary compromised organs and species of properties of CCP and that extrapulmonary cryptococco- Candida. sis is one of the most frequent HIV-related opportunistic Results: During the study period a total of 20 patients infections in our region, the evaluation of potential patho- were identified. However, 2 patients were excluded, due physiological interactions between these pathogens are of to insufficient data in the medical records. Ten patients importance for development of therapeutic strategies. were male (55%); age: median 40 days (range 7-117 ds). Methods: Prospective collection of pretreatment blood All patients were admitted to the NICU, immediately after samples from antiretroviral naive HIVinfected patients with birth. None of them was less than 28 weeks gestation. The culture-confirmed cryptococcal meningitis assisted at the weight at birth was less than 1500 g in only one patient. The Infectious Diseases Hospital ‘‘Francisco Javier Muniz’’,˜ most frequent underlying disease was surgical pathology of Buenos Aires, Argentina (period 2004-2006). the gastrointestinal tract (9/18, 50%). Most of the patients Informed consent was obtained from all patients. HIV had risk factors for candidemia as CVC (14/18, 77,7%), par- plasma viral load was measured by reverse transcriptase- enteral nutrition (15/18, 83%) and previous use of broad polymerase chain reaction using the Cobas Amplicor HIV-1 spectrum antibiotics (100%). Candida albicans resulted the Monitor Test 1.5 (Roche). CCP antigen concentration main agent (9/19, 47%). One patient had two different was determined by a standard commercial assay (Latex- species of Candida: albicans and tropicalis. The global mor- Cryptococcus Antigen Detection System-IMMY, Immunomy- tality rate was 27.7% (5/18). Mortality was associated with: cologics). A linear regression analysis was performed with later removal of catheter, mean 1.9 ds vs. 5.8ds, (p = 0.02) Statistix 7.0 software. Florencio Fiorini ‘‘Estimulo’’ Schol- and days to first negative blood culture: mean 4.36 ds vs.9 arship by Florencio Fiorini Foundation and by Asociacion ds (p = 0.025), in survivors vs patients who died, respectively. Medica Argentina was obtained for the development of the Conclusion: The high mortality rate by Candida in our study, as part of an investigation of HIV-1 related cryptococ- setting was similar to the reported by the literature. Can- cosis. dida albicans remained the most common isolated specie. Results: During the study, 37 HIV-infected patients with Mortality was statistically significant related to persistent cryptococcal meningitis were enrolled. Data regarding HIV-1 candidemia and the delay to remove CVC. plasma viral load and CCP concentrations were available for 25 patients for the final analysis. Median HIV plasma con- doi:10.1016/j.ijid.2010.02.1760 centration (copies/mL) was 296000 (range: 1000-750000). Median serum CCP antigen titer was 100 (range: 0-10000). 14th International Congress on Infectious Diseases (ICID) Abstracts e125

30.020 diffusion and E-test had good CA and may be an alternative Analysis of candidemia epidemiological data and anti- methodology for routine Latin America laboratories. fungigram by distinct methodologies in a large Brazilian teaching hospital doi:10.1016/j.ijid.2010.02.1761 A. Motta 1,∗, G.D. Almeida 2, J.N. Almeida Jr. 3, M.I. Pinto 1, 30.021 M.N. Burattini 4, F. Rossi 5 Prevalence of Cryptococcal meningitis among HIV seropositive patients in Georgia 1 Hospital das Clinicas da Faculdade de Medicina da Univer- sidade de São Paulo, São Paulo, Brazil L. Gatserelia ∗, L. Sharvadze, M. Karchava, L. Dzigua, N. 2 Hospital das Clinicas da Faculdade de Medicina da Univer- Dvali, N. Badridze, T. Tsertsvadze sidade de Sao Paulo, São Paulo, Brazil 3 Hospital das Clinicas da Faculdade de Medicina da Univer- Infectious Diseases, AIDS and Clinical Immunology Research sidade de Sao Paulo, São Paulo, Brazil Center, Tbilisi, Georgia 4 Hospital das Clínicas da Faculdade de Medicina da Univer- Background: Cryptococcal meningitis is a frequently sidade de São Paulo, São Paulo, Brazil observed opportunistic fungal infection in HIV seropositive 5 Hospital das Clínicas da Faculdade de Medicina da Univer- patients in Georgia and an important cause of mortality sidade de São Paulo, SAO PAULO, SP, Brazil among these patients. This study estimates the prevalence Background: Candidemia results in substantial morbidity of cryptococcal disease in Georgia in 2003-2008 among and mortality and species distribution and its suscepti- human immunodeficiency virus (HIV)-infected patients who bility profile should be locally monitored. Antifungigram were at risk. still a challenge but few laboratories have microdilution Methods: Numerator data were generated by surveying techniques in Latin America, in a routine basis, and other all HIV infected patients in Georgia during 2003- 2008 years. methodologies should be evaluated. A routine serum cryptococcal antigen screening was per- Methods: Epidemiological data from candidemia episodes formed on 920 HIV-positive/AIDS patients by ELISA (Premier were collected during 2006 in a large teaching hospital. Inci- Meridian, Italy) to improve the prognosis of cryptococcal dence was calculated by 1,000 admission and 1,000 patient meningitis in HIV-infected patients through earlier diagno- days. sis. The cerebrospinal fluid (CSF) samples were processed Minimal inhibitory concentrations (MIC) were determined for ELISA testing after preliminary microscopic examination, using Sensititre Yeast-One Y8, and E-test. The follow- comprising wet mount, Indian ink. ing drugs were tested: amphotericin B (AMB); caspofungin Results: Cryptococcal antigen was detected in the sera of (CAS); posaconazole (POS), fluconazole (FLU), Itraconazol 103 (11.2%) of them. Cerebrospinal fluid was obtained from (ITRA) and voriconazole (VOR). The disk diffusion method 98 of these 103 patients and the presence of Cryptococcus was also performed for FLU and VOR according to CLSI. neoformans was demonstrated by direct microscopy in 64 Results: One hundred and thirty-six cases of candidemia (66%) of them. This represents 7% of the originally screened were identified and represented 3.5% of the overall pos- HIV seropositive group. The incidence of cryptococcal isola- itive blood cultures. Incidence was 1.87 cases per 1,000 tion was in the 30-45 age group and predominantly affected admissions and 0.27 cases per 1,000 patient-days. 58.1% were male patients (59 from 64). patients were male and the median age was 40 years Conclusion: In Georgia prevalence of Cryptococcal old being cancer the most frequent associated underlying meningitis among HIV seropositive patients is about 7%. disease. C. albicans (52.2%), followed by C. parapsilo- We found some relationship between age, gender and sis (22.1%), C. tropicalis (14.8%) and C. glabrata (6.6%) prevalence of Cryptococcal meningitis among HIV infected were the more frequent species. Among 100 isolates viable patients. The routine mycological surveillance is required for susceptibility tests 100% were susceptible to AMB (MIC for HIV/AIDS patients to help in an early diagnosis and appro- 90 = 1.0 mg/L) and CAS (MIC 90 = 0.064 mg/L); 98% to VOR priate therapy. (MIC 90 = 0.008 mg/L); 91% to FLU (MIC90 = 0.5 mg/L); and 66% to ITRA (MIC 90 = 0.125 mg/L). doi:10.1016/j.ijid.2010.02.1762 Posaconazole MIC90was 0.032 mg/mL. The percentage of 30.022 essential agreement (EA) and categorical agreement (CA) between broth micro dilution and other methodologies were Clinical analysis of 92 patients with Fungaemia - data from >93%, except for itraconazole (EA 80%, CA 70%). CA between national survey in Slovakia Sensititre Yeast-One versus disk diffusion and E-test versus L. Drgona 1,∗, J. Trupl 2, H. Hupkova 3 disk diffusion for FLU were respectively: (94%; 95%) and for 1 VOR(96%,98%). Minor errors accounted for the majority of Comenius University and National Cancer Institute, categorical errors. Bratislava, Slovakia 2 Conclusion: Candidemia by C. albicans still the majority AlphaMedical s.r.o., Bratislava, Slovakia 3 of episodes in our Hospital but non-albicans C species are Comenius University, Bratislava, Slovakia a growing problem and its susceptibility should be closed Background: A prospective national survey on fungaemia monitored even though overall resistance still very low. Disk was done during 2005-2007 in Slovakia. The increasing incidence of fungaemia and candidaemia was documented (2.57 and 2.16/100.000/year, respectively) comparing previous e126 14th International Congress on Infectious Diseases (ICID) Abstracts survey. 38% of cases of candidaemia were caused by C. albi- production of urease and the presence of a capsule. Results cans and 62% by non-albicans strains. were confirmed using the API 20C (bioMerieux, St Louis, Methods: 92 episodes in 92 patients with fungaemia and USA). L-canavanine-glycine-bromothymol blue agar (CGB) available clinical data were analysed according to data from was used to distinguish C. gattii from C. neoformans. Min- CRFs. Informations about risk factors, antifungal treatment imal inhibitory concentrations (MIC) to amphotericin B, and outcome 4 weeks after the onset of infection were col- caspofungin, 5-fluorocytosine, posaconazole, fluconazole, lected. itraconazole and voriconazole were determined using Sen- Results: All patients except 16.3% were adults >18 years sititre Yeast-One Y8TM (TREK Diagnostic Systems, Cleveland, old. Majority of patients were hospitalized on ICU (59.7%); USA). 43.4% of patients had cancer and 16.3% had haematological Results: In the study period 43 isolates were included. malignancy. 20% of patients were neutropenic at the onset Thirty three (77%) were C. neoformans and 10 (23%) were of candidaemia. Previous antibacterial treatment (93.4%), C. gatti. C. neoformans MIC 50/90 for antifungal drugs were inserted central venous catheter (83.6%), total parenteral as follow: amphotericin B.(0.5 mg/L -1 mg/L,) caspofungin nutrition (55.4%), surgical procedure (52%) and colonisation (16 mg/L-16 mg/L), posaconazol (0.064 mg/L-0.25 mg/L), with Candida spp. were the most common risk factors asso- fluconazole, (4 mg/L-16 mg/L); itraconazol (0.125 mg/L- ciated with candidaemia. Fluconazole was the preferred 0.5 mg/L) and voriconazol (0.032 mg/L-0.125 mg/L) C. 1st line drug (58.6% of all treated patients) followed by gatti MIC 50/90 mg/L for antifungal drugs were as Voriconazole (18.4%) and Amphotericin B (10.8%). 6 patients follow: amphotericin: (0.5 -1 mg/L); caspofungin (16 mg/L- (6.5%) did not receive any antifungal therapy - 2/6 died and 32 mg/L); posaconazole (0.125 mg/L-0.25 mg/l); flucona- 4/6 survived. zole: (8 mg/L-16 mg/L); itraconazole (0.25 mg/L-0.5 mg/L) Fungaemia-related and candidaemia-related mortality and for voriconazole (0.125 mg/L-0.25 mg/L). Fluconazole was 33.7% and 27.2%, respectively. 16/25 (64%) deaths were MICs equal or higher than 16 mg/L was observed among 40% due to candidaemia caused by non-albicans candida strains of C. gattii and only 18% among C. neoformans isolates. and 9/25 (36%) were associated with C.albicans. Conclusion: Species identification among Cryptococcus Conclusion: Mortality of patients with candidaemia spp isolates is an important epidemiological tool and should reflects the epidemiological trend in Slovakia where major- be done in a routine basis. C gattii showed higher flucona- ity of cases are caused by non-albicans strains. The choice of zole MICs and it should be closed monitored. antifungal therapy should be in concordance with epidemiological data. doi:10.1016/j.ijid.2010.02.1764 30.024 doi:10.1016/j.ijid.2010.02.1763 Saccharomyces fungemia associated with esophageal dis- 30.023 ease identified by D1/D2 Ribosomal RNA gene sequence Cryptococcus: species distribution and susceptibility pro- A. Cheema 1,∗, J. Farrell 2, C. Kurtzman 3 file of isolates in a teaching hospital from São Paulo-Brazil 1 ,∗ University of Illinois College of Medicine at Peoria, Peoria, A. Motta 1 , G.D. Almeida 2, J. Almeida 3, M.I. Pinto 4,S. IL, USA Onorio 5, F. Rossi 6 2 OSF St. Francis, Peoria, IL, USA 1 Hospital das Clinicas da Faculdade de Medicina da Univer- 3 National Center for Agricultural Utilization Research, ARS, sidade de São Paulo, São Paulo, Brazil USDA, Peoria, IL, USA 2 Hospital das Clínicas da Faculdade de Medicina da Univer- Background: We describe two immunocompromised sidade de São Paulo, São Paulo, Brazil patients with ultimately fatal esophageal pathology and Sac- 3 Hospital das Clínicas da Faculdade de Medicina da Univer- charomyces cerevisiae fungemia. Originally misidentified by sidade de São Paulo, São Paulo, São Paulo, Brazil Vitek automated techniques, both yeast were ultimately 4 Hospital das Clinicas da Faculdade de Medicina da Univer- identified by D1/D2 LSU rRNA gene sequence. Neither sidade de São Paulo, Sao Paulo, Brazil patient had received probiotics. 5 Hospital das Clinicas da Faculdade de Medicina da Univer- Methods: Case 1: A 49-year-old intoxicated homeless sidade de Sao Paulo, SP, Brazil male with a history of chronic alcoholism was admitted 6 Hospital das Clínicas da Faculdade de Medicina da Univer- for workup of hypoxia. Patient described a chronic cough sidade de São Paulo, São Paulo, NA, Brazil and a 60 pound weight loss over six months. Examination Background: To describe the percentage of Cryptococ- was notable for cachexia, poor dentition, and inspiratory cus neoformans and Cryptococcus gattii encountered in our stidor. CT scan revealed a neck mass compromising the hospital, a 2500-bed teaching hospital of São Paulo, and patient’s airway. A PET scan demonstrated a hyperme- to compare minimal inhibitory concentrations to different tabolic mass in the mediastinum with paratracheal lymph antifungal drugs. node uptake consistent with metastatic malignant disease. Methods: Consecutive and no duplicate clinical isolates Zygosaccharomyces bailii was identified in blood cultures recovered from patients with infections (meningitis, cryp- from admission and on hospital day three. Intravenous tococcaemia, pneumonia and peritonitis) between 2006 and Amphotericin B treatment was initiated. Subsequent cul- 2008 were included for analysis. Identification to the species tures were negative. level was performed by conventional methods based on Results: Case 2: An 87-year-old woman with hiatal hernia growth appearance on Sabouraud dextrose agar at 37 ◦C, was admitted with gastrointestinal obstruction. Examination 14th International Congress on Infectious Diseases (ICID) Abstracts e127 was remarkable for hypotension and tachycardia (no oral patients. Incidence of resistance of commonly susceptible thrush). Esophagogastroduodenoscopy revealed fecal mat- species to the tested antimycotics was rare. The resis- ter in the esophagus and stomach. Post volvulus repair, the tance to 5-FC (MIC ≥ 32 ␮g/mL) was showed only in case patient developed sepsis, secondary to an esophageal perfo- of two C. albicans strains. The highest resistance, specif- ration. Surgical closure was performed and she was treated ically to azole antimycotics, was observed in C. glabrata with broad spectrum antibiotics and corticosteroids. Blood strains, amongst which, except VRZ (MIC ≥ 32 ␮g/mL), resis- cultures were positive for Candida albicans (two occasions) tant strains to FLZ (MIC ≥ 64␮g/mL), KTZ (MIC > .125 ␮g/mL) and Saccharomyces cerevisiae (one occasion) fungemia. Flu- and ITZ (MIC ≥ 1 ␮g/mL) were found. conazole was added to the antibiotic treatment. Patient Conclusion: Results obtained in the study showed a higher never fully recovered and care was withdrawn. incidence of non-albicans Candida yeasts in immunocompro- Conclusion: Disseminated Saccharomyces infection has mised patients. We did not find significant differences in been reported in immunosuppressed patients treated with susceptibility of yeasts isolated from immunocompromised probiotics, but disseminated Saccharomyces cerevisiae and immunocompetent patients. infection associated with underlying esophageal disease is not previously described. Saccharomyces cerevisiae (which doi:10.1016/j.ijid.2010.02.1766 occasionally colonizes the gastrointestinal tract) is closely related to Candida albicans, and may be misidentified by 30.026 common automated microbiologic systems. The relative Candidemia in third level hospitals in Bogotá, Colombia resistance of Saccharomyces cerevisiae to azole drugs and J. Cortes 1,∗, P. Reyes 1, C.H. Gomez 2, S.I. Cuervo 1,P. its ability to cause widespread infections with multi-organ Rivas 3, R. Sanchez 1 involvement makes rapid, correct identification critical. Using the standard yeast card, the Vitex-2 system iden- 1 Colombia tified one yeast as Saccharomyces cerevisiae and one 2 Hospital Universitario San Ignacio, Bogota, Colombia as Zygosaccharomyces bailii. We found no documented 3 Instituto Nacional de Cancerologia, Bogota, Colombia cases of Zygosaccharomyces fungemia so we employed DNA sequencing to confirm the Vitek identification. Based on the Background: Candidemia is a serious infectious compli- nucleotide sequence of the D1/D2 LSU ribosomal RNA gene cation among critical and immunosupressed patients. both the fungi were identified as Saccharomyces cerevisiae. Methods: Patients with laboratory confirmed candidemia were prospectively followed. Candida isolates were sent to a reference laboratoryfor identification and susceptibility. doi:10.1016/j.ijid.2010.02.1765 Risk factors and clinical data were taken from the medical 30.025 record. Antifungal use and final outcome were registered. Determination of antifungal susceptibility in immunocom- Results: 131 episodes were followed, 61% women, with promised patients ages between 9 days and 87 years. 50% of blood cultures were positive after 34 hours (in 44% of the patients blood ∗ L. Siegfried , V. Hrabovsky, M. Sabol cultures were posiitve in more than one bottle). More frequently found risk factors for candidemia were stay in ICU University P.J.Safarik,Faculty of Medicine, Kosice, Slovakia 78%), previous antibiotic use (77%), parenteral nutrition Background: The aim of the study was to compare anti- (54%), previous abdominal surgery (40%), previous use of fungal sensitivity of yeasts to selected antimycotics isolated immunosuppresors (29%). Candida species identifies were C. from immunocompromised patients with hematooncological albicans (67%), followed by C. parapsilosis (14%) and C. trop- disorders and critically diseased patients in intensive care icalis (10%). Susceptibility to fluconazole were high among units with sensitivity of yeasts isolated from immunocompe- C. albicans and C. tropicalis isolates, but not for the other tent individuals. Nonalbicans isolates. Fluconazole was the preferred drug of Methods: Within the period between August 2007 and choice (57%), followed by amphotericin deoxycholate (18%). October 2008, we examined 450 samples of clinical mate- 18% of the patients never received antifungal therapy. Mor- rial isolated from hospitalized patients with both proven tality was high after two weeks of treatment (20%) and was and suspected mycotic infection. Yeasts isolates were iden- even higher at discharge (36%). tified by Chromagar Candida and AUXACOLOR 2 biochemical Conclusion: Candidemia is a severe complication with test. Susceptibility to antimycotic agents such as fluconazole high mortality. In Colombia, a high proportion of patients (FLZ), ketoconazole (KTZ), itraconazole (ITZ), voricona- never received antifungal therapy even with laboratory zole (VRZ), flucotysine (5FC), amphotericin B (AMB), and proven infection. caspofungin (CAF) was determined by microdilution method according to CLSI M27-A2 standard procedure. doi:10.1016/j.ijid.2010.02.1767 Results: Among all isolates nine yeast species were identified, the most frequently C. albicans strains (n = 151), followed by C. glabrata (n = 21), C. krusei (n = 11), S. cerevisiae (n = 8), C. parapsilosis (n = 7), C. tropicalis (n = 3), C. guiliermondii (n = 3), C. kefyr (n = 2) and C. lusitaniae (n = 2). Among yeasts isolated from immunocompromised patients the incidence of non-albicans Candida was 42.6% while only 17% among yeasts isolated from immunocompetent e128 14th International Congress on Infectious Diseases (ICID) Abstracts

Non-tubercolous Mycobacteria (Poster Presenta- 31.002 tion) FOXO3a Transcription Factor mediates Apoptosis of 31.001 Mycobacterium bovis BCG-Infected Macrophages ,∗ AIDS-associated atypical mycobacteriosis other than M. Essafi 1 , M. Houas 1, A. Mallavialle 2, N. Laabidi 3,M. Mycobacterium avium-intracellulare: a 16-year survey deckert 2, M.R. Barbouche 1 of Mycobacterium xenopi, Mycobacterium kansasii and 1 Institut Pasteur de Tunis, Tunis-Belvedere, Tunis, Tunisia Mycobacterium fortuitum infections in the setting of HIV 2 Institut National de la Santé et de la Recherche Médicale disease INSERM, UMR 576, Nice, France R. Manfredi 3 Institut Pasteur de Tunis, tunis, Tunisia University of Bologna, Bologna, Italy Background: Phagocytosis of Mycobacterium tuberculosis (Mtb) by macrophages is the first event in the host-pathogen Background: A prompt and effective diagnosis and a relationship that decides outcome of infection. Apoptosis of timely treatment of atypical mycobacteriosis, and espe- infected macrophages occurs during the course of Tuberculo- cially Mycobacterium kansasii, Mycobacterium xenopi, and sis, and most research indicates that it acts as a host defense Mycobacterium fortuitum disease, remains a serious chal- mechanism leading to the elimination of the pathogen. How- lenge for clinicians engaged in the management of the ever, the mechanisms of this process are not well-defined. immunocompromised host, including HIV disease. Forkhead transcription factors of the Box-O family (FOXOs), Methods: Eighteen, twelve, and three HIV-infected major targets of the PI3K/Akt pathway, have been reported patients with a microbiologicallyconfirmed M. kansasii, M. to regulate cell-cycle progression, life span and apopto- xenopi, and M. fortuitum respiratory infection respectively, sis. In the present study, we investigated the involvement have been observed in a 16-year period, out of over 4,700 of FOXO3a transcription factor in the regulation of BCG- hospitalizations performed because of HIV-associated disor- mediated apoptosis in PMA-differentiated THP-1 cells. ders at our inpatient centre. These episodes were carefully Methods: Human THP-1 cells were treated with phor- evaluated from an epidemiological, bacteriological, clinical, bol 12-myristate 13-acetate (PMA) to induce maturation and therapeutic point of view. of the monocytes to a macrophage-like adherent pheno- Results: In 15 out of the 33 overall episodes (45.5%), type before get infected or not with BCG. Cell survival was a concurrent bacteremia was also retrieved, as a sign of assessed by annexin V/7-AAD staining and visualization of disseminated infection. A rapid and significant reductin of nuclear condensation by a Giemsa staining. Whole cell pro- the crude frequency of atypical mycobacteriosis as a major teins, cytoplasmic and nuclear extracts were analyzed by HIV-related complication, occurred shortly after the intro- wester blot using specific antibodies. Real-Time PCR was duction of potent antiretroviral combinations (cART) in the used to analyze Gene’s expression profile of infected and year 1996. In fact, until early nineties, the lack of potent non infected cells. antiretroviral regimens made frequent the association of Results: Similarly to Mtb, BCG significantly induced this opportunism with full-blown AIDS, a mean CD4+ lympho- macrophage apoptosis when high multiplicity of infection ␮ cyte count of around 20-50 cells/ L, and extremely variable (MOI) was used, while cell death was delayed at a lower chest X-ray features and systemic presentations. The recent MOI. BCG infection was associated with a decrease of both detection of 9 further episodes of atypical mycobacterio- Akt and FOXO3a phosphorylation two hours post infection sis in the year 2009 was due to a late recognition of a far along with FOXO3a translocation to the nucleus. Moreover, advanced HIV disease (the so-called ‘‘AIDS presenters’’), Real-Time PCR analysis of gene’s expression profile of the which were already complicated by multiple opportunistic BCG-infected macrophages revealed an upregulation of two disorders. pro-apoptotic FOXO3a targets, the tumour necrosis fac- Conclusion: M. kansasii, M. xenopi, and M. fortuitum res- tor related apoptosisinducing ligand (TRAIL) and the TNF piratory and/or disseminated infection continues to occur, Receptor-Associated Death Domain (TRADD). and pose relevant diagnostic problems, including late or Conclusion: FOXO3a plays an important role in BCG- missed identification due to slow culture and frequently induced cell death of human macrophage through the concurrent opportunistic disease. Serious therapeutic dif- induction of pro-apototic factors. Understanding the ficulties, due to the unpredictable in vitro antimicrobial Akt/FOXO3a pathway and its associated death mechanism susceptibility profile of these organisms, and the need to in macrophages during Mycobacteria infection would lead start as soon as possible an effective combination therapy to identification of potential therapeutic avenues for the which should not interfere with other medications (espe- treatment tuberculosis. cially cART), are also of concern. doi:10.1016/j.ijid.2010.02.1769 doi:10.1016/j.ijid.2010.02.1768 14th International Congress on Infectious Diseases (ICID) Abstracts e129

31.003 practical distinction between MTC and other mycobacterial Hansen’s disease in Northeast Brazil pathogens is a difference in their habitats and contagious- ness. Members of theMycobacterium avium complex (MAC) ,∗ F.Pucci 1 , C.R. Teófilo 2, T.S. Feitosa 2, S.G.A. Aragão 2, L.F. may be found in drinking water systems and is now more Távora 2 frequently isolated than MTC and represents the 26% of the total mycobacterial isolates from chronic pulmonary 1 UNIFOR, Fortaleza, ceara, Brazil disease of NTM. Since the ubiquitous occurrence of MAC 2 UNIFOR, Fortaleza, Brazil organisms in the environment, and the clinical presentation Background: Hansen’s disease is an infectious malady may be indistinguishable from tuberculosis, the diagno- with an insidious evolution caused by Mycobacterium leprae. sis of pathogenic agent is important to apply the correct This bacteria is transmitted through contact with damaged antibacterial treatment. In order to find a diagnostic tool to skin/mucosa or oropharyngeal/nasal secretions of infected distinguish between MAC from MTC, we have use an immuno- patients. Peripheral nerves can be affected by this disease proteomic approach to find immunogenic proteins from M. too, which can be incapacitating if left untreated. In spite avium and Mycobacterium bovis BCG strain México to rep- of the Brazilian government efforts to contain the dissemi- resent MAC and MTC respectively. nation of Hanseniasis, it is still an important public health Methods: With a panel of 52 serum samples classified into problem, mainly in the poorer areas of the country, includ- four groups: patients with active pulmonary tuberculosis, ing the Northeast region. Knowing the disease epidemiology, patients with chronic pulmonary by NTM, subjects with pos- making early diagnosis and initiating adequate treatment itive reaction to protein derivative (PPD) who were healthy and follow up are indispensable tools to achieve its control. household contacts and those with negative reaction who In order to understand the epidemiology of Hansen’s disease were the healthy uninfected controls, ELISA test was per- in our city, we conducted the present study. formed for titration of IgG2 against 16 mycobacterial strains Methods: This is a retrospective cohort study of all the from three groups: M. tuberculosis, M. bovis BCG and NTM. patients with Hansen’s disease diagnosed and treated in the The sera with higher titers were used to obtain the immuno- Dona Libânia Dermatology Reference Center, in Fortaleza, proteomes. A standard proteomic analysis of BCG Mexico and Ceará, Northeast Brazil, in 2008. Patients’ medical records M avium M7 began with the separation and visualization of were reviewed and the data collected was analyzed utilizing the protein mixture using two-dimensional polyacrylamide the Epi Info 3.5 program. gel electrophoresis (2-DE) followed by Western blotting for Results: A total of 273 patients were included in the study the screening of immunogenic proteins using selected sera. and 52% were female. Most prevalent age intervals were Results: The comparison between the immunodetection 41-60yrs (39,19%) and 20-40yrs (35,16%). Hypochromic or of different sera: TB, MNT and PPD+/− against BCG Mex- eritematous patches, presence of skin nodules or plaques, ico gave about 80% of unique proteins and 20% of proteins neuropathic pain and functional sequelae were the most shared among different sera. The immunodetection in M. frequent signs/symptoms found on admission, with preva- aviumgave 90% of unique proteins and 10% of proteins shared lence of 81,7%, 59,6%, 23,1% and 13,3% respectively. In 27,8% among the same sera. patients the disease could not be classified. The remaining Conclusion: The comparative analysis between immuno- was classified as follow: 37% borderline, 20,5% tuberculoid, proteomes of BCG Mexico and M. avium allowed the 11,4% lepromatous and 3,3% indeterminate. Only in 16,5% of identification of candidate proteins for the differentiation the patients a household contact was identified as a reser- between pulmonary disease caused by NTM and BCG Mexico voir of the bacteria. as a member of MTC. Conclusion: Hansen’s disease is still a prevalent disease in our city. Most of the patients were adults, in productive doi:10.1016/j.ijid.2010.02.1771 working ages. Some of them presented with functional incapacity or advanced neural damage on admission suggesting 31.005 an unacceptable delay in the diagnosis. Our findings point to Characterization of nontuberculous mycobacteria iso- the necessity of a better identification of risk factors, inves- lated of potable water distribution system and wastew- tigation of reservoirs and the use of more sensitive methods ater of Mexico City Metropolitan Area for early detection of leprosy in order to achieve adequate L. Lloret-Sanchez, A.I. Castillo ∗, M. Mazari-Hiriart, M. control of the disease. Vargas, Y. López-Vidal doi:10.1016/j.ijid.2010.02.1770 UNAM, Mexico City, Mexico 31.004 Background: Background: Nontuberculous mycobacteria Identification of immunogenic proteins of Mycobacterium (NTM) are normal inhabitants of the environment and they avium with diagnostic potential are found in soil, dust and water including natural and potable water and since there is no evidence of person- ∗ E. Amador , L. Lloret, A.I. Castillo, Y. López to-person transmission, the water is considered the main vehicle for transmission of nontuberculous mycobacteria. UNAM, Distrito Federal, Mexico Some studies have shown that the rate of infection by non- Background: Non-tuberculous mycobacteria (NTM) is the tuberculous mycobacteria is increasing in predisposing hosts term used to define all the remaining species from Mycobac- as well as healthy persons. On the other hand NTM may terium tuberculosis complex species (MTC). The major alter replication of vaccine Mycobacterium bovis Bacillus e130 14th International Congress on Infectious Diseases (ICID) Abstracts

Calmette and Guerin in animal model and influence in the ity (85.7% and 79.0%) and specificity (91.0% and 92.0%) than protection subsequent BCG vaccination. The aim of this self-reported fever. Of the three methods evaluated (ITDS, study was the isolation and identification of nontubercu- self report, and a combination in which a signal on either lous mycobacteria in: drinking water distribution systems ITDS or self report indicated a fever), ITDS (OptoTherm Ther- in the Mexico City Metropolitan zone.Methods: Water sam- moscreen and FLIR A20 M) had the highest total sensitivity ples were decontaminated by NaOH/SDS and cultured onto and specificity for fever detection. Correlations between Lowenstein Jensen to 37 ◦C/ 30 days. Different colonies were ITDS measurements and oral temperatures were similar identified by PCR-PRA 65 kDa gen, sequencing and phyloge- for the OptoTherm Thermoscreen (r = 0.43) and FLIR A20 M netic inference. (r = 0.42), and significantly lower for Wahl HSI2000S (r = 0.14, Results: We isolated NTM in both water sources. The most p)0.001 for both comparisons). frequently occurring isolates in potable water supply system Conclusion: When compared with oral temperatures, were M. nonchromogenicum, M. arupense, M. peregrinum two ITDS (FLIR A20 M and OptoTherm Thermoscreen) were and M. gordonae. Eleven species were isolated in wastewa- reasonably accurate in detecting fever and were better pre- ter and one Mycobacterium spp. dictors of fever than self report. These findings may be Conclusion: It is important to know the geographic distri- particularly important in the context of travel in which fever bution of nontuberculous mycobacteria presence in drinking may not be reported or cannot be measured using contact and wastewater because represent a risk for the population thermometers. In such settings, ITDS could provide an objec- health. tive means for detecting fever as part of a comprehensive public health screening strategy. doi:10.1016/j.ijid.2010.02.1772 doi:10.1016/j.ijid.2010.02.1773 Travel Medicine and Travel Health (Poster Presenta- 32.002 tion) Characteristics of travelers to developing countries: Find- 32.001 ings from the 2008 consumer styles survey Mass screening for fever: A comparison of three infrared X. Davis 1,∗, E. Jentes 2, P. Han 1, W. Pollard 2, C. Marano 2 thermal dectection systems and selfreported fever 1 Centers for Disease Control and Prevention, Atlanta, GA, 1,∗ 2 1 1 A. Nguyen , N. Cohen , H. Lipman , C. Brown ,D. USA 3 Fishbein 2 CDC, Atlanta, GA, USA 1 Centers for Disease Control and Prevention, Atlanta, GA, Background: Developing countries, while gaining in pop- USA ularity as travel destinations, may present increased or 2 Centers for Disease Control and Prevention, Chicago, IL, unfamiliar health risks to travelers from developed countries USA and require important pre-travel preparation such as seek- 3 Centers for Disease Control and Prevention, 30333, GA, ing medical advice, medications, and vaccinations. Studying USA the characteristics of travelers to developing countries can Background: During the 2003 severe acute respiratory help formulate more effective messages for healthy travel. syndrome and 2009 pandemic influenza A (H1N1) outbreaks, Methods: We analyzed survey data from Porter Novelli infrared thermal detection systems (ITDS) were used at ConsumerStyles 2008, a mail survey with a U.S. represen- international ports of entry and in hospitals to screen for tative sample, to understand characteristics of overnight fever. However, evidence is limited to support the accuracy stay travelers to developing countries (countries except the of ITDS and their benefit over self-reported fever for mass United States, Canada, Europe, Japan, Australia, and New screening. In this study, we compared three different ITDS Zealand). Odds rations (OR) and logistic regression were to self-reported fever.Methods: A cross-sectional study of used in the analysis (all p-values < 0.05). 2986 patients (age≥18 years) was conducted in three hos- Results: Among the 10,108 survey respondents, 913 (9%) pital emergency departments. Patients were asked if they were travelers. Only 331 (36%) travelers sought pre-travel felt that they had a fever (selfreported fever). We mea- medical advice from one of the 11 sources listed, 157 (47%) sured patient skin temperatures by using three ITDS (FLIR of those 331 sought advice from multiple sources. The top A20 M, OptoTherm Thermoscreen, Wahl HSI2000S) and oral reasons for not getting pre-travel medical advice were the temperatures (≥100oF = confirmed fever) by using digital belief that pills/shots were not needed (35%), followed by thermometers. ITDS temperature measurements and self- not thinking about it (27%). A specific question for travelers reported fevers were compared using oral temperatures as who visited yellow fever endemic countries (Kenya, Nigeria, a reference. Data were analyzed using simple and multiple Ghana or Senegal) revealed that only 52% (38/73) got yellow linear methods. fever vaccine. Compared to non-travelers, travelers were Results: Of 2873 patients with an oral temperature more likely to be male (OR = 1.24, 95% confidence interval recorded, 64 (2.2%) had a confirmed fever. Fever was (CI): 1.08-1.42), Hispanic (OR = 1.38, CI: 1.15-1.67), over age reported by 476 (16.6%) patients and 48 (10.1%) of these 55 years (OR = 1.26, CI: 1.09-1.45), living in smaller house- were confirmed. Self-reported fever had 75.0% sensitivity holds (<4 members, OR = 1.29, CI: 1.12-1.5), from richer and 84.7% specificity. At optimal cutoffs for detecting fever families (>$60k, OR = 2.94, CI: 2.54-3.4), and nonwhite as found in this study, the OptoTherm Thermoscreen and (OR = 1.19, CI: 1.03-1.37). They were more adventurous FLIR A20 M temperature measurements had greater sensitiv- (OR = 1.34, CI: 1.17-1.54), and in better health (OR = 1.82, 14th International Congress on Infectious Diseases (ICID) Abstracts e131

CI: 1.59-2.09). Most of the 913 travelers traveled for leisure TDC were more likely to view travel programs on televi- (77%), followed by visiting friends and relatives (17%), and sion (OR = 1.6, CI = 1.4-1.9, p < 0.0001). However, for both business (10%). Logistic regression showed that age over 65 newspaper and television, the two groups did not differ sig- years, traveling for business, and volunteering were posi- nificantly in reading the health section or watching health tively associated with pre-travel advice seeking while being shows. Hispanic was negatively associated. Conclusion: Given the initial spread of the 2009 H1N1 Conclusion: Our study showed that travelers to devel- virus through travelers and the ongoing threat of A/H5N1, oping countries were more likely to be male, healthy, it is important to tailor health messages carefully to best adventurous, and have higher income. More than half of communicate the importance of avian influenza risk to trav- the travelers surveyed did not seek any pre-travel medi- elers. TDC will likely be better reached via information on cal advice. Messages targeted to Hispanic travelers could the Internet and travel-related media sources. improve their awareness of the need to get medical advice before traveling. doi:10.1016/j.ijid.2010.02.1775 32.004 doi:10.1016/j.ijid.2010.02.1774 Demographics, medical conditions, and use of immu- 32.003 nizations and chemoprophylaxis among international Attitudes towards Avian influenza and sources of media travelers within the Global TravEpiNet U.S. National Clinic information in travelers to developing countries Network P. Han 1,∗, E. Yanni 2, E. Jentes 3, X. Davis 1, W. Pollard 4,C. R. LaRocque 1, S. Rao 1, E. Yanni 2, N. Marano 3,N. Marano 4 Gallagher 3, C. Marano 3, G. Brunette 3, J. Lee 4, V. Ansdell 5, B.S. Schwartz 6, M. Knouse 7, J. Cahill 8, S. Hagmann 9, 1 Centers for Disease Control and Prevention, Atlanta, GA, J. Vinetz 10, R. Hoffman 11, S. Alvarez 12, J. Goad 13,C. USA ,∗ Franco-Paredes 14, P. Kozarsky 14, D. Schoenfeld 1, E. Ryan 1 2 Centers for disease Control and Prevention, Atlanta, GA, USA 1 Massachusetts General Hospital, Boston, MA, USA 3 CDC, Atlanta, USA 2 Centers for Disease Control and Prevention, Atlanta, GA, 4 CDC, Atlanta, GA, USA USA 3 Centers for Disease Control & Prevention, Atlanta, GA, Background: Although there is an on-going 2009 H1N1 USA influenza epidemic, avian influenza virus (A/H5N1) contin- 4 Travel and Immunization Center, Northwestern Memorial ues to be a significant public health threat. Currently, 442 Hospital, Chicago, IL, USA cases have been confirmed worldwide with 262 deaths, 5 Kaiser Permanente Honolulu Travel Medicine Clinic, Hon- mostly in Asian countries. Risk of disease may be higher olulu, HI, USA in travelers to developing destinations, where these cases 6 University of California-San Francisco Travel Medicine & occur more frequently. This study investigated travelers to Immunizatiion Center, San Francisco, CA, USA developing countries (TDC) and described their attitudes 7 Keystone Travel Medicine, Lehigh Valley Medical Center, towards A/H5N1 and defined their sources of media informa- Allenton, PA, USA tion in order to inform focused avian influenza prevention 8 Travel & Immunization Center, St Luke’s Roosevelt, New campaigns for travelers. York, NY, USA Methods: Data were analyzed from the 2008 Porter- 9 Bronx Lebanon Hospital Center Neighborhod Clinic for Novelli ConsumerStyles survey, an annual national mail- Travel Health, Bronx, NY, USA in survey that gathers demographic information and 10 University of California, San Diego Travel Clinic, La Jolla, media/consumer information about the US population. TDC CA, USA were defined as persons traveling outside the United States 11 University of California Los Angeles Travel & Tropical for ≥1 day anywhere other than Canada, Europe, Japan, Medicine Clinic, Los Angeles, CA, USA Australia, or New Zealand. Odds ratios (OR) and logistic 12 Mayo Clinic, Jacksonville, FL, USA regression were used. 13 USC International Travel Medicine Clinic, Los Angeles, CA, Results: Of 10,108 respondents, 913 (9%) reported being USA TDC; compared to non-TDC, TDC were less likely to be 14 Emory TravelWell, Atlanta, GA, USA worried about getting ill from A/H5N1 (OR = 0.5, CI = 0.4- 0.8, p = 0.002). Further, TDC were less likely to have Background: International travelers play a significant role followed news stories about A/H5N1 (OR = 0.72, CI = 0.56- in the global spread of infectious diseases. Despite this, 0.95, p = 0.02) and were more likely to feel that news media data are limited on travel patterns, medical conditions, and were ‘‘exaggerating the dangers’’ (OR = 1.3, CI = 1.1-1.5, medical interventions among international travelers prior to p = 0.006), compared to feeling the ‘‘news reports are about departure. right.’’ Methods: Global TravEpiNet is a U.S. CDC-sponsored net- Overall, TDC were more likely to refer to the Inter- work of U.S. clinics that care for international travelers. net (OR = 1.5, CI = 1.3-1.7, p < 0.0001) for health information We report analysis of health data for 3,159 international than were non-TDC. They were also more likely to read the travelers seen at U.S. Global TravEpiNet sites in 2009. national news (OR = 1.3, CI = 1.2-1.5, p < 0.0001) or travel Results: Females accounted for 56% of travelers. The sections (OR = 3.0, CI = 2.6-3.4, p < 0.0001) of the newspaper. median age was 33 years; the median duration of travel e132 14th International Congress on Infectious Diseases (ICID) Abstracts was 14 days. Thirty-five percent of international trav- Results: Of the 1,254 travelers, 671 (54%) were traveling elers were traveling to low-income countries, 46% to to LMICs. The mean age of travelers to LMICs was 42 years, low-middle income, 16% to upper-middle income, and 2% to and 30% were traveling for more than 2 weeks. Purposes upper-income countries. The main purposes of travel were of travel included vacation/holiday (63%), business/work vacation/leisure (63%), business (20%), extreme-adventure (11%), educational/cultural exchange (6%), performing vol- travel (14%), education/research (11%), visiting friends and unteer work (10%), adventuring (7%), attending a large relatives (10%), non-medical service work (6%), and pro- gathering (2%), providing medical care (3%), receiving medi- viding medical care (4%). Two percent of travelers were cal care (0.5%), and adoption (0.3%). Nineteen percent were attending large gatherings. Ten percent were children less traveling as part of a family that included children, and 104 than 18 years of age; 4% were less than 5 years of age; (16%) were born overseas and returning to visit friends or and 6% of travelers were over 65 years of age. Sixty-four relatives (VFRs). percent of travelers listed a medical condition; 70% were Among travelers to LMICs, 50% did not seek any medi- on daily medication. Ten percent of travelers reported a cal advice and 74% did not see a healthcare professional pre-existing neurologic or psychiatric condition; 7% reported prior to travel. For travelers who did not seek medical a pre-existing intestinal condition; 2.5% were immunocom- advice, the most common reasons cited were lack of con- promised; and 0.4% of female travelers were pregnant or cern about health issues (60%), not thinking of it (35%), not breastfeeding. We analyzed vaccine usage for prevention of having enough time (7%), inconvenience (3%), and expense hepatitis A, yellow fever, and influenza. Eightyone percent (2%). of travelers received immunization against hepatitis A; 7% A significantly lower percentage of VFRs sought any- were considered preimmune. Of the 38% of travelers visit- source medical advice prior to travel compared with other ing countries that included areas endemic for yellow fever, travelers (37% vs 52%; p = 0.004). VFRs were less likely than 67% received yellow fever immunization; 18% were consid- other travelers to use the Internet (12% vs 24%; p = 0.004), ered pre-immune. Yellow fever vaccine was administered and less likely to see a specialist practitioner prior to to 407 travelers 60 years of age or older. Forty percent of travel (2% vs. 15%; P < 0.001). VFRs and other travelers were international travelers received influenza vaccine; 30% were equally likely to seek advice from primary care providers considered pre-immune. Of the 2082 travelers traveling to prior to travel (21% vs. 17%; p = 0.32). countries that included areas endemic for malaria, 65% Conclusion: Our results suggest that half of travelers to received malaria chemoprophylaxis. Of these, 66% received LMICs do not seek any healthcare advice prior to their trip, prescriptions for atovaquone-proguanil, 3.5% received doxy- and that most of such travelers do not seek advice from cycline, and 14% received mefloquine. a health care professional. The most common reason these Conclusion: These data suggest that international trav- individuals cite for not seeking medical advice is lack of con- elers range widely in age and frequently have co-morbid cern about health problems related to travel. These results medical conditions that heighten the need for pre-travel suggest a need for health outreach and education programs advice. targeting travelers to LMICs. doi:10.1016/j.ijid.2010.02.1776 doi:10.1016/j.ijid.2010.02.1777 32.005 32.006 Use and sources of medical information among departing Transporting a critically ill patient from the Canadian international travelers to low and middle income coun- north - lessons learned from almost a decade of SkySer- tries at Logan International Airport-Boston, MA, 2009 vice Medevac experience R. LaRocque 1, S. Rao 1, T. Lawton 1, A. Tsibris 1,D. G. Samoukovic 1,∗, E. Farias 2, T. Malas 2, H. Petrie 3,M. Schoenfeld 1, A. Barry 2, E. Yanni 3, N. Marano 4,N. Churchill Smith 2 Gallagher 4, C. Marano 4, G. Brunette 4, E. Ryan 1,∗ 1 McGill University Health Sciences Centre, H3A 1A1, QC, 1 Massachusetts General Hospital, Boston, MA, USA Canada 2 Communicable Disease Control, Boston Public Health Com- 2 McGill University Health Sciences Centre, Montreal, QC, mission, Boston, MA, USA Canada 3 Centers for Disease Control and Prevention, Atlanta, GA, 3 SkyService Medevac, Montreal, QC, Canada USA Background: Canadian North is vast territorially, yet med- 4 Centers for Disease Control & Prevention, Atlanta, GA, ical resources are lacking manpower, expertise, equipment USA and facilities. Transport of seriously ill patients is, hence, a Background: International travelers play a significant role common necessity frequently requiring both ground and air in the global spread of infectious diseases, especially trav- transportation. SkyService Medevac is the major medevac elers to low and middle-income countries (LMICs). Despite air-transporter in Canada and one of the global leaders in this, limited data exist on sources of health information used the field. by these travelers. Methods: We reviewed the data related to a total of Methods: To address this, we surveyed 1,254 interna- 988 cases of medical evacuations from 2002 to 2008. The tional travelers who reside in the U.S. and were departing data reveals information regarding demographics, pathol- from Boston-Logan International Airport in 2009. ogy prompting the transport as well as medical expertise required for the transport. We pay special attention to the 14th International Congress on Infectious Diseases (ICID) Abstracts e133 parameters concerning the neonatal and pediatric popula- Antimotility drugs were the most common medication car- tion. ried by backpackers, followed by oral rehydration salts Results: Of the 988 cases (Table 1) of medical evacuation (ORS), and antibiotics. Although 61% of participants had from Baffin Regional Hospital in Iqaluit, Nunavut, between received information about travelers’ diarrhea before the 2002 and 2008, pediatric population comprised 35.6%, current trip, their practices were far from ideal; 95.7% had majority of whom were neonates. Almost 17% of the patients bought food from street vendors, 92.5% had drunk bever- were critically ill, intubated and required intensive-care ages with ice-cubes, 34.6% had eaten leftover food from a hospitalization. The most common pathologies prompting previous meal, and 27.5% had drunk tap water. Only 23% of evacuation were those involving cardiovascular and respi- backpackers always washed their hands before eating food. ratory systems. There were no in-flight mortalities, while In this study, 31% (130/408) of backpackers had experienced invasive interventions by the medical staff were extremely diarrhea during their trip. Most cases (88.4%) were mild and rare after departure. recovered spontaneously. However, 8.5% of cases required Year Total Vented Non Age Age Age a visit to a doctor, and 3.1% needed hospitalization; 16.28% Pts Vented <1 1-18 >18 had to delay or cancel their trip due to a diarrheal attack. Conclusion: About one third of the foreign backpackers in 2002 111 24 87 19 20 69 Southeast Asia had experienced diarrhea during their trip. 2003 169 44 124 40 20 96 Their current state of awareness and practices related to 2004 100 22 18 21 9 70 the risk of travelers’ diarrhea were inadequate and should 2005 104 22 82 19 20 63 be improved. 2006 119 19 96 29 15 75 2007 164 21 143 25 26 113 2008 221 35 187 52 19 150 doi:10.1016/j.ijid.2010.02.1779 Total 988 165 823 205 147 636 32.008 Conclusion: Safe air transport from any destination is fea- The health surveillance stations at points of entry in sible, but required detailed planning, pre-flight preparation Brazil under the revised International Health Regulations and expertise. SkyService Medevac data demonstrate that - IHR/2005 transport from Canadian North is not only safe, but also ∗ economically advantageous. C. Gregis , F.V. Pascalicchio National Health Surveillance Agency (Anvisa), BRASILIA, DF, doi:10.1016/j.ijid.2010.02.1778 Brazil 32.007 Background: The recent revision and update of the Inter- Incidence and impact of travelers’ diarrhea among foreign national Health Regulations, IHR (2005), provides a new backpackers in Southeast Asia approach to deal with international reaction to public health ∗ events and to ensure global health security. Therefore, it W. Piyaphanee , T. Kusolsuk, C. Kittitrakul, W. Suttithum, is a priority to build, strengthen and to mobilize the nec- T. Ponam, P. Wilairatana essary resources. The National IHR Focal Point must notify Faculty of Tropical Medicine, Mahidol University, Bangkok, within 24 hours all events which may constitute a public Thailand health emergency of international concern. This study aim to assess the effectiveness of Health Surveillance Units at Background: Travelers’ diarrhea is the most common dis- points of entry in Brazil regarding health control of interna- ease reported among travelers visiting developing countries, tional travelers and epidemiological investigation conducted including Southeast Asia, which is visited by large numbers of in accordance with the IHR (2005). backpackers each year. Current knowledge of this particular Methods: It was analyzed the public health events noti- group is limited. This study aimed to determine the inci- fied to the Health Surveillance Units at points of entry that dence and impact of travelers’ diarrhea among this group. occurred in the first year after IHR (2005) entry into force The secondary objective was to assess their attitudes and in accordance with the attributes of usefulness, sensitiv- practices towards the risk of travelers’ diarrhea. ity, timeliness, and stability, and their relation with Malaria Methods: Foreign backpackers in Bangkok, Thailand, imported cases into Brazil at the same period. were invited to fill out a study questionnaire, in which Results: Since 1975, Brazil has a broad national epi- they were queried about their demographic background, demiologic surveillance system to reporting infectious and travel characteristics, pre-travel preparations, and actual no-infectious diseases and that enables the assessment and practices related to the risk of travelers’ diarrhea. For control of these events timely. Until 2007, the main activ- backpackers who had experienced diarrhea, the details and ity at points of entry was the supply of the yellow fever impact of each diarrheal episode were also assessed. vaccine and its verification when an international traveler Results: In the period April-May 2009, 408 completed was arriving from an affected country. At the first year, 26 questionnaires were collected and analyzed. Sixty percent suspected events of public health concern were reported of participants were male; overall, the median age was by points of entry to central office after 4.2 days average, 26 years. Nearly all backpackers (96.8%) came from devel- such as unknown death (6 events), chickenpox (5), malaria oped countries. Their main reason for travel was tourism (4), tuberculosis (2), outbreaks of foodborne illness (2), and (88%). The median stay was 30 days. More than half the one of rubella, hanseniasis, acute fever illness, hepatitis, backpackers (56%) carried some antidiarrheal medication. norovirus, conjunctivitis and accident. At the same time, e134 14th International Congress on Infectious Diseases (ICID) Abstracts

203 Malaria imported cases occurred among 30 percent of cases, likely decreased transmission and prevented travel employees and 60 percent of cases arriving from Africa. related outbreaks of varicella. Conclusion: The structure of the health surveillance at points of entry in Brazil has changed after the IHR/2005 doi:10.1016/j.ijid.2010.02.1781 implementation. The low sensitivity for detection of events in points of entry are in agreement with the relevant litera- 32.010 ture. There is the necessity of further research on imported Foreign travel associated with increased sexual risk: A cases of notifiable diseases and improvement of the investi- cohort study gation and notification to the central level. R. Vivancos 1,∗, P.R. Hunter 2, I. Abubakar 2 doi:10.1016/j.ijid.2010.02.1780 1 Health Protection Agency, Liverpool, Merseyside, United Kingdom 32.009 2 University Of East Anglia, Norwich, United Kingdom Varicella (Chickenpox) outbreak in Bhutanese refugee camps in Eastern Nepal Background: An increasing number of people travel abroad for their holidays each year. New sexual relations ,∗ A.K. Mishra 1, O. Gorbacheva 1 , M.M.T. Hasan 2, N. Rimal 3 while abroad may result in the acquisition and introduction of novel strains of sexually transmitted infections (STIs). 1 International Organization for Migration, Jhapa, Nepal Methods: We conducted a prospective cohort study to 2 UNHCR Sub Office Damak, Jhapa, Nepal assess the impact of alcohol and drug use, and foreign travel 3 Association of Medical Doctors of Asia (AMDA), Jhapa, on casual travel sex in students from a British university Nepal during the summer break in 2006. Background: Approximately 100,000 Bhutanese refugees Results: Two thirds of students traveled abroad. They live in seven camps in southeastern Nepal. For those offered were more likely to consume alcohol (RR 1.59, 95% CI 1.17- resettlement to the USA, Canada, Australia, New Zealand, 2.16) and use drugs (RR 1.31, 95% CI 0.88-1.94), particularly Denmark, Norway, or Netherlands, the International Orga- Cannabis, and to have new sexual partnerships during holi- nization for Migration (IOM) in Nepal conducts medical days. They were also more likely to report sexual relations screening and arranges travel, moving up to 15,000 refugees after holidays (RR 1.29, 95% CI 1.09-1.53). New partnerships annually. Varicella spreads primarily by airborne droplets were associated with being single, traveling abroad, drink- and patients with infectious varicella are prohibited from ing large amounts of alcohol, having previously had large the air travel. Varicella vaccine in Nepal is not licensed. number of sexual partners. The adjusted relative risk of In March 2009, an outbreak of varicella was detected at developing new sexual partnerships with foreign travel was a refugee transit center (TC). Outbreak response was con- 2.70 (95% CI 1.11-6.61). Testing for a STI after the summer ducted jointly by UNHCR, IOM, and Association of Medical break was associated with both foreign travel (aRR 2.80, 95% Doctors of Asia (AMDA), implementing partner for refugee CI 1.16-6.74) and younger age. camp health services. Conclusion: People who travel abroad are more likely to Methods: A varicella case was defined as an illness engage in risk taking behavior and to develop new sexual with acute onset of diffuse papulovesicular rash without partnerships during their holidays. They are also more sexu- other apparent cause. Refugees received additional health ally active on their return to the UK, increasing the chance education regarding signs and symptoms of varicella and of introducing new and resistant strains of STIs in the UK. importance of limiting contacts with sick people. Prior to These individuals are, however, also more likely to be tested travel, medical staff screened departing refugees for fever for STIs. and conducted careful skin inspection. For cases with immi- nent travel, cases and their family were deferred from travel doi:10.1016/j.ijid.2010.02.1782 or travel-related screening for 21 days. Refugees identified with varicella in TC were isolated until lesions crusted. Results: From 25 February to 25 May 2009, 473 cases of Varicella were registered (cumulative incidence 50 per 10,000 refugees). Among the seven camps, incidence ranged from 9 per 10,000 to 124 per 10,000; outbreak duration ranged from 37 to 87 days. The age ranged from 01 month to 30 years, mean 6.5 years. The incidence was the highest among children of 0-4 years (242 per 10,000), and decreased with each successive age group. Eight cases and their families (total 21 refugees) were deferred from travel for 21 days. 14 refugees and their families (total 63 refugees) were deferred from travel-related screening. 3,860 refugees departed during the outbreak period to United States. No refugees were reported to develop varicella during the flight or upon arrival to the final destination. Conclusion: In a setting with endemic varicella transmission, systematic surveillance, combined with isolation of 14th International Congress on Infectious Diseases (ICID) Abstracts e135

32.011 32.012 Management of an international outbreak of norovirus on Medical tourism research: A systematic review board a cruise ship V. Balaban 1,∗, C. Marano 2 R. Vivancos 1,∗, A. Keenan 2, W. Sopwith 3, C. Quigley 4,K. 1 Centers for Disease Control and Prevention (CDC), Atlanta, Mutton 5, G. Nichols 6, J. Harris 6, Q. Syed 4, J. Reid 1 GA, USA 1 Health Protection Agency, Liverpool, Merseyside, United 2 CDC, Atlanta, GA, USA Kingdom Background: Medical tourism, foreign travel for the pur- 2 Health Protection Agency, Liverpool, MERSEYSIDE, United pose of seeking medical treatment, is an important new Kingdom development in healthcare. Medical tourism is a world-wide, 3 Wirral Primary Care Trust, Wirral, United Kingdom multibillion dollar phenomenon that is expected to grow 4 Health Protection Agency North West, Liverpool, United substantially in the next 5-10 years. To provide a foundation Kingdom for future investigations, a systematic review was conducted 5 Health Protection Agency, Manchester, United Kingdom to identify and evaluate current data on medical tourism and 6 Health Protection Agency, London, United Kingdom associated health impacts. Background: Managing an outbreak of gastroenteritis on Methods: PubMed, EMBASE and Medline databases and board a cruise ship while minimising disruption to passen- the World Wide Web were searched to identify studies of gers’ enjoyment is difficult. This can be more complex medical tourism from 1990-2009 containing data. with international cruises. We describe epidemiological Results: 44 studies were identified. 75% (n = 33) were investigation and control of an outbreak of Norovirus on reports oncomplications associated with medical tourism an international cruise around the British Isles and the for: commercial organ transplantation (n = 30), cosmetic Netherlands managed through an international multi-agency surgery (n = 1), dental care (n = 1), and fertility treat- incident control team. ments (n = -1). There were 9 (20%) surveys of travelers Methods: A cohort study was conducted using information and/or medical tourism providers, and 2 (4%) business from lists routinely collected by the cruise ship to assess the studies. Methodologies used were primarily retrospective possible sources of exposures. record reviews (75%) and interview surveys (23%). Stud- Results: A total of 191 of the 1,194 passengers (16%) ies of commercial organ transplantation reviewed 2506 and 5 crew (1%) became ill with gastrointestinal symptoms. cases, primarily kidney (92%) and liver (8%) transplants. Norovirus was identified through PCR at one of the ports China and India were the most frequent transplant desti- of call. Attack rate was higher among passengers staying in nations. Studies’ results suggest an apparent increase in the main deck (RR 3.41, 95% CI 1.47- 7.94), which houses ‘‘transplant tourism’’ from 1990-2009, and higher incidence both passengers’ cabins and leisure facilities (e.g. shops). of post-operative tissue rejection and severe infectious Also, passengers who went on one of the organised coach complications among transplant tourists compared to other tours where there were symptomatic passengers were at transplant patients. These studies are limited by lack of increased risk of infection (RR 2.14, CI 1.51-3.03). denominator data for transplant tourism, exclusive focus An international multi-agency Outbreak Control Group, on complications, survivorship bias, and the possibility that involving port health authorities and public health agencies transplant touristsmay not be representative of all medical in the ports of call, was convened to oversee control mea- tourists. Business studies calculate widely varying estimates sure and advice the incident management team on board the of the frequency of medical tourism, ranging from 60,000- ship. This allowed continuity, ensuring that port health offi- 750,000 medical travelers annually. These studies are lim- cers inspecting the ship at each port were aware of what had ited by variability in the definitions and methodologies used been previously recommended and could monitor progress. to study medical tourism. Survey studies are limited by lit- Conclusion: Controlling outbreaks on board a cruise can tle or no data on treatment(s) received, reasons for seeking be complex when the ship moves from one country to foreign healthcare, or treatment outcomes. another and the leadership of the investigation changes. To Conclusion: Current epidemiological data on medical ensure that an outbreak is appropriately managed, multina- tourism are limited. Basic questions such as the preva- tional outbreak control groups are needed with one agency lence of medical tourism and associated complication rates taking the lead throughout the outbreak. International have not been established. Important directions for future agreement between public health authorities in different research include: developing consistent definitions, and con- countries is needed. ducting prospective studies of demographics, motivations, treatment outcomes, and cost benefits to better understand doi:10.1016/j.ijid.2010.02.1783 the healthcare implications of medical tourism.

doi:10.1016/j.ijid.2010.02.1784 e136 14th International Congress on Infectious Diseases (ICID) Abstracts

32.013 32.014 Preventing enteric fevers in London VFR travellers International traveler and prevention of diarrheal diseases characterization of the international traveller to Y. Knight ∗, E. Dapaah, B. Walsh whom has been prescribed cholera vaccine at the interna- South West London Health Protection Unit, London, United tional vaccination center of Oporto during the years 2007 Kingdom and 2008 Background: Enteric fevers have recently increased in the G. Saldanha UK; 40% of the 288 cases in 2007 were in London. South West Public Health, Porto, Portugal London Health Protection Unit saw a doubling of enteric fever cases from 2007 (n = 16) to 2008 (n = 32). An initia- Background: Each year more than 50 million people tive has been launched in south west London to provide travel from industrialized countries to developing coun- pre-travel health promotion, particularly for travellers vis- tries. The most common health problem in people who iting friends and relatives (VFR) and of Indian, Pakistani or travel to these countries is diarrheal diseases, an important Bangladeshi ethnicity in whom the majority of UK enteric cause of morbidity and mortality. The recent commercial- fever cases occur. An enhanced surveillance questionnaire ization of a new recombinant vaccine of cholera (the most revealed many VFRs do not seek pre-travel health advice, severe enterotoxic enteropathy) has created new expecta- particularly not from expected sources such as general prac- tions in the protection of travelers. An additional advantage titioners or travel clinics. Enteric fever health promotion of this vaccine is its ability to induce a protective immune needs to be targeted at London’s VFR travellers and Asian response against labile toxin of enterotoxigenic E.coli (the communities. most frequent cause of traveler’s diarrhea). The first aim Methods: We present 4 approaches to improving enteric of this study was the determination of prescription rate of fever health promotion. Using feedback from an enhanced cholera vaccine, the period of the year when there were surveillance questionnaire we have developed a travel a higher number of prescriptions and the characterization health information leaflet containing typhoid/paratyphoid of the international traveler regarding the gender, age, prevention advice aimed at VFRs. The leaflet is the first of occupation, residence, travel destination, time spent at des- its kind in the UK, giving food, water, hygiene and immu- tination, type of accommodation. In a second phase will be nization advice. We performed two qualitative surveys: i) a assessed the vaccine efficacy. targeted reader’s group (n = 15) to ascertain the accessibility Methods: Descriptive, quantitative and retrospective and appropriateness of the leaflet to our target population; study. The sample was the population of Travel Consulta- ii) in a sample of VFR and Asian Londoners we conducted tion of the International Vaccination Center of Oporto, who a focus group (n = 8) to identify the perceived barriers to has been prescribed cholera vaccine during the years 2007 accessing travel health information, and more suitable set- and 2008. The records of the Center’s archive were consul- tings for travel health promotion in this population. All work tated and Microsoft Office Excel® 2007 was used for data was performed in collaboration with Leicester NHS, and the processing. Health Protection Agency’s Communications and Travel & Results: The prescription percentage of cholera vaccine Migrant Health Sections. was 6.4%. The great number of prescriptions occured at Results: Of 30 cases of enteric fever in south west Lon- 1st trimester of 2007 and 2nd and 3rd trimesters of 2008. don in 2008, 53% were typhoid, 70% were VFR travellers, and Males are the one that prevails in travellers (82%). Most 67% were of Asian ethnicity. Content and style of the typhoid travelers (79%) belong to the age group of 21-50 years. The travel health promotion leaflet was found to be accessible construction, technical occupations and occupations related to our target audience; concern was raised over potentially to administration includes the majority of travelers. The inaccessible use of language specific to typhoid and faeces. most common destination is Angola (88%) and in most cases Perceived barriers included cultural views and notions of users on business trips (78%). Most users stay in hotel (31%), the purpose of travel. More appropriate settings for dissem- although a significant proportion also stay with relatives ination would include community pharmacies, school nurses (29%) or on company premises (27%). Most travelers (92%) and community centres. remains for over a week. Conclusion: We have developed an appropriate, innova- Conclusion: The proposed objectives were achieved and tive travel health promotion leaflet aimed at preventing the results were consistent with health professional’s typical typhoid/paratyphoid in London VFR travellers which is addi- traveller perception - male, working-age, Oporto resident, tionally tailored toward the Asian community. construction worker, which travels to Angola for professional reasons, staying in hotels or in relatives or business houses, doi:10.1016/j.ijid.2010.02.1785 for more than a week.

doi:10.1016/j.ijid.2010.02.1786 14th International Congress on Infectious Diseases (ICID) Abstracts e137

32.015 32.016 Travelers’ diarrhea (TD) incidence in argentine travelers First tavel medicine center in a public hospital from to high-risk destinations. A telephonic survey at a private Buenos Aires province, Argentina. The first 18 months of ambulatory center for infectious diseases (ID) and travel experience medicine (TM) in Buenos Aires M.L. yantorno ∗, G. de la Parra, M. Lares, K. Aguilera, D. M.A. Botas 1,∗, C. Biscayart 2, P.Elmassian 2, D. Stamboulian 3 Lizaso, M. Correa, A. Esposto 1 Centros Médicos Dr. Stamboulian, Buenos Aires, Argentina HIGA San Martin, La Plata, Argentina 2 Centros Medicos Dr.Stamboulian, Buenos Aires, Argentina Background: Despite the expansion of the Speciality 3 Fidec(Fighting Infectious Disease in Emerging Coun- achieved in the last years in the world, its influence in tries)/Funcei(Fundacion Centro de Estudios Infectologicos), Argentina has been limited and shortened only to a few Buenos Aires, Argentina center Although Buenos Aires is the biggest province in our Background: TD is the most common travel-associated country it did not have a Travel Medicine Center in a Public health problem in people visiting high-risk destinations in Hospital. Latin America, Southeast Asia, the Indian Subcontinent and Methods: From March 2008 to August 2009 retrospec- Africa. Most episodes occur in the first two weeks after tive, descriptive and longitudinal research has been done arrival. Twenty percent of episodes can limit travelers’ with the travellers who consulted the Center before trav- activities and 1% can lead to hospitalization. The reported eling. Demographical characteristics, purpose of travelling, incidence of TD for highrisk destinations is up to 40%. destinations, style and duration have been analysed. It has This telephonic survey was performed as part of a risk also been considered what sources suggested the travellers evaluation for future studies and consisted in an estimation they should consult the center. People who have consulted of TD incidence among travelers seeking pre-travel advice through e-mail or telephone have been excluded from the at an ambulatory, private ID and TM center in Buenos Aires. research. Methods: Medical records of pre-travel consults between Results: 193 people were evaluated. Female 110/193 October, 2008 and March, 2009 were reviewed. This time- (57%), none of them pregnant. Average age 39,3 years old frame corresponds to Argentinaˇıs yearly summer vacation. (6-81); thirteen children under 15 years old (6,7%). Each Only travel to high-risk areas such as Latin America, South- interview was held on average 27 days until travelling (1- east Asia, Indian Subcontinent and Africa were included. 210 days). None of the travellers was adviced to come by Queries included demographic data, destination, travel Travel Agencies. Forty six percent (89/193) of the interviews duration, new onset of a diarrheic episode, and manage- were held in the months preceeding the summer sea- ment. Every patient had received the clinic standard oral son. Purpose of travelling: holidays 153/193(79,27%), VFR and written recommendations delivered as comprehensive 13/193(6,7%). Destination: South America 134/193 (69,4%): handouts with management orientation. Bolivia and Peru 43, Brazil 41 and Argentina 27. Asia: 28/193 Results: A total of 2,020 records were pre-selected. From (14, 5%). Africa: 16/193 (8,2%). Central America and the those, 242 were eligible. Sixty were excluded for different Caribbean 11/193 (5,7%). Style of travelling: Urban 72/193 reasons. One hundred eighty phone calls were done. Twenty (37,3%), Urban-Rural 113/193 (58,54%), Rural: 8/193 (4,1%). percent of the 100 that responded, (n = 20) presented at Accomodation in hotel 85/193(44%), tent 2/193(1%). The least one diarrheal episode, but only in 10% of episodes duration of the trip was longer than a month in 51/193 (n = 10) the traditional TD definition was fulfilled. Mean age (26, 4%). Travelling to malaria and yellow fever endemic of travelers was 29 (range: 16-60). Sex distribution was the countries 69/193(35,75%) and 76/193 (39,37) respectively. same (50%). Postravelling interviews: 5 (two of them had also consulted Travel destinations were Indian Subcontinent (n = 10; pre-travelling). 50%), Peru and Bolivia (n = 8; 40%), Colombia (n = 1; 5%), and Conclusion: Most of the travellers were young people, Southeast Asia (n = 1; 5%). interviewed before the summer season, due to holiday trips Out of the 20 patients that reported diarrhea, 7 improved to countries in South America, urban-rural, with a duration without treatment. Thirteen patients decided to take lop- of less than 30 days, staying in hotels. They consulted with eramide, among them the 10 patients with TD. Of them, 2 a reasonable anticipation. There were no interviews with patients also added a quinolone. In all cases the episodes pregnant women and none of the travellers were adviced to resolved in less than 24 hours. come by the Travel Agency. Conclusion: From this series, it seems that with previous, comprehensive pre-travel evaluation and education, only a doi:10.1016/j.ijid.2010.02.1788 minor percentage of travelers develop TD and that they can manage it adequately. doi:10.1016/j.ijid.2010.02.1787 e138 14th International Congress on Infectious Diseases (ICID) Abstracts

32.017 32.018 Trends in fatal snakebites in Venezuela, 2003—2007 Epidemiology of drowning deaths in Venezuela, 1996- 2007 L. Parra 1,∗,J.Pena˜ 1, A. Rísquez Parra 2, L. Echezuria 2,A. Rodriguez-Morales 2 C. Madrid 1,∗, M.H. Maldonado 1, A. Rísquez Parra 2,A. Rodriguez-Morales 2 1 Razetti Medical School, Faculty of Medicine, Universidad Central de Venezuela, Caracas, Venezuela 1 Department of Pediatrics, Hospital Jose Ignacio Baldo„ 2 Department of Preventive and Social Medicine, Razetti Caracas, Venezuela Medical School, Faculty of Medicine, Universidad Central 2 Department of Preventive and Social Medicine, Razetti de Venezuela, Caracas, Venezuela Medical School, Faculty of Medicine, Universidad Central de Venezuela, Caracas, Venezuela Background: There have been few studies evaluating snakebite mortality in Venezuela and South merica. In this Background: Over the past four decades, medical study we evaluate trends in fatal snakebites occurring in community has learned considerably more about the patho- Venezuela, 2003-2007. physiology and treatment of drowning. This, coupled with Methods: Epidemiological data for this study were increased emphasis in improvement in water safety and retrieved from the records of the Ministry of Health of resuscitation, has produced a threefold decrease in the num- Venezuela (ICD-10 codes to search for deaths due to ber of deaths, indexed to population, from drowning in snakebites). We analyzed the impact of these envenoma- countries such as United States and Australia yearly. How- tions in Venezuela during the study period. ever in many countries these trends are not the same. Results: During the study period, there were 176 reports Methods: Epidemiological data for this study were of death due to snakebite (0.63 deaths/100,000pop., rang- retrieved from the records of the Ministry of Health of ing from 0.08 to 0.17), showing a slight decrease in the Venezuela, using ICD-10 codes to search for all deaths due mortality rates from 0.13 deaths/100,000pop. in 2003 to to drownings during the study period (1996-2007). Using 0.08 in 2007 (r2 = 0.3942,b = -0.014000, P = 0.2634); 72.7% these data, we analyzed the impact of these accidents in were males, 27.3% were females (P < 0.05). Annual mean Venezuela, a significant beaches touristic destination for deaths numbered 35 per year. Of total deaths, 30.1% travelers. occurred in victims 55—70 y-old (age adjusted rate of Results: During the study period, there were 7,071 1.4 deaths/100,000pop.). Deaths in young children (<5 y- reports of death due to drownings (rates ranging from 1.88 old) accounted for 4.5% of the total (age adjusted rate deaths/100,000pop. to 2.87), showing a significant decrease of 0.28 deaths/100,000pop.). Mortality by age showed an in the mortality rates from 2.87 deaths/100,000pop. in 1996 agedependent pattern, with higher rates in older ages to 1.88 in 2007(r2 = 0. 8971,b = - 0.947,P < 0.001); 81.97% (r2 = 0.259,b = 0.392998,P = 0.0156). Regard the place of were males (rates 3.11-4.55 deaths/100,000pop), and envenomations occurrence in 15.3% were at home, 12.5% 18.03% were females (rates 0.70-1.16 deaths/100,000pop) at roads and 5.1% at farms (P < 0.05). (P < 0.01). Annual mean deaths numbered 589 per year Conclusion: These figures are similar to a previous report (±32). Highest rates occurred in victims aged less than 5 y- (Wilderness and Environmental Medicine 2007;18:209-213), old (3.71 deaths/100,000pop.), however when adjusted by however previously was reported a slight increase in the sex highest rate was observed in males 15-24 y-old (4.86 mortality in the last eight years, herein we showed a deaths/100,000pop.). Female rates were highest at less decrease. Additionally also an increase in the female deaths than 4 y-old (3.03 deaths/100,000pop.). Regard the place of has been observed. Unfortunately morbidity data at the drowning occurrence in 52% was at natural waters (beaches, national level is not optimal (underreporting) to perform rivers, lakes) (1.04 deaths/100,000pop.), 4% at swimming further analyses beyond the primary analysis of the trends pools (0.08 deaths/100,000pop.) and 1% at bathtub (0.02 in snakebite mortality. Conversely, all cases of deaths deaths/100,000pop.). are specifically and obligatorily reportable, and mortality Conclusion: Drownings in male adolescents and young information is more available and accurate. Snake enven- adults (and female children less than 5 years) continue to omations are an important cause of injury and deaths in be a great challenge for water safety organizations, legis- Venezuela as in many American countries. Surveillance of lators and parents. Drownings in the indigenous community envenomations is essential for establishing guidelines, plan- and among tourists requires more detailed study and action. ning therapeutic supplies, and training medical staff on Prevention especially during holydays or vacations requires a snakebite treatment, as well as assessing risk zones for trav- multidisciplinary approach, including travel medicine prac- elers. titioners, in order to keep the decrease of these fatalities. doi:10.1016/j.ijid.2010.02.1789 doi:10.1016/j.ijid.2010.02.1790 14th International Congress on Infectious Diseases (ICID) Abstracts e139

32.019 must be applied to prevent person-to-person transmission. Travellersˇı Hantavirus Pulmonary Syndrome in Andean Molecular characterization is useful to identify the infecting Patagonia. Argentina genotype. ,∗ M.E. Lazaro 1 , G. Cantoni 2, L. Calanni 3, A.J. Resa 4,E. doi:10.1016/j.ijid.2010.02.1791 Herrero 2, M. Iacono 3, L. De Wouters 5 32.020 1 Hospital Zonal Bariloche, Bariloche, Rio Negro, Argentina Characterization of pre-travel consults at a travel 2 Unidad Regional de Epidemiología y Salud Ambiental, Bar- medicine clinic in Buenos Aires in 2008: Experience with iloche, Rio Negro, Argentina 1,439 Travelers 3 Hospital Castro Rendón, Neuquen, Neuquen, Argentina 4 Hospital de Área El Bolsón, El Bolsón, Rio Negro, Argentina P. Elmassian 1,∗, A. Macchi 1, C. Biscayart 1, V. Verdaguer 1, 5 Hospital Privado de la Comunidad, Mar del Plata, Buenos M.P. Della Latta 1, D. Stamboulian 2 Aires, Argentina 1 Centros Medicos Dr.Stamboulian, Buenos Aires, Argentina Background: Andean Patagonia is an important tourist 2 FUNCEI; Clinical Director, Ciudad Autonoma de Buenos destination in Argentina. It offers beautiful wild landscapes Aires, Argentina -mountains, lakes and forests-. Andes virus (ANDV) is the etiologic agent of hantavirus pulmonary syndrome (HPS) in Background: Travel industry grows steadily even in the this region and Chile. Transmission to humans occurs through middle of economic crisis, highimpact outbreaks or tragic inhalation of rodent excreta and person-to-person trans- events. The vast majority of travelers, however, do not seek mission has also been demonstrated for this genotype. The pretravel advice. To date our center has a large experience incubation period is between 8 and 45 days. HPS has low in Latin America, since the launch of the Travel Medicine incidence but high mortality rate (40%). Division in 1993. We have counseled 54,100 travelers. The Objective: To identify ANDV infection cases associated objective of this study is to describe some aspects of our with travelling in the region. experience during 2008. Methods: Epidemiological charts of 80 HPS cases were Methods: This is a retrospective observational study. reviewed. A randomized sample of pre-travel consults stratified by Results: Cases were grouped according to different month was obtained. Medical records were reviewed. Data ‘‘travel circunstances’’: collected included age, sex, destinations, trip purpose, length of stay, time to consult before departure and evalu- A) International travellers (n = 0). ation of malaria chemoprophylaxis. B) Argentine travellers far (>1000 km) from home (n = 7). a) Results: Among the 1,439 travelers included for analysis, One tourist started symptoms 21 days after cleaning a 562 (42.4%) were female and 763 (57.5%) male, mean age rodent infested cabin; b) one tourist guide, exposed in was 35.3 years (+/-13.8). a National Park; c) five cases belonging to an outbreak Main reasons for travel were tourism, 849 (58.3%) and in 1996 that started in El Bolsón (with one index-case business, 517 (35.4%). followed by 15 secondary patient-cases). These five Conventional tourism accounted for 433 consults (51%); patients lived and started symptoms in Buenos Aires adventure tourism for 236 (28%) and ecotourism for 180 (1400 km from El Bolsón). Travelling people and inter- (21%). human transmission resulted in this phenomena. Main destinations were: South America, 510 (31,6%); C) Local travellers (n = 4). Two children from different cities Africa 267 (16,4%); Central America and Caribbean, 176 shared common rodent exposures during a weekˇıs holiday (11%); Argentina, 145 (9%), Indian Subcontinent, 117 (7,2%). in a wild area; symptoms started 22 and 24 days after Median length of stay was 16 days. (cluster for coexposition). Other 2 patients who lived in High-risk travel was the most prevalent category 683 urban centers were exposed during holidays (fishing and (54,2%). trekking). The number of vulnerable travelers (HIV, cancer, pregnancy, diabetes) was very low 37(<0.5%). The situation of workers exposed when moving from their The median time from consult to departure was 20 days. urban residence to wild areas for deforestation, building Only 141 (24%) high-risk travelers consulted with enough and ecologic activities, was considered: 7 men became ill. anticipation. Two of the workersˇı wives were also infected by interhuman Malaria chemoprophylaxis was prescribed to 398 (31,6%) transmission (family clusters). travelers, being mefloquine the most frequent drug (62,3%). Conclusion: Precautions to avoid exposure to rodents Mistakes in the selection of chemoprophylaxis for chloro- should be strongly recommended. In patients with febrile quine resistant areas were not found. Chemoprophylaxis for respiratory distress syndrome, HPS should be considered: short stays in the Indian Subcontinent was prescribed in 31% travel and possible exposure antecedents, and estimation of cases. of incubation period will help to identify imported cases. Conclusion: Tropical and subtropical regions were the If no epidemiologic risk is found, data of previous con- most common destinations chosen in our series. tact with a febrile patient exposed in ANDV endemic area Despite a majority of high-risk travelers, only 24% con- may suggest interhuman transmission. Isolation precautions sulted with enough anticipation. Thus, we should place further emphasis on travelers education in order to optimize pretravel consult time, par- e140 14th International Congress on Infectious Diseases (ICID) Abstracts ticularly for high-risk destinations, and to detect vulnerable occupation). We conclude that a significant proportion of population for counseling. ecotourists are uninformed of the risks they pose to nonhu- The low rate of malaria chemoprophylaxis for travelers man animal health. It is the combined responsibility of the to the Indian Subcontinent agrees with recent changes in medical and tourism communities to accurately communi- prevention recommendations for that region. cate the risks of zoonotic and anthropozoonotic infections in ways that best support the needs of humans and wildlife doi:10.1016/j.ijid.2010.02.1792 alike. 32.021 doi:10.1016/j.ijid.2010.02.1793 Risk assessment of potential anthropozoonotic pathogen transmission from ecotourists to wildlife populations in 32.022 Borneo Malaria in a community hospital M. Muehlenbein 1,∗, L.A. Martinez 1, A. Lemke 2, L. Ambu 3, O. Mascaro ∗, C. Socolich, A. Pedragosa, E. Reynaga, G. S. Nathan 3, S. Alsisto 3, R. Sakong 4 Lucchetti, X. Gimeno, J. Brugues 1 Indiana University, Bloomington, IN, USA Consorci Hospitalari de Vic, Vic, Spain 2 University of Wisconsin, Milwaukee, WI, USA Background: To identify all the cases of malaria in our 3 Sabah Wildlife Department, Kota Kinabalu, Malaysia region during the last decade, clinical features, diagnosis, 4 Red Ape Encounters, Sandakan, Malaysia severity, prophylaxis and treatment. Background: Over half of all human infections are Methods: Descriptive retrospective study of malaria zoonotic in origin. Nonhuman animal populations are also cases in Osona (Barcelona) admitted to the Department of susceptible to human pathogens. Expanding travel and eco- Internal Medicine in a community hospital since January tourism are increasing the likelihood of contact between 2000 to November 2009. We reviewed all cases with the populations of immunologically-naïve animals and poten- microbiological diagnosis of malaria. We analyzed the epi- tially infectious travelers. While the benefits of ecotourism demiological and clinical data. The inclusion criteria were: appear clear, anthropozoonotic pathogens transmitted from older than 15 years, and admission in hospital > 24 h. ecotourists could negatively impact wildlife populations. Results: We had 48 cases of malaria (40 with the inclu- Methods: To better understand potential infection trans- sion criteria). The age average was 33.78 years (21-71): 31 mission associated with ecotourism travel, we employed the men (75.03%) and 9 women (24.97%). We classified the cases largest survey to date of self-perceived health and vaccina- according to their nationality: Ghana 19 (47.5%), Nigeria tion status in ecotourists. Anonymous surveys were randomly 10 (25%), Iberian Peninsula 7 (17.5%), Mali 1 (2.5%), Sene- obtained from 633 visitors at the Sepilok Orangutan Reha- gal 3 (7.5%). 85% (34 cases) were black, and 6 caucasians bilitation Centre (Sabah, Malaysia), Asia’s most frequented (15%). The average stay in Spain before the episode was wildlife tourism destination. The questionnaire recorded 54.28 months (12-96). 17.5% (7 cases) had previous episode demographic information, history of recent travel, recalled of malaria. The classification according to the visited area recent contact with livestock, domestic and wild animals, was: Ghana 19 (47.5%), Nigeria 10 (25%), Senegal 5 (12.5%), recent diagnoses and symptoms of various infections, and Honduras 2 (5%), Guinea Bissau 1 (2.5%), Cameroon 1 (2.5%), recalled current vaccination status for several infectious Mali 1 (2.5%), Uganda 1 (2.5). The average stay in hospital diseases. was 4.02 (1-13 days). 25% of cases (10) took any prophylaxis, Results: Over half of the sample reported being currently 3 cases (7.5%) were successful. The most frequent type of vaccinated against tuberculosis, hepatitis A, hepatitis B, Plasmodium was falciparum 37 (92.5%), only one case due polio, and measles. 15% of the sample self-reported at least Plasmodium ovale (2.5%), and two were undetermined for one of the following current symptoms: cough, sore throat, low parasitemia (5%). 10% had one or more severity cri- congestion, fever, diarrhea, and vomiting. Participants with teria of WHO. 92.5% had thrombocytopenia (<150000). All recent animal contact were more likely to report current cases were treated with quinine sulfate and doxycycline, respiratory symptoms compared to individuals with no such except 2 cases treated with chloroquine and one case with animal contact (aOR 2.4). Likewise, participants with a the unknown treatment. We found one case of recurrence. medical-related occupation were more likely to report cur- Conclusion: Most reported cases were people from rent respiratory symptoms compared to participants with endemic areas (most of Ghana) and were black people. non-medical occupations (aOR 2.2). 67.1% of those with The most frequent type of Plasmodium was falciparum. 75% medical-related occupations reported not being currently of patients did not took any prophylaxis. The thrombocy- vaccinated for influenza. topenia was the most frequent laboratory finding, without Conclusion: Ecotourists represent a potentially signif- any relation with severity criteria. Complications were rare, icant source of anthropozoonotic infections. Like other probably related to the epidemiological characteristics of international travelers, ecotourists are not adequately patients (originating from endemic areas, black race...). protected against vaccine-preventable illnesses. We demonstrate that potentially infectious tourists were visiting a doi:10.1016/j.ijid.2010.02.1794 wildlife sanctuary, despite significant animal contact prior to arrival (which may have exposed them to other sources of infection), and despite having at least some basic knowledge about infection transmission (i.e., medical-related 14th International Congress on Infectious Diseases (ICID) Abstracts e141

32.023 relatives. He had chicken pox when he was 4 years old, and Meningococcal disease in travelers: A problem more than the family medical history was positive for tuberculosis in a 100 years old the patientˇıs father. Methods: One week before coming back to Argentina ∗ L. De Tora, L. Da Silva he experienced cough and low grade fever for which he was treated: Ibuprofen and amoxicillin. Nine days after he Novartis Vaccines and Diagnostics, Cambridge, MA, USA was back from Peru, he experienced headaches, vomiting. Background: The risk of meningococcal disease to trav- His parents noticed mild right ptosis, he developed acute elers has been of increased interest in the past few ataxia. MRI findings: two ring-enhancing lesions, one in the decades due to the well-known risk in Hajj pilgrims fol- left occipital area and other one in the brain stem. Spinal lowing outbreaks of invasive disease caused by serogroup tap: CSF: cell/mm3, Glucose level: 58 mg/dl,Protein level: W-135. In addition, cases have been associated with air 0.38 mg/dl. PCR assays for HVS-VZV and cultures for bacte- travel Currently, preventive vaccination against appropri- rial, mycobacterial and fungal were negative. ate serogroups is recommended for travelers to regions with Results: Serologic studies: HIV(-),ELISA Cysticercus(-), hyperendemic or epidemic disease such as the ‘‘meningitis IgM Mycoplasma (-), IgG Mycoplasma (+), ID Histoplasma belt’’ in Africa. (-).PPD 2 UT (-) Preliminary diagnosis was Acute Dissemi- Methods: As part of an ongoing project on the history of nated Encephalomyelitis which was treated with parenteral meningococcal disease in Novartis Vaccines and Diagnostics, steroids. He showed no improvement, he started treatment we investigated the occurrence of invasive disease in trav- with intravenous immunoglobulin. The patient showed dete- elers in historical documents and recent historical reviews rioration: MRI showed that the lesions had progressed in size. gleaned from various sources, including Medline, Google, Excisional biopsy of the occipital lesion was performed. In and Web of Science. Disease entities such as sinking typhus, the tissue sections there was no evidence of granulomas cerebral typhus, spotted fever, cerebrospinal fever, epi- with caseification, toxoplasmosis, cysticercosis, fungi and demic cerebro-spinal meningitis, which have been strongly desmielinization. associated with meningococcal disease, were investigated. The presence of structures with spheroid nucleus and Results: Several case histories and historical events place clear cytoplasm induced to search for amoebas. The meningococcal disease as a recognized risk of travel in the Trichromic modified stain Gomori Wheatley showed images late nineteenth century, shortly after the first isolation of simillar to the ones of the amoebic trophozoites. the bacterium. Dissemination across large distances was He received treatment with pentamidine, rifampicine, well-recognized by the beginning of the twentieth century, liposomal, amphotericin, sulfamethoxazole trimethoprim, particularly among the military, in which small outbreaks clarithromycin and fluconazol for a period of 60 days. were observed periodically. The first clear mention of the He remained clinically stable throughout that period but disease as associated with travel dates from 1898, when experienced gross neurological sequelae. Serial MRI studies several authors describe outbreaks in ships carrying Indian showed gradual resolution of the lesions with a decreased in laborers from Calcutta to East Africa and the West Indies size. After 6 months of finishing his treatment, at this day (specifically Jamaica and the then British Guyana). Fol- he still remains alive. lowing the increased development of institutions of public Conclusion: Even though the confirmation of the diagno- health and epidemiology in the United States, an epidemic sis of free-living amoebae encephalitis was not confirmed by of meningococcal disease in Asia in 1928-1929 was tied to the indirect immunofluorescence assay, the clinical course cases in the West Coast, carried by steerage passengers of the illness, the imaging studies, the microscopic findings from the Philippines. In addition to new rules for steerage, and the fact that he didn’t get worse induces us to believe the National Origins Formula of 1929 drastically restricted that Granulomatous Amebic Encephalitis is a possible diag- immigration and travel from Asia to the US. nosis. Conclusion: Literature about travel and meningococcal disease shows clear evidence of risks to travelers for at least doi:10.1016/j.ijid.2010.02.1796 110 years. The long-standing nature of invasive meningococcal disease as a human-specific pathogen causing potentially 32.025 fatal illness is of interest when investigating new options for New world cutaneous Leishmaniasis in travelers (1994- prevention and control. 2008) experience In Argentina T. Orduna 1,∗, S. Lloveras 1, G.D. Gonzalez 1, C.C. Falcone 1, doi:10.1016/j.ijid.2010.02.1795 S.L. Garro 2, S.E. Echazarreta 3 32.024 1 Hospital F. J. Muniz,˜ Buenos Aires, Argentina Free living amoebae encephalitis infection in a child who 2 Hospital F.J. Muniz,˜ Buenos Aires, Argentina travelled to Peru 3 Hospital F.J.Muniz,˜ Buenos Aires, Argentina ∗ C.A. Mora , N. Orellana, A. Schteinschnaider, N. Arakaki, Background: Leishmaniasis is a common cause of der- M. Del Castillo matosis in returning travelers. The New World cutaneous leishmaniasis (NWCL) is caused by multiple species including FLENI, Buenos Aires, Argentina complexes L (V) braziliensis and L (L) mexicana. Background: An 8 year-old Hispanic boy who was living in Materials and methods: A retrospective, cross-sectional Argentina, travelled to Perú in December 2008 to visit some and descriptive analysis was performed based on medical e142 14th International Congress on Infectious Diseases (ICID) Abstracts reports of travellers with clinical and epidemiological diag- ellers with diagnosis of imported malaria, assisted from 1981 nosis of NWCL, assisted from 1994 through 2008. through 2008. Results: 39 cases of NWCL were recorded (29 males, 10 Results: Of 1010 returned travelers (domestic and inter- females, with age ranged from 17 to 72 years). Twenty-nine national) seen at our clinic, 337 (36.36%) patients cited fever (74%) patients were residents of Argentina, 10 (26%) were as a chief reason for seeking care and 143 (42.43%) of them foreigners in transit. The reason for travel was tourism in 21 had malaria. (54%), work 14 (36%) and friends and relatives visit (VFR) 4 There were 135 (94.40%) cases of imported malaria, 100 (10%). (74.07%) males and 35 (25.92%) females, from 3 to 73 years. 26 patients (67%) acquired the disease outside Argentina; 127 (94.07%) travelers were residents. 13 (33%) in Argentina, who were domestic travelers to The species involved was P. vivax in 61 cases (46.18%), P. endemic areas. falciparum in 59 (43.70%); P.ovale in 1 (0.74%), mixed infec- At query time 16 (41%) patients had lesions 30 to 60 days tions of P. falciparum and vivax malaria in 3 (2.22%) and 11 of development, 19 (49%) 75 to 120 days. cases (8.14%) without identification. Estimated average time of exposure in risk area was 20 74 (54.81%) travelers acquired malaria in Africa, 48 days. (35.55%) in South America, and 7 (5.18%) in Central America. Thirty patients (77%) had multiple lesions and 9 (23%) had The reasons for travel were: 56 (41.48%) work/business; single lesion. 47 (34.81%) tourism; 18 (13.33%) visiting friends and rela- 84.61% of the lesions were ulcers; 67% of the lesions were tives; 13 (9.62%) missionary/volunteer; and 1 (0.74%) per localized in the extremities, 23% of the face and 10% in education. In travelers to Africa the species most frequently trunk. involved was P. falciparum (52/74, 70.27%) and P. vivax in The diagnosis was made by direct microscopic examina- South America (38/48, 79.16%). tion in 29 (74%), and 10 (26%) by biopsy, 7 were cultured Only 40 (2.96%) travelers received medical advice before (5 were positive). No species identification was made in the trip, of them 32 (80%) received chemoprophylaxis for either case. 36 patients received as first treatment sched- malaria, 3 (9.37%) of which were inappropriate according ule meglumine antimoniate intramuscular (20 mg/kg/day to the area visited. None of the chemoprophylaxis included for 21 days), 2 patients amphotericin B deoxycholate primaquine. All patients improved with treatment. 5 / 59 0.5 mg/kg/day up to 1,5 grams total and 1 patient who trav- (8.47%) travelers had P. falciparum severe malaria. elled around Panama received fluconazole 200 mg/day for 6 Conclusion: In febrile returned traveler, we must always weeks. 4 patients treated with meglumine antimoniate had consider the diagnosis of malaria regardless of the time adverse effects. elapsed since leaving the malaria area. Plasmodium fal- 85% of patients cured with first therapeutic regimen. ciparum malaria is a medical emergency. The treatment 3 patients treated with antimonials reported relapses, depends on the knowledge of the geographical distribution one patient had therapeutic failure. All healed without sub- of parasite resistance against antimalarial drugs, especially sequent relapse. when no parasite species identification is possible. Conclusion: Cutaneous leishmaniasis is a risk for travelers It should be emphasized prevention with personal pro- to tropical areas of America and is necessary to include pre- tection measures and adequate chemoprophylaxis. vention guidelines in pre travel advisory. It is important that physician be trained in the recognition of this condition and doi:10.1016/j.ijid.2010.02.1798 consider the possibility of mucosal involvement in patients infected with L braziliensis. 32.027 Travel medicine working group doi:10.1016/j.ijid.2010.02.1797 ,∗ A. Macchi 1 , A. Lepetic 2, C. Biscayart 1, P. Elmassian 1,V. 32.026 Verdaguer 1, M.P. Della Latta 1, C. Torroija 1, E. Sturba 3,M. Arrestia 1, D. Stamboulian 4 Imported malaria in travelers assisted in Buenos Aires 1 ,∗ Centros Medicos Dr. Stamboulian, Buenos Aires, Argentina S. Lloveras 1 , S.E. Echazarreta 2, S.L. Garro 3, C.C. 2 GSK, Corunna, Argentina Falcone 4, G.D. Gonzalez 4, T. Orduna 1 3 FUNCEI, BUENOS AIRES, Argentina 1 Corunna, Argentina 4 FUNCEI; Clinical Director, Ciudad Autonoma de Buenos 2 Hospital F.J.Muniz,˜ Buenos Aires, Argentina Aires, Argentina 3 Hospital F.J. Muniz,˜ Buenos Aires, Argentina Background: Travel Medicine Working Group (TMWG), 4 Hospital F. J. Muniz,˜ Buenos Aires, Argentina established in 1992, is the first program for prevention Background: Malaria is the most important parasitic of travel medicine related infectious diseases in Buenos infection that produces human disease. It is caused by pro- Aires. TMWG aims to improve travelers health and to raise tozoa of the genus Plasmodium and transmitted by the bite awareness of its importance to the argentinean public. The of the female Anopheles mosquito. It’s endemic in over 90 objective of this presentation is to describe the scope of a countries and is the most common specific etiologic diagno- multidisciplinary TMWG. sis in febrile travelers. Methods: TMWG comprises infectious diseases spe- Methods: A retrospective, cross-sectional and descriptive cialists, high-tech, up-to-date laboratory facilities and analysis was performed based on medical reports of trav- vaccination centers. We designed a program aimed to assist travellers before departure, en route, after return and to 14th International Congress on Infectious Diseases (ICID) Abstracts e143 optimize vaccination in adult population. Activities focus on The main visited countries were Angola with 92 cases four basic areas: (57,5%), followed by Mozambique with 23 (14,4%), São Tomé Community-oriented education: travel-oriented with 7 (4,8%), and the rest distributed over fifteen other brochures and handouts, travel medicine newsletters countries.The most common agent of plasmodium identi- and travel warning. fied by laboratorial exam was P.falciparum with 31 cases Health care professional education: Seminars and sym- (19,38%), followed by P.vivax with 26 (16,25%). Although, in posia, medical rounds, periodic work meetings and annual 91 cases (56,88%) was not possible to detect the plasmodium courses. species. Research: Characterization of medical consults. The malaria chemoprophylaxis was not made by 85 Medical assistance: pre-travel consult, specific medi- patients (53,12%). Those who did it, 38 (84,44%) took meflo- cal record, tailored counseling, telephone and electronic quine. real-time support and referral to local reference medical The inpatient ratio was 43 (26,88%) of the 160, with a centers. Post travel medical evaluation of asymptomatic fatal case (0,63%). long-term travellers, prompt diagnosis and treatment of Conclusion: The geographic areas of acquisition were symptomatic travellers and epidemiological surveillance the former Portuguese Colonies in Africa, with 78,75% of activities. imported malaria. Results: Between 1992 and 2008 the TMWG has counseled The P. falciparum was the most frequent species. 54,100 travelers. The average annual consult increase was Another problem was the diagnosis made by microscopy 25% in last four years. In 1998 only 11.8% of high-risk travel- with lower parasitemia, that did not identify the plasmod- ers consulted with enough anticipation; in 2008, 24%. 0.4% of ium species. By this reason, more sensitive and accurate a sample of travelers came to our center referred by travel methods must be used. agencies and 0.5% by embassies. Routine and special vac- To reduce risk of imported malaria, all travelers should cine shots increased progressively each year. In a group of have a pre-travel counselling, so major investment is advised 10-50 years old travelers, 8.3% were susceptible to chicken- to be made in this important emerging field of Travel pox, 11.4% to mumps, 10.2% to rubella and 8.9% to measles. Medicine in Portugal. Hepatitis A seroprevalence was 40%. Conclusion: Our experience shows this new medical spe- doi:10.1016/j.ijid.2010.02.1800 cialty is increasingly demanded. We must deepen our work in an interdisciplinary manner to obtain traveler referrals 32.029 from embassies and travel agencies, because of individual Demographics and travel patterns of travelers to Central and community travel associated health risks. America, South America and the Caribbean seen in the The development of TMWG has created awareness of Boston Area Travel Medicine Network (BATMN) the need for pre travel advice in the medical and general J.B. Trivedi 1,∗, N.S. Hochberg 2, W.B. Macleod 3, M. Pfaff 3, community and provides opportunities to update routine M.M. Sosa 4, C. Benoit 5, L.H. Chen 6, M.E. Wilson 6,L. vaccinations in adults. Kogelman 7, W.W. Ooi 8, A.W. Karchmer 4, E.D. Barnett 1, D.H. Hamer 3 doi:10.1016/j.ijid.2010.02.1799 1 Boston Medical Center, Boston, MA, USA 32.028 2 Boston University, Boston, MA, USA Profile of imported malaria in travelers from the north of 3 Boston University School of Public Health, Boston, MA, USA Portugal 4 Beth Israel Deaconess Medical Center, Boston, MA, USA 5 ,∗ Boston Medical Center, Boston, MA, USA A. Silva 1 , A.R. Silva 1, T. Teixeira 1, H. Coelho 1, R. Sar- 6 Mount Auburn Hospital, Cambridge, MA, USA mento e Castro 2 7 Tufts Medical Center, Boston, MA, USA 1 Hospital Joaquim Urbano, Porto, Portugal 8 Lahey Clinic, Burlington, MA, USA 2 Porto, Portugal Background: Travelers to Central America (CAm), South Background: Malaria was irradicated from Portugal since America (SAm) and the Caribbean may face regional the 50s, but every year, hundreds of Portuguese travelers travel-related health risks. Our objective is to describe arriving from Malaria Endemic Countries are diagnosed plas- demographics, trip characteristics and differences in pre- modium positive. travel antimalarial prescriptions for travelers to CAm, SAm The objective of this study is to investigate the clini- and the Caribbean. cal and epidemiological imported malaria between January Methods: Demographics, health, and trip information was 2004 and October 2009 in the Travel Medicine Departament collected for travelers seen in the 5 clinics of the Boston of Hospital Joaquim Urbano in Porto - Portugal. Area Travel Medicine Network (BATMN) from March 1, 2008 Methods: Review of the records and datas of 160 malaria to September 30, 2009. For analysis, Mexico was included in diagnosed positive cases, confirmed by microscopy, in the CAm category. the last 6 years.Variables analyzed: age, gender, country Results: Of 9203 travelers seen in participating clinics, visited, pre-travel consultation, chemoprophylaxis, plas- 2834 (30.8%) planned to visit CAm, SAm and the Caribbean modium species, reason of travel and symptoms. including 1411 (49.8%) to SAm. Travelers to CAm and SAm Results: The average age of the 160 patients was 42,18 were predominantly white (>80%) and less often black (2.6%) years old. From this group 108 patients (67,5%) were male. compared with 58.3% white and 20.8% black travelers to the e144 14th International Congress on Infectious Diseases (ICID) Abstracts

Caribbean. Most trips (71.6%, 53.8%, and 72.8% for CAm, recorded. Two patients (3.12%) required a second course of SAm and the Caribbean respectively) were <2 weeks dura- therapy. tion. Most traveled for tourism (53.7%, 56.6% and 30.3% Conclusion: As travel to the tropics increases, many trav- of visitors to CAm, SAm and the Caribbean) while visiting elers may be returning to their countries with this infection, friends/relatives (VFR) accounted for 7.3%, 13.5% and 23.7% which is often misdiagnosed or incorrectly treated. of visits to these regions, respectively. Caribbean and CAm Although there are various treatments available, it is nec- travelers also went for missionary/volunteer work (21.9% essary to have prospective and randomized controlled trial and 13.3%). Travelers to the Caribbean were more likely to compare their efficacy. to stay at a local residence (49.8%) than those traveling to Among the preventive measures, that can be suggested CAm or SAm (27.9%/31.9%); however, CAm and SAm travel- to travelers, are to avoid walking barefoot has proved to ers were more likely to stay at a hotel/hostel (70%) than decrease the disease impact and also reduce the contact of Caribbean travelers (40%). More travelers to CAm (65.6%) skin areas with contaminated soil or beaches, by lying on a and the Caribbean (68.8%) visited a malaria risk country than canvas for sunbathing or to rest. Furthermore, Public Health those traveling to SAm (43.6%). Of the Caribbean travelers measures must be put into practice to avoid the presence of who were prescribed antimalarials, the vast majority (96%) loose animals and to promote deworming of the same. were visiting Haiti and the Dominican Republic. Caribbean and CAm travelers were predominantly prescribed chloro- doi:10.1016/j.ijid.2010.02.1802 quine (82.3% and 74.5%) or Malarone (18.6% and 23.7%); SAm travelers appropriately received Malarone (85.4%) or 32.031 doxycycline (8.2%). Immunocompromised travellers in the pre-travel appoint- Conclusion: Caribbean travelers were more likely to ment: A report from Portugal travel as VFRs or volunteers and stay in local residences than R. Coelho 1,∗, C. abreu 2, F. Danina 1, J. Nuak 1, C. Caldas 1, those traveling to CAm or SAm. South American travelers vis- E. Quintas 1, N. Darwich 1, A. Sarmento 3 ited for longer periods of time and often to non-malarious areas. All travelers received antimalarials appropriate for 1 Hospital Sao Joao, Porto, Portugal their destinations. 2 hospital s. joão, Porto, Portugal 3 Hospital S. João, Porto, Portugal doi:10.1016/j.ijid.2010.02.1801 Background: As both international travel and the num- 32.030 ber of immunocompromised travellers increase, concerns Hookworm-related cutaneous Larva Migrans: An annoying related to the efficacy of immunizations and malaria pro- souvenir of some trips phylaxis, drug interactions and worse of the basal medical condition in this population are a challenge for practitioners. ,∗ S. Lloveras 1 , S.E. Echazarreta 2, T. Orduna 1 Methods: The charts from pre-traveller appointments of consecutive travellers were reviewed selecting our 1 Corunna, Argentina target population: those with HIV infection, malignant 2 Hospital F.J.Muniz,˜ Buenos Aires, Argentina diseases in treatment, solid organ or stem cell recep- Background: Hookworm-related Cutaneous Larva Migrans tors, under immunossupressive therapy and splenectomized. (HrCLM) in travellers is a common but neglected parasitic Demografic data, destination, duration and reasons of skin disease that results from a zoonotic nematode infec- travel, malaria quimioprophylaxis and immunizations were tion and shows a characteristic creeping eruption due to considered. penetration and migration of the larva within the epidermis. Results: From the 2101 travelers 23 (1,1%) meet crite- Methods: We performed a retrospective survey of ria for immunosuppression. Eleven (48%) had HIV infection patients with this illness assisted at our Unit from 1999 (all with CD4+ counts between 200-500/ul, 5 AIDS, 8 under trough 2008. HAART,3 HCV co-infected), 10 (43%) were under immunosup- Results: A total of 64 individuals received a diagnosis of pressive drugs (7 had autoimmune diseases, 2 solid organ HrCLM, and among them there were 55 (85.93%) who had transplant receptors, 1 under systemic corticotherapy for acquired it in the Brazilian beaches, but also in Costa Rica, severe asthma), 2 (9%) were splenectomized. Their ages Paraguay, Peru, Senegal, Thailand and Venezuela. ranged from 21-56 years, mean 41; 17 (74%) were man. Mean Three patients were domestic travelers and they had time between the consultation and the date of travel was acquired the creeping eruption in Argentina. Fifty percent of 23 days. Africa was the destination of 16 (70%) travelers the 64 affected patients were young adults between 20—39 (13 for Angola), tropical South America in 5 (22%), Indian years. Lesions were mainly unique (90.6%) and affected feet subcontinent and Central America in 1 each. Excluding 2 (82.75%). travelers (one emigrant and one who lived in the country The symptoms appeared to 70.35% (n = 45) of patients, of destination) the duration of travel ranged from 3-180 between 3 and 7 days after returning from the trip. Eleven days, mean 29days. The reason for travelling was work in (17.18%) patients had secondary bacterial infection. Out 12 (52%), tourism in 9 (39%), humanitarian mission in 1 and of 64 patients assisted, 62 (96.87%) were cured by a 1 was resident. Malaria quimioprophylaxis was indicated in single course of treatment: 48 patients with ivermectin, 12 (52%) and in 3 drug interactions changed the the first 11 with oral thiabendazole plus topics of 10% thiaben- choice. Yellow fever vacination was required for 12 travel- dazole cream; one received oral albendazole, 400 mg a ers, in 6 a medical excuse was done, 4 were vaccinated (2 day for 3 days and one patient’s treatment was not HIV not severe immunosuppressed, 1 was splenectomized, 14th International Congress on Infectious Diseases (ICID) Abstracts e145

1 before immunosuppressive drugs) and 2 had actualized mode allows knowing, sharing and learning customs and vaccination. traditions of our country, but travelers are exposed to dis- Conclusion: Immunosupressed represent 1% of our trav- eases acquired by consumption of regional foods. It is very ellers; HIV infected travellers are common, followed by important that international travelers to Argentina consume patients under immunosuppressive drugs for autoimmune cooked pork and they should not eat food from street sellers. diseases. More frequently the traveler is a young male, travelling for a month to Africa for work. The excuse for yellow doi:10.1016/j.ijid.2010.02.1804 fever vaccination and the possibility of drug to drug interaction in malaria prohylaxis makes the medical prevention 32.033 less than optimal in this vulnerable population. Health surveillance of Brazilian military peacekeepers deployed in the United Nations Stabilization Mission in doi:10.1016/j.ijid.2010.02.1803 Haiti (MINUSTAH), 2007 - 2009 ,∗ 32.032 J.R.P. De Andrade-Lima 1 , R.B. Batista 2 Triquinellosis in domestic travelers in Argentina: Which is 1 Universidade Federal da Bahia and Brazilian Army, Sal- the advice for intenational travelers? vador, Bahia, Brazil 2 ,∗ Brazilian Army, 80420-020, Paraná, Brazil S.E. Echazarreta 1, S. Lloveras 2, T. Orduna 2 , S.L. Garro 3, C.C. Falcone 4, G.D. Gonzalez 4 Background: Military are deployed for peacekeeping mis- sions in different regions of the world, being exposed to 1 Hospital F.J.Muniz,˜ Buenos Aires, Argentina some endemic diseases in these operational environments. 2 Corunna, Argentina The surveillance of military health is the tool to the pre- 3 Hospital F.J. Muniz,˜ Buenos Aires, Argentina cocious detection of outbreaks, the adoption of preventive 4 Hospital F. J. Muniz,˜ Buenos Aires, Argentina strategies for the more serious or frequents diseases, as well Background: Trichinellosis is a parasitic zoonosis caused as the appropriate planning of health assistance. by tissue nematodes of the genus Trichinella spp. T. spi- Methods: In the second semester of 2009, a System of ralis is the most frequently involved worldwide. The disease Health Surveillance (VigSau) was adopted in the Medical spreads by eating raw or undercooked meat containing cysts Unit Level 1 (MU 1) of the Brazilian Peacekeeping Battalion of the parasite. Outbreaks occur worldwide, more rarely (BRABATT), analyzing the data of the medical attendance of presented as sporadic cases or travel related disease. about 5,000 Brazilian military deployed in the United Nations Methods: A retrospective, cross-sectional and descrip- Stabilization Mission in Haiti (MINUSTAH), from June 2007 tive analysis was performed based on medical reports of to November 2009. Around 60% of the Brazilian military in travelers with diagnosis of trichinellosis assisted from 1981 Haiti were included in VigSau. A computerized system was through 2008. adopted in MU 1, having all the new medical visits been Results: Of 1010 returned travelers (domestic and inter- registered in 58 categories of attendance. The retrospec- national travelers) seen at our Unit, 296 (29.30%) were tive survey of the data registered in books of MU 1, since domestic travelers and 71(24%) of them had trichinellosis, June of 2007, has also been made. The monthly and weekly 55 (77.46%) males, the age range from 12 to 67 years old. incidence rates were determined and trends were analyzed. 65 travellers (91.54%) acquired the disease by eating food Results: The total incidence rates of patients varied from in the Province of Buenos Aires; 53 cases (74.64%) during an 11,2% to 39.3% of the total of supported military/month. outbreak in Saladillo county, in Easter 2005. Amongst the diagnostic categories, the four categories that The implicated food was pork, 95.77% (n = 68) as food had greater load of diseases and temporary incapacity of processing sausage-shaped, 2.81% (n = 2) as fresh meat and the Brazilian military in Haiti were: infections of the supe- 1.40% (n = 1) have eaten both kinds. All were due to con- rior respiratory system (22%), dermatological diseases (15%), sumption of food purchased commercially produced by small musculoskeletal injuries (14%) and gastroenteritis (11%). The commerce engaged in the slaughter of animals without ade- sazonalidade of some diseases was evidenced. The ﬁrst quate sanitary control. results of the surveillance guided environmental interven- The mean time from ingestion until the presentation of tions in the sanitation of drinking water, food manipulation, symptoms was 15 days (range 4 to 30 days). vectors control and the education in health. All the travelers had fever. The most common symptoms were myalgia (68 cases, 95.77%), periorbital edema (54 cases, 76.05%), headache (52 cases, 73.23%) and con- junctival injection (39 cases, 54.94%). The outcome was favorable. One patient developed a severe form with central nervous system involvement. 65% of patients, who got the result of speciﬁc serology, had at least one positive sample. Conclusion: In our country there are reported cases of trichinellosis annually, often as disease outbreaks involving local people and travelers. Argentina has more than 900 agricultural and livestock establishments for rural tourism and the tourist-recreational e146 14th International Congress on Infectious Diseases (ICID) Abstracts

Conclusion: Despite the logistic difficulties and deficien- between shots given to travelers and people locally bitten cies, the VigSau proved to be a practical and effective tool by animals. for the protection of the health of Brazilian troop in Haiti. Conclusion: The tendency in pre-travel consults and The surveillance to the health of the military is a modern immunizations at our center could reflect that, even tak- strategy to guarantee the troop performance, having to be ing into account Argentina’s unsteady economic situation, enclosed into the doctrine of military health, in times of people are willing to travel and to protect themselves. When peace or war, to cooperate in the reduction of the diseases events such as the yellow fever outbreak in 2008 occur,there rate during the multinational peacekeeping operations. is an extra demand of preventive measures. doi:10.1016/j.ijid.2010.02.1805 doi:10.1016/j.ijid.2010.02.1806 32.034 Tuberculosis: Epidemiology, Prevention & Control Immunizations in travelers attending a private center for (Poster Presentation) infectious diseases and travel medicine in Buenos Aires, Argentina, 2005-2008 33.001 C. Biscayart 1, P. Elmassian 2,∗, A. Macchi 2, V. Verdaguer 1, Clinical manifestations of tuberculosis among pediatric M.P. Della Latta 2, C. Torroija 3, D. Stamboulian 1 household contacts with active culture confirmed disease 1,∗ 2 3 4 1 Centros Médicos Dr. Stamboulian, Buenos Aires, Argentina A. Ackerman , C. Whalen , S. Zalwango , J.I. Shwartz 2 Centros Medicos Dr.Stamboulian, Buenos Aires, Argentina 1 University of Massachusetts Medical Center, Worcester, 3 Centros Medicos Dr. Stamboulian, Buenos Aires, Argentina MA, USA 2 Background: According to Argentina’s official estimations University of Georgia College of Public Health, Athens, GA, for 2006, 1.5 million people traveled abroad. Immuniza- USA 3 tions constitute an important part of the pre-travel consult. Case Western Makerere University Research Collaboration, As such, and with the aim of describing some trends, we Kampala, Uganda 4 present a four-year experience at Centros Médicos Dr. Stam- Yale University Medical Center, New Haven, CT, USA boulian, an ambulatory center for Infectious Diseases and Background: Previous research on tuberculosis in chil- Travel Medicine with vaccination facilities in Buenos Aires dren has been largely limited to cross sectional studies with travelers that sought pre-travel advice. in settings where MTB culture was not performed. To fur- Methods: This is a retrospective, descriptive analysis. ther characterize the clinical presentation of children with Immunization records were reviewed. Hepatitis A and B data TB, we performed a retrospective cohort study of pediatric was excluded (they are part of Argentinaˇıs immunization household contacts (HHC) with culture confirmed disease in program). We focused on locally available recommended Uganda. immunizations: typhoid fever, rabies, inactivated polio vac- Methods: We reviewed clinical, radiologic, and epidemi- cine, and meningococcal A + C. Yellow fever was the only ologic characteristics of 79 pediatric subjects with active required vaccine in Argentina, since A, C, Y, W 135 meningo- culture-confirmed TB. The cohort was derived from a lon- coccal vaccine is not available. gitudinal HHC study of adult infectious cases in Kampala, Results: Between January 2005 and December 2008, a Uganda. Analysis included stratification by age group (young total of 2,342; 2,775, 3,501 and 4,710 travelers attended children (YC) = ages 0-2, older children (OC) = ages 3-14). the center per year, respectively. Most common destinations Results: Median age was 2.7 years, 42 were young chil- were South America, Central America and the Caribbean, dren, and 45 were female. Cough ≥3 weeks was the most Asia and Africa. Recommended vaccine shots taken as a common symptom (80%) and was the only symptom present group increased 141% percent during the studied period in the majority of subjects. Disease presentation varied (typhoid fever shots increased the most: 101%). Yellow significantly by age group. The frequency of abnormal find- fever vaccination increased dramatically in 2008, due to the ings was significantly higher amongst young children (YC) vs ongoing outbreak in Misiones, Paraguay and Brazil. Polysac- older children (OC), including fever (YC 19/42 vs OC 7/37; charide typhoid fever vaccine was almost invariably used, p = 0.01), weight loss (15/42 vs 7/37; p = 0.004), sick gen- except for a brief period of unavailability, when it was eral appearance (17/42 vs 4/37; p = 0.02), and abnormal replaced for oral live vaccine. respiratory exam (20/42 vs 9/37; p = 0.03). Number of vaccines per year Conclusion: Clinical assessment of TB in child household contacts of infectious cases is challenging given the Vaccine 2005 2006 2007 2008 relative paucity of findings on clinical, microbiologic, and Meningococcal A + C 664 784 667 537 radiographic examination. In our study, cough was the only Polio Salk 90 924 926 948 symptom present in the majority of cases, CXR was posi- Rabies 224 238 267 177 tive in 55% of cases, and AFB smear was only positive in 22% Yellow fever 261 194 234 2495 of cases. Clinical manifestations of disease varied signifi- Typhoid fever (Polisaccharide) 1571 1978 2600 2901 cantly with age. Young children were more symptomatic and Oral Typhoid fever 37 304 0 0 more likely to have multiple abnormal findings on physical Total 3240 4512 5255 7807 exam than older children who had few signs or symptoms. Of note, rabies vaccine shots include only records of In fact, more than one third of older children had no signs corporate travelers, since we are not able to discriminate at all on physical exam. The reasons for these differences in 14th International Congress on Infectious Diseases (ICID) Abstracts e147 presentation are unknown; it is possible that the immature 33.003 immune response of children < 2 years is dysregulated and Genetic diversity of Mycobacterium tuberculosis popula- over-produces pro-inflammatory cytokines resulting in sys- tion in Bulgaria temic symptoms. Whereas in older children, the mature host cellular immune response may be sufficient to contain the V. Valcheva organism in granulomas with minimal systemic signs or symp- Institute of microbiology, Sofia, Bulgaria toms. Further research is needed to understand the effect of age and immune response to M. tuberculosis. Background: Molecular typing of Mycobacterium tuberculosis isolates is a useful tool for epidemiological studies doi:10.1016/j.ijid.2010.02.1807 at different levels. Tuberculosis remains an important public health issue for Bulgaria, a Balkan country located in the 33.002 world region with contrasting epidemiological situation for A validated clinical practice guideline for community tuberculosis. Here we presents the insight into the popula- health nurses working in tuberculosis Out-patient Clinics tion structure and drug resistance of M. tuberculosis strains currently circulating in Bulgaria, as a necessary step towards A. Ahmed ∗, S. Soliman, L.A. Awad an implementation and better understanding of molecular Faculty of Nursing Mansoura University, Dakahlia, Egypt epidemiology of TB here. We further looked at our data at a global scale through comparison with the international Background: Tuberculosis is a major contributor to dis- SITVIT2 database. ease burden in developing countries; it is considered the Methods: Study sample included 133 M. tuberculosis clin- second fatal disease all over the world and the third most ical isolates originating from different regions of Bulgaria important public health problem in Egypt. The direct causes and analyzed by various DNA fingerprinting methods We of increasing the burden of tuberculosis are the inconsistent additionally investigated molecular basis of drug resistance and fragmented health services. The nursing interventions of of the studied strains. tuberculosis in community settings require system of recom- Results: Comparison with SITVIT2 database (Institut Pas- mendation that ensures the consistency of care. The present teur de Guadeloupe) revealed a heterogeneous population study aimed at provid a valid clinical guideline that assist structure of M. tuberculosis in Bulgaria. The Beijing geno- nurses to intervene consistently to the newly diagnosed pul- type strains were not found in spite of close links with monary tuberculosis patient. Russia in the recent and historical past. Novel 15/24-loci Methods: The needs analysis of community health nurses MIRU-VNTR format achieved the highest discrimination. We working in out patient chest clinics in addition to the expec- additionally investigated molecular basis of drug resistance tation of newly diagnosed pulmonary tuberculosis patient of the studied strains. Three types of the rpoB mutations regarding nursing interventions. The guideline development were found in 20 of 27 RIF-resistant isolates; rpoB S531L process established according to the criteria of experts of was the most frequent. Eleven (48%) of 23 INH-resistant guideline development organizations. The Scottish Intercol- isolates had katG S315T mutation. inhA -15C>T mutation legiate Guidelines Network (Sign) research appraisal tools was detected in one INH-resistant isolate and three INH- were used for the critical appraisal phase of the obtained susceptible isolates. A mutation in embB306 was found in evidence. AGREE instrument was used for assessing the 7 of 11 EMB-resistant isolates. internal validity of the guideline. The guideline and apprised Conclusion: This study gave a first molecular snap- for internal validity by academic nursing and medical staff, shot of M. tuberculosis strains circulating in Bulgaria. It nursing, and medical practitioners. demonstrated a heterogeneity of the Bulgarian M. tubercu- Results: The scores of all appraisers in relation to losis population that appears to be dominated by several scope and Purpose, stakeholder involvement, rigour of worldwide distributed and Balkan specific spoligotypes. development ranged from (62.9- 77.7%, 53.5- 77.7%, and Comparison with genotyping data did not reveal a statisti- 66.6-76.2%), respectively. While the scores for the clarity cal difference in the prevalence of drug resistance between and presentation were 50- 76.4, applicability were 61.9- clustered and non-clustered isolates. Emergence and spread 68.5, and editorial independence were 88- 93. The four of drug-resistant and MDR-TB in Bulgaria is not associated groups of revision strongly recommended the application of with any particular spoligotype or MIRU-VNTR cluster. the guideline. Conclusion: In conclusion, the developed guideline based doi:10.1016/j.ijid.2010.02.1809 on the needs of the intended users of nurses and end points beneficiaries, i.e., patients. It was strongly recommended 33.004 by the reviewers and stockholders to be used in the out- Transmission of drug resistant tuberculosis and its impli- patients chest clinics. It is recommended that the guideline cation for TB control in rural China should disseminate to the authoritative level to be applied in ∗ the chest out patient clinics and evaluated for applicability Y. H u , W. Jiang, W. Wang, B. Xu and achieved outcomes. School of Public Health, Fudan University, Shanghai, China doi:10.1016/j.ijid.2010.02.1808 Background: The transmission pattern of drug resistant TB might vary due to the difference in the geographic feature, socio-economic development and TB epidemic from specific areas and populations. This might also matter how e148 14th International Congress on Infectious Diseases (ICID) Abstracts effectively TB control program would work. The present ing and diagnosis of latent tuberculosis infection (LTBI) in a study attempted to describe the transmission of drug resis- cross section of high risk individuals for LTBI in Trinidad and tant TB in two comparable rural Chinese areas albeit with Tobago. different duration of direct observed treatment, short- Methods: During a 9-months period, over 550 subjects course(DOTS) implementation, as well as to discuss about including contacts of TB patients (n = 200), HIV positive its possible implication for TB control policies. patients (n = 70), health care workers (45), prison inmates Methods: Setting in two rural counties: ten years’ DOTS (65) and TB patients (180) used as controls were recruited covered Deqing and one year’s DOTS covered Guanyun, this for the study. Blood specimen was drawn from the subjects study included the pulmonary drug resistant TB patients and processed in the laboratory using QuantiFERON®-TB registered in local TB dispensaries as the subject. Propor- Gold (QFT-G) kit and tuberculin solution was administered tion method and DNA sequencing determined drug resistant on the forearm. Data were analyzed with Epi Info 3.5.1 soft- pattern and genetic mutation of M.TB isolates. IS6110-RFLP ware (CDC, Atlanta, GA, USA). The chi-squared test and identified clustered patients and their epidemiological link Fisher’s exact test were used as appropriate to compare was confirmed using concentric circle method. data from the different groups. Data were descriptive and Results: Totally 223 of 351 isolates(63.5%) were resis- were reported as comparisons of frequency distributions. A tant to at least one anti-TB drug, including 53(15.1%) P value < 0.05 was considered significant. simultaneously resistant to isoniazid and rifampicin or Results: The QFT-G assay detected LTBI in 41.1% of the multidrug resistant(MDR-TB,18 from Deqing and 35 from subjects with the highest (65.6%) positive results occurring Guanyun). Of the 168 patterns identified by IS6110-RFLP, among control group. The TST test detected LTBI in 19.9% 20 were shared only between drug resistant isolates; 12 of the subjects, a lower result than the QFT-G method, were shared between the drug resistant isolates and the (p = 0.001) Overall, QFT-G method detected more LTBI in pan-drug sensitive isolates. Deqing and Guanyun had sig- all the different groups than the TST except among prison nificantly different cluster proportion of drug resistant inmates where the detection was almost similar. The QFT- TB(32/101.vs.55/122,p = 0.041) but similar cluster pro- G gave a high rate of indeterminate and non reactive portion of MDR-TB isolates(11/19.vs.22/34,p = 0.624). The results among HIV positive subjects. Despite using less time significant high cluster proportion was observed in the previ- completing QFT-G assay (23.3 hours) against TST method ous treated patients both in two counties but in the sputum (70.2 hours, p < 0.0001), the cost was less performing the smear positive patients with cavitaries alone in Guanyun, TST in each subject ($3.70) when compared to QFT-G that so does happen to those infected with the strain from Bei- was $18.60, and the difference was statistically significant, jing genotype and resistant to isonazid and/or rifampicin. p = 0.0008. Of 87 clustered drug resistant strain, 67.8% was clustered Conclusion: The QFT-G gave a faster turn around time in same or neighboring village!The remained 71.4% were result, effective and more expensive than TST method. scatted along the traffic arteries. However, because the QFT-G gave indeterminate and non Conclusion: Transmission pattern of drug resistant TB reactive response for immunocompromised subjects such as was consistent with attenuated properties of pathogen as HIV positive patients, care must be taken when screening well as social activity of rural populations. Meanwhile, DOTS or making a diagnosis of LTBI based on QFT-G results in a itself might not work enough on the recent transmission of poor resource and high HIV prevalence setting like Trinidad MDR-TB. These observations might suggest the need of sup- & Tobago. plementing the additional strategies, including active case finding within village and effective treatment on patients doi:10.1016/j.ijid.2010.02.1811 previously treated or with cavitaries. 33.006 doi:10.1016/j.ijid.2010.02.1810 HIV prevalence and MDR TB among DOTS attendees in a rural area of Haryana, India 33.005 R. kumar ∗, S. Rai, S. Kant, K. Anand, L. Dar, U. Singh Evaluation of cost and methods for detecting latent tuberculosis infection among target individual groups in All India Institute of Medical Sciences, New Delhi, Delhi, Trinidad & Tobago India ,∗ P.E. Akpaka 1 , S. Baboolal 2, D. Ramoutar 3 Background: MDR-TB was a potential threat to tuberculosis control in India. We wanted to estimate the prevalence 1 The University of the West Indies, Faculty of Medical Sci- of HIV infection and MDR TB among DOTS attendees in Bal- ences, Champ Fleurs, Trinidad and Tobago labgarh, Haryana, India. 2 The University of the West Indies, Faculty of Medical Sci- Methods: The study was carried out in two DOTS cen- ences, St. Augustine, Trinidad and Tobago tres of Ballabgarh Tehsil of district Faridabad, Haryana. It 3 North Regional Health Authority, Caura, Trinidad and was a health facility based cross sectional survey. Study sub- Tobago jects were all TB patients (Pulmonary and Extra Pulmonary) Background: A huge amount of valuable time and who were registered for DOTS. Data was collected from Jan- resources is expended in the country using tuberculin skin uary 2007 to June 2008. We enrolled 413 eligible patients test (TST) assay to screen for TB contacts and other subjects who were informed about the study objectives and written in the country. This study was carried out to compare using consent was obtained. All patients were offered free Liver TST and QuantiFERON®-TB gold (QFT-G) assays in screen- Function Test. Unlinked anonymous testing on aliquot of LFT 14th International Congress on Infectious Diseases (ICID) Abstracts e149 blood samples was performed after removing all identifiers. beginning of treatment. Q3, (A) Because symptoms decrease HIV testing was done using three E/R/S. Sputum was col- or disappear and patients feel good and think they’re cured; lected from patients belonging to Categories I and II, under (B) Due to lack of consciousness and responsibility and lack Revised National TB Programme. Anti TB sensitivity testing of love to life, health and to the next one; (C) Due to side was done on randomly selected patients of Category I (50% effects and lack of information regarding the treatment of of patients) and all of the Category II patients. TB. Results: Four hundred and thirteen TB patients [CAT Table 1 The social representation of DOT-related tuber- I-220(53.3%), II-101(24.5%), and III-92 (22.2%)] were inter- culosis by patients of Guarulhos at the metropolitan area of viewed and blood samples could be obtained from 368 Sao Paulo, Brazil patients (89.1%). Four blood samples got contaminated and Questions Results labels of ten samples was lost during the transportation. Central Ideas presented** N N1 N2 % Finally, of the 354 samples tested two were found HIV sero 1 ‘Someone tells A. it’s a guidance 65 119 45 69.2 you about DOT. regarding where reactive. Prevalence of HIV among TB patients was 0.56% What is DOT for treatment will take place (95% CI 0.068-2.02). Sputum collection was attempted from you?’ 211 patients. Thirty eight patients (18%) had difficulty in B. It’s a guidance 30 46.2 regarding time and producing sputum. Of the 173 sputum samples collected, frequency of TB drugs eighty were culture positive for Mycobacterium tuberculo- C. It’s an explanation 17 26.2 sis. Among them nine samples were found to be multi drug about TB D. Others (7 categories)27- resistant by RLBA. The prevalence of MDR among TB patients 2 ‘Tell us about A. Patients report to go to 82 24 36.9 was 11.25% (95% CI 5.27 — 20.28). DOT on a daily HCS to take TB drugs basis?’ Conclusion: HIV prevalence was low and similar to the B. Patients report the 17 26.2 rate observed among pregnant women (0.13%) who could side-effects to TB drugs be considered as proxy to general low risk population. Multi and to the aggressive treatment drug resistance was high among TB patients. It was reassur- C. Patients report that 14 21.5 ing that HIV — TB co infection was low and none of the MDR treatment is incorporated TB patients were HIV positive. on routine and do not affect the routine D. Patients report 12 18.5 doi:10.1016/j.ijid.2010.02.1812 improvement of health condition after the 33.007 beginning of treatment E. Others (5 categories) 15 - The social representation of DOT-related tuberculosis by 3 ‘DOT takes six A. Because symptoms 90 39 60.0 months and decrease or disappear and patients of Guarulhos at the metropolitan area of Sao after one month patients feel good and Paulo, Brazil patients do not think they’re cured have more V. Souza Pinto ∗, V.M.N. Galesi, M.I.P.S. Braz symptoms. Why do you think this Sao Paulo State Secretary of Health, Sao Paulo, SP, Brazil happen?’ B. Due to lack of 17 26.2 Background: Setting: Public healthcare service (HCS) consciousness and responsibility and lack of of Guarulhos municipality, in the metropolitan area of love to life, health and to Sao Paulo, Brazil. Objective: Analyzing the individual per- the next one C. Due to side effects and 14 21.5 ception of patients concerned to supervised treatment lack of information (DOT)-related tuberculosis (TB) offered by HCS. regarding the treatment Methods: Qualitative approach using interviews with of TB D. Others (8 categories) 20 - patients. The Collective Discourse (CD) allows capturing a ** Interviewers can give more than one central idea pool of social representations, gathering answers from dif- N Number of TB patients interviewed in the study ferent individuals with discourse content of similar sense to N1 Number of answers presented in this question build collective statements. N2 Number of ideas in the category presented (unfolding Results: Answers of 65 patients (interviewers can give of central ideas) more than one central idea), in three questions (Q) about Conclusion: TB patients have correct knowledge about DOT — (Q1) ‘Someone tells you about DOT. What is DOT the disease, understanding the necessity of DOT and also for you?’; (Q2) ‘Tell us about DOT on a daily basis?’; and they report their ways on the process of TB diagnosis which (Q3) ‘DOT takes six months and after one month patients can their treatments. So, it is necessary that HCS pay do not have more symptoms. Why do you think this hap- attention on TB diagnosis with commitment and training of pen?’. According to Table 1 the central ideas presented professionals on DOTS Strategy. They don’t perceive DOT as a were: Q1, (A) It’s a guidance regarding where treatment barrier, but as a strengthening for a very difficult treatment. will take place; (B) B. It’s a guidance regarding time and frequency of TB drugs; and (C) It’s an explanation about TB. Q2, (A) Patients report to go to HCS to take TB drugs; (B) Patients doi:10.1016/j.ijid.2010.02.1813 report the side-effects to TB drugs and to the aggressive treatment; (C) Patients report that treatment is incorporated on routine and do not affect the routine; and (D) Patients report improvement of health condition after the e150 14th International Congress on Infectious Diseases (ICID) Abstracts

33.008 33.009 Prevalence of bacteriologically confirmed pulmonary Newly diagnosed tuberculosis patients and tobacco use in tuberculosis in the Bhutanese refugees in Nepal. Results North Malaysia: The prevalence of tobacco use, knowl- of active case finding edge, and attitudes O. Gorbacheva ∗, A.K. Mishra, D. Shapovalov, S. Sudtasay A. Awaisu 1,∗, M.H. Nik Mohamed 2, N. Mohamad Noordin 3, A.R. Muttalif 4, A. Ahmad Mahayiddin 5, A. Saad 6, S. Muham- International Organization for Migration, Jhapa, Nepal madu Gobir 7 Background: Approximately 100,000 Bhutanese refugees 1 Universiti Sains Malaysia, Penang, Penang, Malaysia live in camps in southeastern Nepal. Since December 2007 2 International Islamic University Malaysia, Kuantan, Pahang the International Organization for Migration (IOM) in Nepal DM, Malaysia has conducted medical screening of Bhutanese refugees 3 National Institute of Health, Ministry of Health, Kuala prior to resettlement in USA, Canada, Australia, New Lumpur, Kuala Lumpur, Malaysia Zealand, Denmark and Norway. Screening for TB included 4 Penang Hospital, Penang, Penang, Malaysia both sputum smears and cultures. The estimated prevalence 5 Institut Perubatan Respiratori, Wilayah Persekutuan Kuala of all forms of TB was 243 per 100,000 in Nepal (WHO, 2006), Lumpur, Kuala Lumpur, Malaysia and 217 per 100,000 in Bhutanese refugee camps prior to 6 Universiti Putra Malaysia, Serdang, Selangor DE, Malaysia resettlement (UNHCR, 2007). 7 Universiti Sains Malaysia, Kubang Kerian, Kelantan, Methods: Depending on the age group and specific Malaysia instructions of the resettlement countries, suspected TB cases were identified with the combination of the medi- Background: Sufficient evidence concludes that tobacco cal history, physical examination, CXR and TST. Suspected smoking is strongly linked to tuberculosis (TB). It was sug- cases were referred for microbiological examination of three gested that a considerable proportion of the global burden of sputum samples by both acid-fast bacilli staining and liquid TB may be attributable to smoking. This study aimed to doc- culture for TB. Drug susceptibility testing (DST) was per- ument the prevalence of smoking among newly diagnosed TB formed on all new positive cultures. If smears or cultures patients and to learn about their tobacco use knowledge and were positive, or if clinical and radiological findings were attitudes. consistent with active TB, directly observed treatment was Methods: Data on smoking prevalence were obtained performed. based on reviews of routinely collated data from January Results: From December 13, 2007 to July 31, 2009, IOM through December 2008 in the state of Penang. The study Nepal conducted medical examinations of 23,459 refugees, setting comprised of five chest clinics located within Penang of which 2,391 (10.2%) were suspected TB cases. Preva- and Wilayah Persakutuan Kuala Lumpur health districts, lence of bacteriologically confirmed (positive sputum smears Malaysia. A validated 58-item questionnaire was used to or/and cultures) was 644 per 100,000. Prevalence of smear- assess the tobacco use knowledge and attitudes of those TB positive cases was 230 per 100,000. Compared with culture, patients who were smokers. sensitivity of sputum smears was only 32%. DST yielded 2% Results: Smoking status was determinant in 817 of 943 MDR TB among culture confirmed cases; 5% with resistance new cases of TB during study period. Of this, it was to more than one drug, but not MDR TB; 3% INH monoresis- estimated that the prevalence rates of current and ex- tant TB; 3% PZA mono-resistant TB. smoking among TB patients was 40.27% (329/817) and Conclusion: Results of this cross-sectional study show 13.95% (114/817), respectively. Of 86 cigarette smokers who high prevalence of infectious pulmonary TB among the were eligible for a larger project, 93% responded to the Bhutanese refugees in Nepal. These results highlight the survey. The mean (±SD) total score of tobacco use knowl- increase in case detection when sputum culture is per- edge items was 4.23 ± 2.66 (maximum possible score = 11). formed, which can detect TB cases with low bacillary load. More than half of the participants (51.3%) were moderately We identified prevalence of pulmonary TB at least 2.7 times dependent on nicotine and less than half (47.5%) had knowl- greater than previously reported prevalence of all forms. edge about the body system on which cigarette smoking has This points out the benefit for wider use of sputum culture the greatest negative effect. The majority wrongly believed to detect infectious TB in high burden countries. A significant that smokeless tobacco can increase athletic performance proportion (13%) of cases with drug resistance highlights the (60%) and that it is a safe and harmless product (46.2%). need for DST to direct TB therapy. However, an overwhelming proportion (>80%) of the patients believed that: tobacco use is dangerous to health and that doi:10.1016/j.ijid.2010.02.1814 smokers are more likely to die from heart disease when compared with nonsmokers. The use of smokeless tobacco was moderately prevalent among the participants with 28.8% reporting ever snuffed, but the use of cigar and pipe was uncommon. Conclusion: Smoking prevalence rate was high among patients with TB in Malaysia. These patients generally had deficiencies in knowledge of tobacco use and its health dangers, but had positive attitudes against it. Efforts should be 14th International Congress on Infectious Diseases (ICID) Abstracts e151 geared towards reducing tobacco use among this population not primarily suspected to have TB and, therefore, play an due to its negative impact on TB treatment outcomes. important role in recent TB transmission in Qeshm. doi:10.1016/j.ijid.2010.02.1815 doi:10.1016/j.ijid.2010.02.1816 33.10 33.011 Frequency of tuberculosis in the biggest island of the Per- The clinical and epidemiological characteristics of sian Gulf Mycobacterium tuberculosis Beijing/Wfamily strains in a major immigrant-receiving province of Canada K. Hamdi 1,∗, A. Shoae Hassani 2, A. Akhavan Sepahi 3 D. Langlois-Klassen 1,∗, D. Kunimoto 1, D. Saunders 1,J. 1 Young Researchers Club (YRC) of Islamic Azad university, Boffa 1, L. Chui 2, R. Long 1 Tehran, Iran, Islamic Republic of 2 Islamic Azad University (IAU), Fars, Iran, Islamic Republic 1 University of Alberta, Edmonton, AB, Canada of 2 Alberta Provincial Laboratory for Public Health, Edmon- 3 Tehran North Branch of IAU, tehran, Iran, Islamic Republic ton, AB, Canada of Background: Tuberculosis resulting from the Beijing/W Background: Despite availability antituberculosis drugs family of Mycobacterium tuberculosis strains is a global for almost 50 years, tuberculosis (TB) continues to exert concern due to associations with tuberculosis outbreaks, an enormous toll on world health. The incidence of TB is antituberculosis drug resistance, and treatment failure and increasing all over the world. Qeshm represents a region in relapse. This study sought to determine if Beijing/W stains south of Iran that is the biggest island in the Persian gulf with represent an emerging public health threat within Canada, 23 thousands inhabitants with a long tradition in TB control, a major immigrant-receiving country with low tuberculosis including a centralization of the bacteriological diagnostic incidence. facility. The present study was intended to analyze the trans- Methods: This population-based cohort study investi- mission of Mycobacterium tuberculosis by a combination of gated archived culture-positive M. tuberculosis isolates conventional epidemiological approaches. from cases diagnosed in the province of Alberta, Canada Methods: Mycobacterium tuberculosis analyzed in this between 1990 and 2007. Isolates were Beijing/W genotyped study were collected at the Health Care Center in Qeshm, with PCR-based region of difference analysis and DNA finger- Iran. A total of 81 new, bacteriologically verified TB cases printed with IS6110 RFLP. In 449 isolates, Beijing/W status were registered in Qeshm Island between 2003 and 2008. was validated with spoligotyping. Demographic and clini- All the isolates were examined for their susceptibility to cal data for each isolate was obtained from the provincial ethambutol, isoniazid, streptomycin, rifampin, and pyrazi- TB Registry. Statistical analyses consisted of Pearson’s chi- namide by using a radiometric culture system (BACTEC). The square test, Fisher’s exact test, and independent sample data obtained from the cultures analyses were interpreted t-test. by using demographic data, such as age, sex, ethnicity, Results: Nearly 99% (n = 1,900/1,927) of isolates were and residence, for the patients. The risk factors among the available for genotyping. Beijing/W strains comprised 19% patients for being part of an active chain of transmission, (n = 372) of isolates, with foreign-born persons contribut- as opposed to demonstrating reactivation of a previously ing 91% (n = 337) of all Beijing/W isolates (p < 0.001). The acquired latent infection, were estimated by statistical distribution of Beijing/W strains within the foreign-born analyses (SPSS). population was remarkably heterogeneous; 90% (n = 302) Results: A total of 81 clinical isolates belonging to of Beijing/W isolates occurred among persons from the patients having pulmonary and extra pulmonary tuberculosis Western Pacific region (p < 0.001). Conversely, the Canadian- were collected during Jan 2003 to Nov 2008. The incidence born Aboriginal and non-Aboriginal subpopulations had of tuberculosis in female was 25.9% and in male was 74.1%. similar distributions of Beijing/W strains (n = 19 and 16, This survey observed 47.1% of immigrated Afghans and 39.1% respectively; p = 0.389). Cases attributed to Beijing/W and of Pakistanis were infected with tuberculosis. Regarding non-Beijing/W strains were comparable in terms of age at the literacy 57% were unlettered. 91.7% of people refer- diagnosis (p = 0.055), sex (p = 0.488), disease phenotype (res- ring to health center were new patients. 68.8% people were piratory or non-respiratory disease) (p = 0.947), and sputum infected with pulmonary tuberculosis. The peoples over 60 smear positivity (p = 0.121). Beijing/W and non-Beijing/W year were highest group infected to pulmonary tuberculosis strains also had similar associations with first-line drug resis- (30.4%) and age groups 30-44 were highest the cases infec- tance among Canadian-born persons (p = 1.000) as well as tion external pulmonary tuberculosis. The major chains of within each foreign-born subpopulation, namely persons recent transmission were localized to distinct geographical from the Western Pacific region (p = 0.902) and other regions regions in the area. (p = 0.512). Although a comparable proportion of foreign- Conclusion: TB is frequent among immigrants, especially born Beijing/W and non-Beijing/W cases were involved from Afghanistan and Pakistan, but it is apparently read- in transmission clusters (p = 0.329), non-Beijing/W strains ily suspected, diagnosed, and treated by the health care accounted for a significant proportion of clustered cases system. Indigenous patients with pulmonary symptoms are within the Canadian-born population (p = 0.023). e152 14th International Congress on Infectious Diseases (ICID) Abstracts

Conclusion: Within a major immigrant-receiving country, 33.013 Beijing/W strains appear to pose no more or less of a public Analysis of the decentralization of tuberculosis control health threat than non-Beijing/W strains. The findings also program in the sanitary district of Cabula-Beirú (SDCB) suggest that current TB control programmes within low inci- Salvador-Bahia-Brazil, 2008 dence settings can appropriately manage Beijing/W strains. S. Cerqueira 1,∗, L.G. Almeida 2, B.A. Santos 3 doi:10.1016/j.ijid.2010.02.1817 1 Federal University of Bahia, Salvador, Bahia, Brazil 33.012 2 Federal Nursing University of Bahia, Salvador, Bahia, Brazil 3 Federal University of Bahia, Salvador, Bahia, Brazil Evaluation of the performance of TB Control in Apac Dis- trict in 2008 using Direct Observed Therapy (DOTS) Background: The National Program of Control of Tubercu- losis (PNCT) decentralization process began in the decade of S.M. Nakaggwa 1980 from the federal level to the state level, extending to Inter - Religious Council Of Uganda, Kampala, Uganda the municipal level since 1990.OBJECTIVE: Describe the process of decentralization of Tuberculosis Control Program in Background: DOTs is a WHO Global TB monitoring, treat- SDCB, Salvador - Bahia-Brazil. ment and surveillance strategy based on case detection at Methods: A descriptive qualitative and quantitative study lower treatment levels. One of its tools is detection of pul- has been done with views to produce information on the monary TB by sputum smear microscopy. Research questions process of decentralization of PCT in SDCB of the munici- for the study were: Can we use the DOTS strategy to predict pal district of Salvador-Bahia-Brazil in 2008. Techniques for the TB burden in Apac District annually?; Did the TB control interviewing were applied in questionnaires and analysis of program in Apac District measure up to WHO standards rec- content of the speeches for the collection of the primary ommended for areas under DOTS?; How useful is DOTS as a data, the secondary data were obtained consulting the Book planning, monitoring and surveillance tool for TB control in of Registration of PCT, Report of Administration 2005-2008, Apac District? Municipal Plan of Health and the database of the confirmed Methods: This was a cross sectional study carried out cases of tuberculosis registered in SINAN. The quantitative in Apac District in Northern Uganda. The district has Kole, data were treated and analyzed using the programs EPI-INFO Maruzi and Kwania HSD. Main study subjects were persons and presented under the form of tables. The qualitative who went for sputum smear examination and were recorded analysis was accomplished starting from the depositions of in laboratory registers and HMIS Forms 055a and 055b (HMIS the informers. 055a is the laboratory summary forms per health unit; 055b Results: 1,781 cases were confirmed from (2000 to 2008) is the district summary for all laboratories reports from dis- of these 1,131 they presented positive bacillus-carriers. trict health units). From (2005 to 2008) 1,924 cases were confirmed of these Results: The highest prevalence (877 TB cases per 86, 64% (1,667 cases) bacillus-carriers. It was observed that 100,000 people) and incidence (280 TB cases per 100,000 PCT of DSCB was implanted in one unit in 2004 and seven in people per year) were in Kole Health Sub District (HSD). Dis- 2008. In relation to the diagnosis in 2004 73% of the bacillus- trict incidence was 66 cases per 100,000 persons per year. carriers were positive in 2008 for the three studied units. Maruzi HSD had the highest case detection (93%) while Kole 59.2% of the bacillus- carriers that tested positive, the rates HSD (27%) registered the lowest. District case detection was of discharge for the cure were from 71.3% (2004) to 68.3% 49%. Kwania HSD had the highest number of sputum exami- (2008) the adhesion tax to the treatment was from 75.6% nations (1,628) but with lesser sputum smear positives than (2004) to 83.6% (2008) and the tax of abandonment 5.9% Maruzi HSD. (2004) and 5.5 (2008). The factors that caused obstacles Conclusion: The district case detection rate of 49% com- to the decentralization of PCT: the medical professional’s pared well with the national figure but was below the WHO absence, structures inadequate physics, disabled team and target of 70%.The incidence of TB was 66 new sputum smear the stigma of the disease for the professionals of health. positives per 100,000 people in the district. However, the Conclusion: The program was decentralized for seven same must be established in the different HSD to know where units of health, with increase in the adhesion taxes. That the highest burden is found. DOTs tools are applicable to process guaranteed larger access to the diagnosis and the Apac district useful planning and can be used by the dis- treatment supervised by the population, with the reduction trict Health Teams to monitor and evaluate progress in TB of the taxes of abandonment for the District. control.More intense case finding and surveys are needed in the district to establish the actual prevalence of TB. A study doi:10.1016/j.ijid.2010.02.1819 should be done to include treatment outcomes as required in the DOTS strategy. doi:10.1016/j.ijid.2010.02.1818 14th International Congress on Infectious Diseases (ICID) Abstracts e153

33.014 33.015 A community based tuberculosis control project in chil- Patterns of tuberculosis health problem in India: A gender dren in urban and rural settings: A public-private mix perspective approach S. Gupta B. Cabrera 1,∗, J. Aldaba 2, R. Buzon 3, A. Fernandez 3, B.J. International Institute for Population Sciences, Mumbai, Sablan 3, F. Valdes 4 India, Mumbai, Maharashtra, India 1 Philippine Ambulatory Pediatric Association,Inc, Pasay Background: Tuberculosis is the most common cause of City, Philippines infectious disease—related mortality worldwide. The WHO 2 Philippine Ambulatory Pediatric Association,Inc, Manila, estimates that 2 billion people have latent TB, while another Philippines 3 million people worldwide die of TB each year. Although TB 3 Philippine Ambulatory Pediatric Association,Inc., Manila, rates are decreasing in the India, the disease is becoming Philippines more common in many parts of the world. Tuberculosis is an 4 The Medical City hospital, PAsig City, Philippines airborne contagious disease that is transmitted by cough- Background: The control of tuberculosis in children ing or sneezing. Exposure to cooking smoke can increase the entails a concerted effort of both the government and pri- risk of tuberculosis by reducing resistance to initial infec- vate sectors thus a public-private partnership was formed tion or by promoting the development of active tuberculosis and will serve as a model. in already infected persons. Air pollution is a major public Methods: One urban (Sta. Rosa City) and two rural health problem in developing countries including India due (Florida Blanca and Mabalacat) were chosen for a pilot to these TB patients has also increased. In India, there is high program for the control of tuberculosis in children by differential in reporting TB patients through sex as well as the Philippine Ambulatory Pediatric Association, Inc (PAPA.) state wise. through the collaboration of the Department of Health Methods: This paper tries to see the levels and pat- National Tuberculosis Program (DOH-NTP), private groups terns of TB patients among men and women in India. This and the Local Department of Education (DepEd). PAPA paper also examines the relationship between TB patients provided the logistics, trainings, medicines and project man- with selected background characteristics using data from agers through funding from Pott’s Foundation and Alliance National Family Health Survey-1998-99 and 2005-06. Bivari- for the Control of Tuberculosis in Children (ACTC). The cho- ate and Multivariate statistical techniques were used to test sen areas were visited by PAPA and DOH for consultation the significance impact of selected background variables on with the Local Chief Executive (LCE) and the signing of prevalence of tuberculosis among men and women aged 15- memorandum of understanding. The Local Government Unit 49 years living in rural and urban areas of the country. (LGU) provided the health personnel. Trainings of the health Results: The analysis suggest that the prevalence of TB personnel were done by PAPA. Initial screenings were fully patients has declined from 550 to 290 patients per 100,000 supervised by PAPA. Screening was done twice a week and population during 1998-2006 time period among women; complete allocation of medicines for active disease were while in case of men, the prevalence is also declining from provided using 2HRZ and 4HR.Directly observed treatment 420 to 350 patients per 100,000 population during same strategy (DOTS) approach was used and the barangay health time period. The results from logistic regression analysis worker (BHWs) served as treatment partners. Weight mon- suggest that persons (male/female) belongs to scheduled itoring and symptom monitoring were done and recorded. caste/scheduled tribes, poor economic status, residing in Mid-project assessments and end —of-project reports in rural area and illiterate are more likely to reported TB than each area were also done. their respective counterparts. Results: The areas yielded 1923 screened patients and Conclusion: Hence we conclude that men has reported treated 538 (28%).The project protocol was validated and higher TB patients compared to women also it is reported later used for National Tuberculosis Control Program for Chil- higher side those who have low standard of living. Further, dren in the Philippines. it reveals that the variables like number of persons per room, Conclusion: It was demonstrated that the control of type of house, cooking under chimney, and caste signifi- childhood tuberculosis through privatepublic partnership cantly influence the likelihood of tuberculosis prevalence contributed a very significant role in the detection and among Indian men and women. monitoring component thus lessening the burden of the disease and ensuring success and possible future eradication of doi:10.1016/j.ijid.2010.02.1821 tuberculosis in children. doi:10.1016/j.ijid.2010.02.1820 e154 14th International Congress on Infectious Diseases (ICID) Abstracts

33.016 Zoonoses and Infectoins in Animals (Poster Presen- Tuberculosis in health-care workers: Results of a surveil- tation) lance program in Mexico City 34.001 ,∗ P. Leal Moran 1 , M. Huertas Jimenez 2, C. Romero 2,A. Prevalence and associated risk factors of mastitis in lac- Chavez RIos 2, A. Haro Osnaya 2, R. De Paz Garcia 2,A.De tating dairy cows la Torre 2, A. Macías Hernandez 2, S. Ponce de León Rosales 3 N. Sharma ∗, V. Pandey, J.S. Joodan 1 National Institute of Medical Sciences, Mexico City, mexico, Mexico Faculty of Veterinary Science & Animal Husbandry, Sher-e- 2 National Institute of Medical Sciences, Mexico City, Mexico Kashmir University of Agricultural Science & Technology of 3 Birmex, Mexico City, Mexico Jammu, Jammu,J&K,India Background: Tuberculosis is major public health prob- Background: Mastitis has been known to cause a great lem, left untreated, each person with active TB disease will deal of loss or reduction of productivity, to influence the infect on average between 10 and 15 people every year. Pre- quality and quantity of milk yield, and to cause culling ventive strategies are essential for the achievement of the of animals at an unacceptable age. Apart of its eco- Millennium Development Goal. nomic importance it also carries public health significance. Methods: In 1992 a HCW’s surveillance program was insti- Although sub clinical mastitis (SCM) is more prevalent than tuted in our hospital, which consist in an initial evaluation clinical mastitis in developing countries including India, as for every worker during their first week of working within the sub clinical disease is not manifested as visible changes in Institute, a questionnaire with demographic and risk vari- the mammary glands or in the milk, it is therefore not easily ables, PPD application, and a basic risk prevention’s course. recognized by farmers. PPD Booster is applied for those with an initial PPD negative Methods: A study was conducted to determine the preva- test, and then annual follow-up is performed. The workers lence of mastitis and associated risk factors. The screening with PPD positive test are evaluated by a physician and a for mastitis was done by Sodium lauryl sulphate test (SLST) chest-Rx is taken. Prophylaxis is indicated in every HCW who as per the method of Pandit and Mehta (1969) and Somatic has a PPD positive test during the follow up or risk factors cell count (SCC) (Schalm et al. 1971). Clinical mastitis was for the disease. confirmed on the basis of physical examination of udder and Results: A total of 5513 HCW have been evaluated since visual examination of milk for presence of flakes, clots, pus, 1992, 61% were women, and the median age was 27. Forty odor and discoloration apart the tests used for SCM. Quarter percent were physicians, 32% nurses, 10% administrative was defined as mastitis positive if it have a SLST score of workers and the rest (18%) from other areas. Of the evalu- >1+ or SCC 5 X 105 per ml of milk and a animal was define as ated workers 1932 (38%) had an initial PPD positive test, all mastitis positive when it has atleast one of quarters with a of them had a normal chest-Rx. After the Booster applica- SLST score 1+ or >5 X 105 per ml of milk. For SCC, a quarter tion we identified 286 workers with positive test. During the will be considered to have mastitis when the SCC >5 X 105 follow up 259 HCW have had a PPD positive test. A total of per ml of milk. 169 prophylactic treatments have been provided, 53 work- Results: In the present study, a total of 46 (18.04%) cows ers did not finish the treatment because of mild secondary and 65 (6.97%) quarters had clinical mastitis. A total number effects and personal decision. Sixteen HCWs have developed of cows affected with sub clinical mastitis were 196 (76.86%) clinical tuberculosis, 9 had a previous PPD positive test and out of 255 by SLST and 172 (67.45%) out of 255 cows by SCC refused prophylactic treatment. and 8.63% teats were blind. Among risk factors, the higher Conclusion: The initial PPD positive test prevalence was prevalence was in 2nd and 8th parities and late stage of 43%. HCWs are in risk of this infection especially in develop- lactation. Age wise 3 to 6 years old cows had high prevalence ing countries. A a specific program for them is essential in (55.10%) followed by >6 years age and <3 years old age cows. order to reduce nosocomial transmission and identify those Conclusion: Sub clinical form of mastitis in dairy animals in risk of tuberculosis. is highly prevalent than clinical. Prevalence is high in 3-6 years old cows. Therefore, need special attention towards doi:10.1016/j.ijid.2010.02.1822 its controll measures by awaring the farmers and updating the veterinary practitioners regarding this deadly disease.

doi:10.1016/j.ijid.2010.02.1823 34.002 The clinico-pathological features associated with experimental concurrent PPR virus and Mannheimia hemolytica A: 2 infections in the West African dwarf goats B.O. Emikpe University of Ibadan, Ibadan, Nigeria Background: Small ruminants represent an important aspect of the livestock economy in developing countries 14th International Congress on Infectious Diseases (ICID) Abstracts e155 in the humid tropics as more than 80% of rural families keep sheep and goats. The most common viral and bacterial respiratory disease of Nigerian goats are Peste des petit Ruminants and Mannheimiosis. The endemic nature of PPR infection especially in goats and the usual association with Mannheimia hemolytica, in the pneumonia of small ruminants on the field, makes it necessary to study the clinicopathological changes associated with experimental co infection of PPRV and MH with a view of understanding the role of this bacterium in the pathology of PPRV infection in West African dwarf goat. Methods: Twenty apparently normal West Africa Dwarf Photomicrograph of the lungs of a WAD goat infected with (WAD) goats six months of age were used for the experiment. PPRV and MH showing giant cells H&E X 400 15 goats were infected by intratracheal inoculation of 1 ml of pure cultured 106.5 TCID50 PPR virus grown in Baby ham- doi:10.1016/j.ijid.2010.02.1824 ster kidney cell lines and a week later 1 ml of pure culture 34.003 (109 CFU) of MH A2 to study its clinicopathological features and five goats served as controls. The clinical signs were Ancylostoma spp. in sand of beaches of Navolato, Sinaloa, observed and two goats were euthanized at predetermined México intervals for gross examinations, bacteriological, virologi- ∗ M.C. Rubio Robles , S.M. Gaxiola C., N. Castro C. cal and histopathological investigations on tissues collected using standard techniques. Universidad Autonoma de Sinaloa, Culiacan, Sinaloa, Mex- Results: The clinical signs were severe and the order of ico manifestation was anorexia, pyrexia, dyspnea, oculo-nasal Background: Eggs of Ancylostoma spp. disseminated for discharge, recumbency and death. The lesions observed defecate of dogs and cats in public areas, are extremely were severe pulmonary consolidation and pleural adhesions resistant to adverse environmental conditions, capable of of the apical lobes and pleurisy with marked erosive stom- surviving in soil for many months; this represent risk for atitis and acute enteritis. The average percentage lung health humans and pets that have contacted with contami- consolidation for the infection was 7.01% and the right nated sand of beaches can act as reservoir or vector of this lung was more affected (p < 0.05) while the overall mor- zoonotic parasite, that potentially can infect the host by tality was 33.3% at 15 dpi. Histologically, the lung lesions eggs and larvae penetrating the skin of bare feet or hands were typical of fibrinous bronchointerstitial pneumonia with and produce Larva migrans, also known as creeping eruption thickened alveolar septa, edema and neutrophilic infil- or sandworm eruption, characterized by tortuous migratory trations of the interstitium with giant cells. Mannheimia lesions of the skin. The objective of this work was to deter- hemolytica A:2 was re-isolated bacteriologically from the mine the presence of Ancylostoma spp. in moist sand of lungs, at necropsy. beaches of Navolato, Sinaloa, Mèxico. Methods: The composite samples of sand of seven beaches were determined for representative samples described by the technique of Thrusfield (2005) was used: n = [t*SD/L]2. Where n = sample size, t = value of the normal distribution (Student t) for a 95% confidence level (t = 1.96), L = accepted error or precision (5%), and SD = weighted disease prevalence (%); the total of composite sample of sand determined by random samplings was 254, took surface moist sand scraping of 100 grams of sand for each sample and deposited it in plastic bags; transferred to the laboratory of parasitology of the FMVZ-UAS to be analyzed by the The lung of a WAD goat infected with PPRV and MH showing sedimentation technique. marked hyperemia, consolidation and fibrinous deposits Results: Of the 254 composite samples of sand of the on the right cranial, middle and anterior portion of the seven beaches, 96 (37.7%), were positive to Ancylostoma caudal lobe spp. Conclusion: The association of the two agents results into Conclusion: The contamination with Ancylostoma spp. very fulminanting disease with severe pulmonary and enteric represent high risk for the pets and public health, yet resi- lesions. This study further showed that the survivability of dents as visitors ignore about parasitic diseases that dogs can animals affected by PPRV and MH depends on the early com- transmit them it is necessary implement control strategies mencement of antibiotics treatment to curtail the bacterial and education for the prevention of the infections. involvement and the electrolyte loss associated with PPR. doi:10.1016/j.ijid.2010.02.1825 e156 14th International Congress on Infectious Diseases (ICID) Abstracts

34.004 34.005 Arconobacterium pyogenes associated with pulmonary Phylogenetic analysis of sporadic hepatitis E virus in East- and submandibular lymph node abscessation in white ern China tailed deer (Odocoileus virginiaus) Y.-G. Xia 1,∗, Y.-T. Li 2, Y.-H. Lu 1,H.Ren2, F.-D.Wang 3, J.-H. R. Afifi 1,∗, J.M. Sleeman 2, G.K. Saunders 3, T. Kaur 3 Yao 3, Q.-W. Jiang 1, Y.-J. Zheng 1 1 Afifi Department of Wildlife & Zoo Medicine, Faculty of 1 School of Public Health, Fudan University, Shanghai, China Veterinary Medicine, Suez Canal University, Ismilia, Egypt 2 Shanghai Municipal Center for Disease Control and Preven- 2 Sleeman, USGS National Wildlife Health Center is located tion, Shanghai, China at 6006 Schroeder Road, Madison, Wisconsin 53711 3 Deqing County Center for Disease Control and Prevention, 3 Saunders,& Kaur, Department of Biomedical Sciences & Deqing County, Zhejiang, China Pathobiology, Virginia—Maryland Regional College of Vet- Background: Recently, evidence for the existence of hep- erinary Medicine, Virginia Polytechnic Institute and State atitis E virus (HEV) was reported all over the mainland University, Blacksburg, Virginia 24061, USA of China. The number of acute sporadic hepatitis E cases Background: Thin, lactating and uncoordinated female increased annually and small outbreaks happened more white-tailed deer was submitted for necropsy as part frequently, probably due to food-borne transmission. The of a surveillance program for chronic wasting disease phylogenetic characteristics of the circulating HEV worth (CWD). Laboratory tests for CWD and rabies were neg- further understanding. ative. Post-mortem examination revealed pulmonary and Methods: A total of 413 serum samples were collected submandibular lymph node abscesses associated with from acute sporadic hepatitis E patients in 14 hospitals in Arcanobacterium pyogenes and Pasteurella. The overall Eastern China from 2005 to 2008 under informed consent. All presentation suggests that the infections may have been the samples were detected with a nested RT-PCR assay for associated with chronic stress. HEV RNA, and a 150-nt fragment within HEV ORF2 region was Methods: Brain tissues were removed aseptically and sequenced for phylogenetic analysis using Neighbor-Joining transferred to Virginia’s Department of Game and Inland method with reference HEV sequences from the GenBank. Fisheries for analysis for CWD and rabies virus, and Brain Results: The ratio of male to female was 1.75: 1 among culture swabs were sent to the Virginia-Maryland Regional all the patients. The majority (61.5%) of them was 40-69 College of Veterinary Medicine for aerobic and anaero- years old, with an average age of 50 ± 16 years old. 140 out bic bacterial cultures, including Listeria monocytogenes of 413 (34.0%) sera were positive in HEV RNA, and all the culture. Lung, lymph node, brain, intestine and heart sam- isolates were sequenced subsequently. Phylogenetic analysis ples were preserved in 10% neutral buffered formalin for revealed that all these isolates belonged to genotype-IV with histopathologic examination. Lung and lymph node samples much high similarities, sharing 77.9%-88.3%, 80.8%-90.6%, were taken aseptically for aerobic culture, including culture 73.4%-85.2% and 91.0%-95.4% nucleotide identities with pro- for Mycoplasma and Salmonella. Lung and lymph node were totype I (D10330, Burma; D11092, China; X98292, India; plated onto Blood Agar, MacConkey Agar and Columbia CAN AY230202, Morocco; AY204877, Chad), II (M74506, Mexico), Agar. Culture swabs of lung tissue were plated onto Choco- III (AB089824, AB189070, Japan; AY115488, Canada) and late agar, TSA and CAN agar. Chocolate Agar plates were IV (AB097812, AY594199, AB108537, China) HEV strains, incubated in 5% CO2 incubated at 37 ◦C with no CO2 analysis. respectively. Those isolates could be further divided into Results: Arcanobacterium pyogenes was isolated from six clusters within genotype IV, but no obvious geographical lung and submandibular lymph node, and identified using difference was observed among the clusters. bioMérieux API Coryne strips. Pasteurella spp. was isolated Conclusion: It is evident that genotype-IV HEV had been from the same lymph node, and identified using bioMérieux the principle causative agent of acute sporadic HEV infection API 20 NE strip. Laboratory tests for rabies, CWD, Listeria, for human in Eastern China. Mycoplasma, Mycobacterium and Salmonella were all negative. Histopathologic examination was performed on lung, doi:10.1016/j.ijid.2010.02.1827 brain, spleen, lymph node, intestine, heart and liver.The lung had multiple discrete nodules of coagulative necrosis 34.006 containing neutrophils and macrophages (figure 1). A rim of Molecular characterization of VP1-3 and NSP1-3 genes of neutrophilic inflammation surrounded the necrosis; periph- porcine group A rotavirus G12 strain RU172: Evidence for eral to this was a layer of fibroplasia and fibrosis. porcine origin of human G12 strains Conclusion: In conclusion, even though it was not isolated S. Ghosh 1,∗, N. Kobayashi 1, M. Ishino 1, T. Naik 2 from the lung, Pasteurella was the primary cause of infection in the lung and from there it spread to the lymph node. 1 Sapporo Medical University School of Medicine, Sapporo, A. pyogenes was considered to be a secondary infection in Hokkaido, Japan the lungs where pneumonia was already present. The final 2 National Institute of Science Education and Research, diagnosis was pulmonary and lymph node abscesses due to Bhubaneshwar, Orissa, India A pyogenes and fibrinopurulent and necrotizing bronochop- neumonia due to a mixed Pasteurella and A. pyogenes. Background: Group A rotavirus is an important cause of infantile diarrhea in humans, and classified into 23 G and 31 P genotypes. Among them, G12 has been regarded as doi:10.1016/j.ijid.2010.02.1826 an important emerging genotype of human strains, world- 14th International Congress on Infectious Diseases (ICID) Abstracts e157 wide. On the other hand, the only G12 strain reported from Results: This Paper focused on an investigation to dter- animals was a G12P[7] strain, RU172, detected in a diar- mine the possible roles of veterinary practitioners in the rheic piglet in Eastern India. The VP4, VP6, NSP4 and NSP5 spread of infectious diseases. genes of porcine G12 strain RU172 exhibited genetic relat- Conclusion: This paper focused on an investigation to edness to human Wa-like G12 strains. Although the origin of determine the possible roles of veterinary practitioners in human G12 genotype remains obscure, some recent studies the spread of infectious diseases, discusses the need for on human G12 rotaviruses suggested that the G12 genotype biosecurity programs in veterinary practices,and relates a might be of porcine origin. To determine the true origin of practical approach for developing biosecurity practices that G12 rotaviruses and decipher the exact genetic relatedness are tailored to individual facilities,to help ensure that vet- between human and porcine G12 strains, we characterized erinary practitioners retain their role in the control rather genetically the remaining six genes (VP1-3 and NSP1-3) of than the spread of infections. porcine G12 strain RU172. Methods: The VP1-3 and NSP1-3 gene sequences of doi:10.1016/j.ijid.2010.02.1829 porcine G12 strain RU172 were obtained by RT-PCR and direct sequencing using end primers and several internal 34.008 primers, designed from conserved stretches of several pub- Trypanosome infections in dogs from Chagas disease lished sequences. endemic regions in Panama, Central America Results: The VP1-3 and NSP1-3 genes of porcine G12 V.J. Pineda Segundo 1,∗, I. Monfante 2, N.L. Gottdenker 3,A. strain RU172 exhibited high sequence identities to Wa-like Saldana˜ 4, A.M. Santamaria 5, S. Puga 6, J.E. Calzada L. 7 porcine and human strains, including human G12 strains, and by phylogenetic analyses, clustered within the Wa 1 Instituto Conmemorativo Gorgas de Estudios en Salud, genogroup along with human Wa-like G12 strains. panama, PAN, Panama Conclusion: Wa-like human and porcine group A 2 Universidad de Panama, PANAMA, PAN, Panama rotaviruses are believed to be genetically related and have 3 Institute of Ecology, University of Georgia, Athens, Geor- a common origin. Therefore, based on full genome analyses gia, Atlanta, US, USA of porcine G12 strain RU172 and human Wa-like G12 strains, 4 Instituto Conmemorativo Gorgas de EStudios en Salud, we propose that the Wa-like human G12 strains might have Panama, PAN, Panama resulted from reassortment events involving Wa-like human 5 Instituto Conmemorativo Gorgas de Estudios en la Salud, non-G12 and porcine G12 strains, or more favorably, both the Panama, Panama porcine and human Wa-like G12 strains might have evolved 6 Instituto Conmemorativo Gorgas de Estudios en la Salud, from a common progenitor, maybe of porcine origin. The Panama, Panama AU-1-like and DS-1-like G12 strains might be the result 7 Instituto Conmemorativo Gorgas de Estudios en Salud, of reassortment events involving non-G12 strains of these Panama, Panama genogroups and human Wa-like G12 strains. Therefore, the present study deciphers the probable origin of human G12 Background: Chagas Disease remains a major parasitic genotype, and provides evidence for porcine-human trans- zoonosis in Latin America affecting 9.8 to 11 million people. mission of rotaviruses. The infection is caused by Trypanosoma cruzi, a protozoan naturally transmitted to mammals, including humans, by triatomines. In endemic areas, humans and animals doi:10.1016/j.ijid.2010.02.1828 become mainly infected through contact with parasite- 34.007 infected excreta from triatomines. The sylvatic triatomine, Veterinary practitioners and the spread of infectious dis- Rhodnius pallescens is considered the main vector of T. eases cruzi and T. rangeli in Panama. In many countries, such as Panama, non-domiciliated vectors remain responsible S.T. Olodo-Atitebi for a significant transmission risk and their control poses a challenge for disease control. Dogs are important reser- Oxford brookes university, 0X3 0BP, United Kingdom voirs of the disease in the domestic transmission, and due Background: There is an increasing overlapping among to the close proximity with humans they may represent a livestock,pets and human beings, highlighting the need for high risk to humans. However, the role of dogs as reser- a well defined biosecurity plan to reduce the opportunity voirs and as risk factor for human transmission in the for infectious agents to gain access to and spread within peridomestic and/or sylvatic habitats has only been par- a veterinary premises or any other animal housing unit.And tially explored. Consequently we evaluate the prevalence the recent outbreaks of infectious diseases around the world of canine trypanosomiasis rural endemic communities where have clearly shown the threats to human and animal health the non-domicilated R. pallescens is responsible for T. cruzi arising from emerging and re-emerging infectious disease, transmission to humans. a fact which has huge economic and public health implica- Methods: During 2007, a cross-sectional study was tions. designed to evaluate the presence of anti-T. cruzi antibodies Methods: In order to provide the best veterinary care and blood trypanosomes in dogs from the rural communi- possible, veterinarians have to redefine their underlying ties of Las Pavas and Lagartera Grande in Central Panama. responsibility to minimize the risk of additional; harm that A questionnaire was applied to the dog owners to assess might unintentionally befall a patient because of their inter- epidemiological data and risk factors associated with the ventions. disease. e158 14th International Congress on Infectious Diseases (ICID) Abstracts

Results: Of the 94 dogs analyzed, 51 were male and beneficial to the better understanding of genetic hetero- 43 females. The mean age for both males and females geneity of Borrelia spirochetes in Taiwan. was 3.6 years (range 4 months — 15 years).Serological and parasitological tests revealed that 12 dogs (12.8%) were doi:10.1016/j.ijid.2010.02.1831 trypanosome infected (Table 1). Nine dogs (9.6%) had antibodies against T. cruzi. Trypanosomes were isolated in three 34.010 (5.3%) hemoculture samples. Molecular analysis showed that Occurrence of Ureaplasma diversum in cows with various isolated trypanosomes were T. rangeli. None of these T. reproductive disorders rangeli positive dogs had detectable antibodies against T. P. Chandra 1, Y. Singh 2,∗, D. Nand Garg 3 cruzi. Four infected dogs belong to people with Chagas disease diagnosis. 1 CCS Haryana Agricultural University, Hisar, Hisar, Haryana, Conclusion: In conclusion our data demonstrate that dogs India are frequently infected with Trypanosomes in this area o 2 CCS Haryana Agricultural University, Hisar, Hisar, India Panama with a prevalence similar to the one observed in the 3 CCS Haryana Agricultural University, Hisar, Hisar, Haryana, human population. This study improves our understanding India of the epidemiology and control of Chagas disease in rural areas of central Panama. Background: Ureaplasma diversum, a bovine species was first isolated by Taylor Robinson and co-workers in 1967 from cattle. The genital ureaplasmosis in cows occurs in vari- doi:10.1016/j.ijid.2010.02.1830 ous clinical forms viz. urethritis, endometritis, salpingitis, 34.009 granular vulvoveginitis, abortion and neonatal calf mortality Molecular evidence of genetic diversity of Borrelia leading to temporary or permanent infertility. burgdorferi sensu lato detected in Ixodes granulatus ticks Methods: During present study, a mycoplasmological removed from rodents in Taiwan examination of cervico-vaginal swabs/vaginal discharges from 136 cows including 86 with various reproductive dis- ∗ L.-L. Chao, C.-M. Shih orders (22 anoestrus, 25 repeat breeder, 6 cervicitis, 17 metritis, 16 abortion/still-birth) and 50 apparently healthy National Defense Medical Center, Taipei, Taiwan, R.O.C cows was conducted.The U-9B liquid medium was used for Background: Genetic diversity of Borrelia spirochetes in isolation of Ureaplasmas. In-vitro antibiotic sensitivity of Ixodes granulatus ticks of Taiwan remains unknown and ureaplasmal isolates against ten selected antibiotics was needs further identified. performed at first stage of their cultivation in U-9B colour Methods: A general survey was conducted to collect test liquid medium. I. granulatus ticks removed from trapped rodents in Tai- Results: The mycoplasmological examination of cervico- wan. Total genomic DNA was extracted from individual tick vaginal swabs/vaginal discharges from 136 cows including specimen by using DNeasy Blood & Tissue Kit (Qiagen). 86 with various reproductive disorders and 50 apparently Genetic identities of Borrelia spirochetes detected in I. healthy cows resulted in isolation of 14Ureaplasma species granulatus ticks were determined by analyzing the gene along with 11 Mycoplasma and 8 Acholeplasma.The inci- sequences amplified by a nested polymerase chain reaction dence of mollicutes was was found higher in genitally (PCR) assay based on the 5S-23S intergenic spacer amplicon diseased cows 929.07%) as compared to apparently healthy gene of B. burgdorferi sensu lato. Phylogenetic relation- cows (16%). The prevalence of Ureaplasma diversum was ships of these detected spirochetes were further analyzed by more in repeat breed cow (20%) than anoestrus (9.8%), cer- neighbour-joining (NJ) compared with maximum parsimony vicitis and metritis (4.9%). However, noUreaplasma strain (MP) methods. was isolated from abortion cases. The concentration of Results: A total of 261 I. granulatus ticks (156 adults nine strains of Ureaplasma isolated from cows with vari- and 105 nymphs) were tested by nested-PCR assay and ous reproductive disorders and 5 from apparently healthy Borrelia spirochetes were detected in 80 adults and 52 ranged between 5x102 to 5x104ccu/ml. All the test strains of nymphs with an infection rate of 51.3% and 49.5%, respec- Ureaplasma, were found sensitive for lincospectin and resis- tively. Phylogenetic analysis reveals that all these detected tant to ampicillin. However, variable resistance was shawn spirochetes constitute two major separate clades distincted by 6 isolates to tetracycline, 4 isolates to enrofloxacin, from other Borrelia genospecies in both NJ and MP meth- spiramycin and chloramphenicol, 3 isolates to tylosin and ods. Within the clades, 10 strains of Borrelia spirochetes erythromycin and one isolate to tiamutin and sparfloxacin. detected in I. granulatus ticks were closely related to Conclusion: All the fourteen strains of Ureaplasma iso- the genospecies of B. burgdorferi sensu stricto and 15 lated from cows with various reproductive disorders show strains of detected spirochetes were closely related to multiple drug resistance against tested antibiotics. B. valaisiana. Conclusion: Our results demonstrate the genetic diver- doi:10.1016/j.ijid.2010.02.1832 sity of B. burgdorferi sensu lato spirochetes detected in I. granulatus ticks collected in Taiwan. The genetic identities of these detected spirochetes were clarified by analyzing sequence homology of 5S-23S intergenic spacer amplicon gene. Further investigations on Borrelia spirochetes detected in variant tick species and reservoir hosts would 14th International Congress on Infectious Diseases (ICID) Abstracts e159

34.011 34.012 One health: Collaboration, recent research and develop- Epizootiology of foot and mouth disease in Nepal ments in the global effort to eliminate Rabies R. Giri ∗, P. Parshin R. Dedmon 1,∗, D. Briggs 2, T. Lembo 3, S. Cleaveland 3 Peoples’ Friendship University of Russia, Moscow, Russian 1 Medical College of Wisconsin, Milwaukee, WI, USA Federation 2 Kansas State College of Veterinary Medicine, Manhattan, Background: Foot and Mouth Disease (FMD) is endemic in KS, USA Nepal. The details of epizootiology of FMD in Nepal were set 3 University of Glasgow, Glasgow, United Kingdom out in this work. We studied epizootiology of the disease for Background: Rabies causes 55,000 deaths annually, half the prevention and control strategies of FMD for the vet- of which are in children less than 15 years of age, and erinary service, taking into account the peculiarities of the has the highest mortality rate of any infectious disease. country. It is both preventable and controllable. Economic impact Methods: We studied the spread of FMD in animals of of rabies in developing countries in Asia and Africa, where different species by seasons of the year, regions and eco- over 98% of all human rabies deaths occur from exposure zones, types, and virus serotypes. The work was carried out to canine rabies, rises each year. Estimated annual human using monthly epidemiological reports on the disease from rabies prevention costs are about $800 million U.S. Even so, 75 districts to Veterinary Epidemiology Centre, Directorate continuing vaccine and RIG shortages in countries with the of Animal Health, Kathmandu, Nepal from 2000 to 2007. The highest incidence of rabies continue unabated, leaving the results were processed and analyzed with the use of the most vulnerable at greatest risk. New lyssavirus genotypes computer program Microsoft Excel Programme. continue to be discovered in bats in Asia and Africa-needing Results: FMD was ranked first in terms of the number of continuing widespread surveillance globally. Burden of dis- outbreaks, the number of affected and dead animals in the ease and suffering cannot be over-stated. Rabies victims in structure of the major infectious and invasive diseases in developing countries are often sent home to die, due to lack Nepal. The predominant serotypes responsible for epidemic of treatment facilities and fear of the disease. Additionally, outbreaks of FMD in Nepal are O, Asia 1 and A, which are lack of surveillance and adequate control measures have identical to other countries in South Asia. Cattle and buf- enabled rabies spread to previously rabies-free areas (e.g faloes are the most susceptible animals to FMD in Nepal, recent outbreak in Bali leading to human rabies deaths). whereas goats and sheep are relatively less susceptible. Hill Methods: Literature review-MesH rabies, monoclonals, and Terai (Plain) ecozones of Nepal are the most stressful vaccine, epidemiology, surveillance Meeting abstracts 2008- areas and persistent disadvantage for the disease. The most 09. vulnerable to the disease are the regions of the Far-west and Results: Recent advances in rabies prevention and control Central. Although the outbreak of FMD is reported all the strategies: 1. New vaccine both for humans and ani- year round, high incidence of FMD is noticed twice a year: mals. Molecular biology has brought new understanding to in April-June and December (the movement of animals in lyssavirus evolution, to possible new reduced vaccine sched- previous religious activities). ules, and to an effective substitute for equine or human Conclusion: On the basis of our study, we recommend to rabies immunoglobulin through the development of promis- launch 100% vaccination of susceptible animals at first in ing monoclonal antibodies now in clinical trials. Oral animal Far-western development region adding other regions in the vaccines have been developed using human adenovirus as next years using trivalent vaccine, containing virus serotypes the rabies G-Protein carrier. 2. Diagnosis of rabies in the O, A and Asia-1 to acquire the herd immunity for success- field has been made posible via the dRIT light microscope ful FMD planning. Expeditionary activities, pre-vaccination immunohistochemical test. 3. GIS systems and computer campaign, increase monitoring of veterinary regulations, modeling have improved rabies surveillance. 4.Partners for disinfection, immediate isolation and vaccination of ani- Rabies Control has developed an action blueprint for control- mals, quarantine, and creation of normative-legal provision ling rabies in developing countries. 5. Substantial funding for the implementation of activities, seminars and training from Bill and Melinda Gates Foundation is targeted to of veterinary professionals are important in Nepal to imple- studues if dog rabies elimination in Tanzania,Kuazulu-Natal, ment prevention and control strategies of FMD. and the Philippines. 6. A registered charity in the U.K. and U.S., the Alliance for Rabies Control, has become a beacon doi:10.1016/j.ijid.2010.02.1834 for rabies education and prevention. Conclusion: Rabies is both preventable and controllable- 34.013 many challenges, but brighter future! The micro-adenomatous lesions associated with Lawsonia intracellularis in the pig intestine doi:10.1016/j.ijid.2010.02.1833 ∗ M. Sueyoshi , R. Uemura, H. Nagatomo University of Miyazaki, Miyazaki, Japan Background: Lawsonia intracellularis orally infects and causes marked hyperplasia of enterocytes in pigs. The infected intestinal wall makes thickening remarkable. This disease is called porcine proliferative enteropathy (PPE) e160 14th International Congress on Infectious Diseases (ICID) Abstracts or porcine intestinal adenomatosis(PIA). L. intracellularis ods for measuring immunity to rabies and for diagnosis are was spreads all over the world and that the microbes were powerful, they include some limitations innate to biological infected with pigs of a lot of farms have been reported. assays. The characteristic pathological lesion of PIA is well known, Methods: For example, we report the results of an inter- but the pathogenesis mechanism is not clear. In this study, laboratory comparison of rabies serology by Kansas State the localization of L. intracellularis and the mucosal lesions University (KSU) and the New York State Department of were investigated on the intestine with onset or healthy Health (NYSDOH). Of 90 samples presented blinded, 37 pigs. were from rabies vaccinated individuals and 53 were from Methods: The histopathological examination of the patients sero-positive for other pathogens. intestines of the 25 poor-growth piglets and 67 healthy Results: Among sera from vaccinated persons, 87% pigs at the meat inspection station were examined by yielded concordant results of ≥0.50 IU/ml. A discordant Hematoxylin-Eosin staining, Warthin-Starry(WS) staining and result occurred in 5 samples at or near 0.50 IU/ml. Among 53 immunohistochemical(IHC) method used the anti-L. intra- samples from non-rabies-vaccinated humans, a low level of cellularis antibody. In addition, it was examined detection neutralizing activity was reported by NYSDOH in 21 samples of a specific gene of L. intracellularis by PCR method about and by KSU in 9 samples, most likely indicative of nonspecific an intestinal frozen-, a formalin- and a paraffinspecimen. antiviral activity or cross-reactive antibodies. Results: In necropsy, no thickened intestinal wall was Conclusion: There remains a need for proficiency testing found in 25 poor-growth piglets, however, in two of them, and advancement of quality control practices to opti- the typical PIA histological lesions were found in from the mize human and animal rabies diagnostic and serological jejunum to the rectum. These cases were diagnosed as practices. Although rabies excites the imagination, cur- atypical PIA. In addition, in the other two of them, an island- rent vulnerabilities include the potential for re-introduction shaped micro-PIA lesion was distributed in the intestinal of dog-to-dog transmitted rabies, a decline in diagnostic mucosa. The comma-shaped small bacteria were observed expertise and capacity, commercial enterprises answering by WS staining, and the antigens of L. intracellularis were a perceived need for diagnosis and serology but with limi- detected with IHC methods in the enterocytes of the micro- tations in test accuracy and specificity, and a lack of basic adenomatous lesions. The antigen of L. intracellularis was research, especially to understand recent advances towards also detected in the intact superficial enterocytes. In 67 treatment of clinical rabies. As a global community with healthy pigs, the thickened intestinal wall was not found rapid and high volume exchange of animate beings and inan- macroscopically. However, the focal adenomatous lesions imate products, diligent attention and dedicated effort will with clear boundaries were observed to three pigs in them. be required to maintain, and indeed, even advance, emerg- A specific gene of L. intracellularis was detected by PCR ing and zoonotic disease control, with rabies as a tangible method in the intestinal frozen-, the formalin- and the ‘‘best-practices’’ template, beyond major advances of the paraffin-specimen. last half-century. Conclusion: In this study, it was confirmed that there was atypical PIA, and the islandshaped or the focal adenomatous doi:10.1016/j.ijid.2010.02.1836 lesions were also distributed in a normal intestine macroscopically. The microlesions was suggested on the stage of 34.015 an early infection or the subclinical infection with L. intra- Identification and characterization of Shiga toxin- cellularis. producing Escherichia coli (STEC) isolated from cattle, sheep and meat samples in Tehran Province, Iran doi:10.1016/j.ijid.2010.02.1835 ,∗ F. Jafari 1 , M. Tajbakhsh 2, S. Morabito 3, M. Azimi Rad 4,P. 34.014 Torabi 4, M. Arabshahi 5, M.R. Zali 6 Emerging and zoonotic disease risk mitigation: Rabies pre- 1 Research Center for Gastroenterology and Liver Diseases, vention as a template for best practices Shaheed Behesti University, M.C., Tehran, Iran, Islamic ,∗ Republic of C. Hanlon 1 , S. Moore 1, R.J. Rudd 2, S.J. Wong 2 2 Research Center for Gastroenterology and Liver Diseases, 1 Kansas State University, Manhattan, KS, USA Tehran, Iran, Islamic Republic of 2 New York State Department of Health, Albany, NY, USA 3 Dipartimento di Sanità Alimentare e Animale, Istituto Superiore di Sanità, Viale Regina Elena 299, Rome, Italy Background: Like many zoonotic and emerging dis- 4 Research Center for Gastroenterology and Liver Diseases, eases, rabies prevention requires the cooperation of animal Tehran, Iran, Islamic Republic of control, law enforcement, natural resource personnel, 5 Veterinary Council, I. R., Tehran, Tehran, Iran, Islamic veterinarians, diagnosticians, public health professionals, Republic of physicians, and other professionals. Despite the forced 6 Tehran, Iran, Islamic Republic of extinction of dog-to-dog types of rabies viruses in most of Europe and the Americas, the recent translocation of dogs Background: Shiga toxin producing Escherichia coli from Puerto Rico, Thailand, India, and Iraq, which devel- (STEC) has been associated with hemolytic uremic syn- oped rabies from their places of origin upon movement into drome, outbreaks of diarrhea and hemorrhagic colitis in the United States, demonstrates the risk of human travel human. Infection is mainly acquired by ingestion of con- and movement of animals, some of which can be mitigated taminated food. In Iran, STEC strains have been frequently through carefully crafted requirements. While the meth- isolated from cattle and humans. This study aimed at the 14th International Congress on Infectious Diseases (ICID) Abstracts e161 assessment of the distribution, virulence gene profile and Another aim is to encourage better cooperation between phenotypes of STEC strains isolated from dairy cows and human, animal medicine and local authorities, in order to sheep feces and from raw meat samples in Tehran province. utilize all resources to combat and control of brucellosis in Methods: A total of 326 samples, including 120 from cat- the most efficient way. tle feces sampled in three farms, 102 sheep feces and 104 Methods: We did a retrospective study of brucellosis files meat samples from slaughtered cattle in Tehran’s abattoir, from three clinics and four departments for infectious dis- were assayed for stx1, stx2, eae and !-hly genes by PCR. eases from both Bosnian entities (Federation of B&H and STEC isolates were further characterized for their O and H Republic of Srpska). Diagnosis was confirmed either by ELISA serotypes by slide agglutination assay. and Rose-Bengal test or by isolation of Brucella species in Results: STEC strains were isolated from 67.5% (81 out blood. of 120) of the cattle stool samples, 83.3% (85 out of 102) Results: In period 2000-2006 brucellosis was spreading of the sheep feces and 49.1% (51 out of 104) of the meat through all the country slowly becoming continuing epider- samples. 52.5% STEC strains isolated from sheep and 36.9% mic. There was 305 cases registered in Federation of B&H, of the cattle isolates possessed the the stx-coding and eae and 5 cases in Republic of Srpska. There were registered genes genes. A-hly-coding gene was observed in 13.5% of 1741 cases for the period 2006-2009 in Bosnia and Herzegov- STEC isolates. E. coli O157:H7 was detected in nine (4.1%) ina, and 283 of them were registered in Republic of Srpska. of the bovine samples (including both faecal and meat sam- Conclusion: Brucellosis has become an emerging zoono- ples). The most commonly isolated STEC serogroups were sis in Bosnia and Herzegovina. First cases were registered O146, O112a and O44 in meat samples and O127a, O142 and after the war in Bosnia (1992-1995). It has become a con- O1 in bovine feces .No E. coli strains belonging to the clas- tinuous infection. For the past ten years it has become an sical pathogenic STEC serotypes, such as O145, O111, O103 endemic disease. Brucellosis cannot be controlled due to and O26 were identified. administrative borders and lack of political will. Scientific Conclusion: The present study confirms the potential of teams must be founded in order to make a national program sheep and cattle to serve as a reservoir for potentially vir- for treatment and control of the disease. ulent STEC strains in Iran. The observation that the most of the STEC strains isolated in study harboring the stx and doi:10.1016/j.ijid.2010.02.1838 eae genes belonged to unusual serogroups may reflect differences in the epidemiology of STEC infection in Iran. This 34.017 finding, should it be confirmed by clinical investigations aim- Prevalence ectoparasites in dogs of beaches and fields ing at defining their role as causative agent of diarrhoea fishing of Navolato, Sinaloa, Mèxico and/or HUS, may influence the strategies to be adopted for M.C. Rubio Robles ∗, S.M. Gaxiola Camacho, N. Castro del C., the diagnosis and control of STEC infections in Iran. J. Gaxiola M. doi:10.1016/j.ijid.2010.02.1837 Universidad Autonoma de Sinaloa, Culiacan, Sinaloa, Mex- ico 34.016 Brucellosis — Emerging zoonosis in Bosnia and Herzegov- Background: Fleas are a nuisance to humans and their ina pets, can cause medical problems including flea allergy dermatitis, secondary skin irritations, in extreme cases, ,∗ S. Krkic Dautovic 1, M. Hadzovic Cengic 1 , S. Mehanic 1, anemia. Although bites are rarely felt, it is the result- S. Ahmetagic 2, N. Ibrahimpasic 3, E. Hadzic 4, I. Curic 5,N. ing irritation caused by the flea salivary secretions that Derviskadic 6, J. Bajic 7, J. Bojanic 8 varies among individuals. Some may witness a severe reaction (general rash or inflammation) resulting in secondary 1 KCUS, Sarajevo, Bosnia and Herzegovina infections caused by scratching the irritated skin area. Also, 2 UKC Tuzla, Tuzla, Bosnia and Herzegovina may transmit Tapeworms (common infection is Dipylidium 3 KB Bihac, Bihac, Bosnia and Herzegovina caninum) normally infest dogs and cats but may appear in 4 KB Zenica, Zenica, Bosnia and Herzegovina children if parts of infested fleas are accidentally consumed. 5 KB Mostar, Mostar, Bosnia and Herzegovina The ticks are painful and sometimes very dangerous. These 6 Bolnica Juzni logor, Mostar, Bosnia and Herzegovina blood sucking insects feed on all vertebrates but are par- 7 KBC Banja Luka, Banja Luka, Bosnia and Herzegovina ticularly skin to dogs and cats as they tend to enjoy the 8 Institut za epidemiologiju, Banja Luka, Bosnia and Herze- same places that pets. They can be found infesting lawn and govina garden, and can transmit diseases how Lyme disease, Rocky Background: Brucellosis is the most widespread zoono- Mountain Spotted Fever, Typhus, Rickettsial Pox, Tularemia, sis, that affects more then a half million people per year, all Babesia and Anaplasma. Generally, these different diseases over the world. Causative agent is Brucella species, domes- are unique to different ticks which carry causal organisms of tic and wild animals are resevoirs, and it affect mostly these such diseases and can be confined to certain regional humans. The disease appeared in Bosnia and Herzegovina areas.. The objective of this work was to determine the right after the war 1992-1995, and ever since then it has prevalence of ticks and fleas in dogs of beaches and fields been constantly spreading among animals and humans, with fishing of Navolato, Sinaloa, Mèxico. no signs of reduction in number of infected and affected. Methods: The samples were determined for a repre- The aim of this work is to analyze cases of human brucellosis sentative sample with both sexes and cradle described by hospitalised in Bosnian hospitals for the period 2000-2009. the technique of Thrusfield (2005) was used: n = [t*SD/L]2. e162 14th International Congress on Infectious Diseases (ICID) Abstracts

Where n = sample size, t = value of the normal distribution serotypes (1/2a, 1/2b and 4b), despite the fact that there (Student t) for a 95% confidence level (t = 1.96), L = accepted are 13 serotypes potentially capable of infecting humans. error or precision (5%), and SD = weighted disease preva- Further genotyping results of the isolated strains will be lence (%). With This technique, the number of animals presented. determined for random sampling was 242; collected into Conclusion: This study shows, that tonsils of wild boars identifed plastic bags; and observed at microscope. are not only a reservoir for Yersinia enterocolitica and Results: 194 (80.16%) positive to ticks; and 211 (79.92%) Yersinia pseudotuberculosis, but also for Listeria monocy- positive to fleas Ctenocephalides spp. togenes. This has mainly to be considered by the hunters, Conclusion: Is considerable number of positives animals who may be handling carcasses under minimal hygiene con- and to continue in the present conditions, this problem can ditions. Moreover, outside rearing of domestic pigs and close take importance in the society, because frequently these contact to wild boars may increase the risk of transmission. dogs are on different points from the town and can pass the infection of other healthy animals, visitors and even the doi:10.1016/j.ijid.2010.02.1840 same family. 34.019 doi:10.1016/j.ijid.2010.02.1839 The ‘‘One Health’’ Initiative: Using open source data for disease surveillance 34.018 M. Greene Phenotypical and genotypical traits of Listeria monocytogens strains isolated from tonsils of wild boars hunted in Science Applications International Corporation, McLean, Switzerland VA, USA ,∗ S. Wacheck 1 , N. Giezendanner 2, M. König 3,M. Background: We have created a self-organizing ontology Fredriksson-Ahomaa 1, R. Stephan 2 that allows us to organize and filter external data by relating email exchanges through their references into ‘‘reference- 1 Institute of Food Hygiene and Technology, Veterinary Fac- connected sets’’. These sets of messages can be generated ulty, Oberschleißheim, Germany dynamically and constructed in real-time to identify sub- 2 Vetsuisse Faculty, Institute for Food Safety and Hygiene, ject categories (e.g. disease outbreaks) as they evolve. This Zurich, Switzerland allows the filtering of less important information into sets 3 Veterinary Affairs Service (SCAV), Geneva, Switzerland of messages that uniquely identify events so the user is not Background: During the last decades, wild boar popula- overwhelmed with irrelevant information. tions have increased in Europe and spread over the entire Methods: This paper describes the approach as it is continent. The population densities of wild boars in Switzer- applied to ProMEDmail, an Internetbased system dedicated land are among the highest reported in Western Europe. to rapid global dissemination of information on infectiouis High wild boar densities and increasing popularity of out- diseases. This official program of the International Soci- door ranging of fattening pigs may intensify the risk of ety of Infectious Diseases has the largest reporting base of contacts between wild boars and domestic pigs and, there- any health organization and can be used as a model for fore, the transmission of microorganisms and parasites. With a bio-threat surveillance system that takes advantage of this background and with the background of increasing per decentralized, Internet-based social networks. capita consumption of wild boar meat and the high per Results: The presenter will demonstrate how the tech- capita consumption of pork, knowledge of the situation of nique was used in an analysis of the evolution of pandemic the food-borne pathogens circulating in the wildlife popula- influenza messages. The presenter will also discuss the ben- tion is an important public health issue. efits of expanding the approach through new science and Methods: In this study, tonsils of 153 wild boars hunted technology solutions to increase global health security. in the Western part of Switzerland were enriched overnight Conclusion: A medical informatics solution to surveil- in TSB and screened on the presence of L. monocyto- lance of outbreaks of zoonotic diseases can be achieved genes using VIDAS®. Positive samples were cultured on two through user-friendly graphic interfaces; automated extrac- selective agar media. Presumptive positive colonies were tion and formatting of data; expert systems for epidemio- biochemically identified. L. monocytogens strains were fur- logic analysis; powerful algorithms for data and information ther characterized by serotyping and genotyping methods. fusion; interconnection with other networks (public health Results: L. monocytogenes are food-borne pathogens agencies, hospitals, animal/zoonotic disease surveillance); that are distributed in a wide variety of environments. standard forms through an internet. Human infection may lead to a serious and potentially life threatening illness known as listeriosis. Reports from the USA doi:10.1016/j.ijid.2010.02.1841 show that L. monocytogenes infections are responsible for the highest hospitalization rates (91%) amongst known foodborne pathogens. L. monocytogenes were isolated from tonsils of twenty-six (17%) animals. Of the 26 isolates, 45% were of serotype 4b, 38% were of serotype 1/2a and 17% were of serotype 1/2b. Epidemiological data from different countries shows that the majority of human infection outbreaks are primarily associated with three L. monocytogenes 14th International Congress on Infectious Diseases (ICID) Abstracts e163

34.020 34.021 Assessment of Brucella melitensis disease burden in lac- Analysis of circulation influenza virus A on the Chany Lake tating goats in Mizque, Bolivia (Novosibirsk region, Russia) in 2008 year J.A. Zambriski 1,∗, M. Saito 2, D.V. Nydam 3, H.A. M. Sivay 1,∗, S. Sayfutdinova 2, M. Kulak 2 Reyes-Garay 2, R. Castillo 4, D. Cepeda 4, M.J. Cespedes- 1 State Research Center of Virology and Biotechnology ‘Vec- Zambrano 5, P. Garcia-Vara 5, R.C. Maves 4, M. Solano 6,F. tor’, Koltsovo, Russian Federation Torrico 6, R.H. Gilman 7 2 State Research Center of Virology and Biotechnology 1 Cornell University, 14853, NY, USA ‘‘Vector’’, Koltsovo, Russian Federation 2 Asociacion Benefica PRISMA, Lima, Peru Background: The natural host species of type A Influenza 3 Cornell University, Ithaca, NY, USA viruses are wild-waterfowl and shorebirds. The virus easily 4 U.S. Naval Medical Research Center Detachment, Lima, transfers to the domestic birds, which congestion promotes Peru spread of the infection. Birds migrations assist spread of 5 Instituto Nacional de Salud, Lima, Peru various variants of virus on the huge territories. Monitoring 6 Colectivo de Estudios Aplicados y Desarrollo Social, and studying genetic, antigenic and pathogenic properties Cochabamba, Bolivia reveal to estimate zoonotic danger of such variants. Biologi- 7 The Johns Hopkins Bloomberg School of Public Health, Bal- cal material was collected from captured free-flying birds on timore, MD, USA the Chany Lake in 2008 year. This is a territory of birds pop- Background: Brucellosis is a zoonotic disease that can ulation from Africa, Average and Southern Asia and Europe be transmitted from goats to people by direct contact during nested periods and migration flights. or through ingestion of unpasteurized dairy products. In Methods: Viruses were obtained from cloacal swab mate- Latin America, where goats are a significant part of agri- rial. Avian influenza was isolated by virus isolation methods culture, human cases of brucellosis are reported in Mexico, in embryonating chicken eggs. chorioallantonic fluid from Argentina, and Peru. In Bolivia, human cases of brucellosis the infected embryos was used as the virus source. RNA was have been described, but there is minimal epidemiologic extracted with SV Total RNA Isolation System () in accor- knowledge. The objective of this study was to assess Bru- dance with manufactures instructions and transcribed into cella melitensis disease burden in lactating goats in Mizque, cDNA for a subset of samples. In RT-PCR subtype-specific Bolivia. primers were used. Sequence analyses of HA and NA genes Methods: Milk and blood samples were collected from 229 were obtained. For each data set, sequence alignments were lactating goats on 26 farms in Mizque, Bolivia, an agricultural created using CLUSTAL. Phylogenetic trees were constructed town 100 km from Cochabamba, where human cases of bru- using MEGA 4.1 cellosis have been described. Herds, and goats within herds, Results: The virus was detected in 12 probes out of 255. were selected via convenience sample. Efforts were made to Subtypes of isolates were identified. After making phylo- minimize selection bias. In herds with 16 or fewer lactating genetic analysis homology of isolates from the Chany Lake goats, all goats were sampled, otherwise, one-third of the with stains circulating in Mongolia, Sweden, Germany and lactating goats were sampled. Information from each herd Hokkaido was shown. and animal was collected by survey. Milk was analyzed via Conclusion: Our findings indicate of facility influenza A culture. Serum was analyzed for antibodies using the Rose virus’s transmission on the long distance by wild birds of Bengal plate test and the Lateral Flow Assay. passage. This work was supported by Russian Government Results: Median herd size was 33 adult goats (range: 10- and Bio Industry Initiative (BII), USA (ISTC#3436) and was 150). The average reported age of the animals sampled was done in collaboration with the Novosibirsk State University. 3.4 years (SD: ±1.5). None of the animals sampled had a reported history of vaccination against Brucella melitensis. doi:10.1016/j.ijid.2010.02.1843 20 (8.7%) goats sampled from 13 (50%) farms had a reported history of abortion. Of the 229 animals sampled, 0 had pos- 34.022 itive milk culture and serology results (95% CI = 0 — 1.6%). Epidemiological study on infectious bovine rhinotra- Conclusion: This region of Bolivia may be free from dis- cheitis in cattle ease, or may have disease prevalence too low to be detected Y. Alomar 1,∗, Y. AlYasino 2 by the sample size. Given the tendency for disease to cluster within herds, the high disease prevalence in bordering 1 Faculty of Vet. Med., -Alamin Road. Fac. Ve. Med., Syrian countries, and lack of disease monitoring within Bolivia, the Arab Republic presence of Brucella melitensis in the Bolivian goat pop- 2 Faculty of Veterinary Medicine, Hama, Syrian Arab Repub- ulation cannot be ruled out. Larger studies conducted in lic multiple geographic regions of the country are warranted. For example, assuming 100% sensitivity of the tests, a pop- Background: The study was conducted on 5 farms belong ulation of 2500 animals, and desiring 95% certainty, the to the General organisation of Cattle (GOC) in Syria for maximum possible prevalence is 1.3% even after finding 0 epidemiological & Sero investigation of infectious bovine of 229 positive in this sample. rhinotracheitis (IBR). Methods: Data was collected from individual farm included animal characteristics and farm specifications. doi:10.1016/j.ijid.2010.02.1842 Random blood samples were colleced from individual ani- e164 14th International Congress on Infectious Diseases (ICID) Abstracts mal from the farms study. ELISA test was used to test all 8,36% of the patients. The most severe form of leptospirosis, samples to detect positive antibodies LPEC model Program Weil’s syndrome, was present in 78.6% (118/150) patients. was used to estimate the economic losses of the disease. 100% of the patients with Weil’s syndrome had renal failure; Results: The sero prevalence of the disease was ranged 50% hemorrhagic syndrome; 45,8% neurological disorders between 10-20 percent in the study farms. It was carried (38,7% meningitis, 5.0% meningoencephalitis, 1,6% convul- out an quantitative epidemiological and economic study to sions, 0,8% poliradiculitis); 43,3% atypical pneumonia; 21,2% evaluation the epidemiology of the disease and econmic gastrointestinal symptoms, 15,2% rash; 8,4% cardiovascular losses caused by the disease. It was confirmed that there disorders; 6,7% sight impairment and 3,3% pancreatitis. In were strength significant association between the occur- patients with a non icterous form of leptospirosis, no lethal rence of the disease and advance ages of animals and outcome has been noted. Among the patients with Weil’s increased the size of herd in individual farms. The economic syndrome the mortality was 16,1% (19) and 65% among the losses resulted of the occurrence of the disease were esti- elderly patients over 60 years. mated as indiviudual level for a cow and gemerally on the Conclusion: Clinical manifestations vary among the farm level.The sero prevalence of the disease was ranged patients, from easy forms to severe multi organ forms of lep- between 10-20 percent in the study farms. It was carried out tospirosis. The highest impact on the prognosis of the disease an quantitative epidemiological and economic study to eval- has the age of the patients, co morbidity (alcoholism), early uation the epidemiology of the disease and econmic losses corticosteroid therapy in patients with pulmonary symp- caused by the disease. It was confirmed that there were tomatology and early haemodialisis in patients with renal strength significant association between the occurrence of failure. the disease and advance ages of animals and increased the size of herd in individual farms. The economic losses doi:10.1016/j.ijid.2010.02.1845 resulted of the occurrence of the disease were estimated as indiviudual level for a cow and gemerally on the farm level. 34.024 Conclusion: The study was conculded that there was an Epidemiology of avian influenza viruses in wild birds in increase in the seroprevalence in dvance ages in all regions Mongolia study, this was because there was no vaccination program in E.-O. Tseren-Ochir 1,∗, B. Damdinjav 1, T. Sharkhuu 1, H.M. all regions study. Biosecurity procedures should be taken in Kang 2, Y. Sakoda 3, B. Purevsuren 4, S. Ruuragchaa 1, Y.J. consideration in order to decrease the disease occurrence. Lee 2, H. Kida 3, B. Khishgee 1, S. Sengee 1 The economic losses resulted from the disease reached to 4000 US$ at the farm level and about 100,000 US$ at the 1 State Central Veterinary Laboratoy, Ulaanbaatar, Mongolia GOC level. Control startegies should be carried out in order 2 National Veterinary Research & Quarantine Service, to prevent the high prevelance level of the diseae Anyang-city, Korea, Republic of 3 Graduate School of Veterinary Medicine, Hokkaido Univer- doi:10.1016/j.ijid.2010.02.1844 sity, Sapporo, Japan 4 Avian influenza and human pandemic influenza prepared- 34.023 ness and response project of World Bank, Ulaanbaatar, Clinical manifestations of leptospirosis Mongolia ,∗ M. Fabri 1 , I. fabri 2 Background: A combination of geographical features makes Mongolia an ideal location for understanding the epi- 1 Clinic Center Vojvodina, Novi Sad, Serbia demiology of avian influenza viruses in wild birds. There are 2 Clinical center of Vojvodina, Novi Sad, Serbia four main migration routes (East-Asia/Australasia, Central- Background: Leptospirosis is an acute generalized infec- Asia/India, West-Asia/Africa and Mediterranean/Black-see) tious disease which belongs to the zoonoses group. passing through Mongolia. Around 391 species of migratory Leptospirosis mainly causes interstitial nephritis in animals, birds arrive in Mongolia. Mongolia also represents an impor- but people accidentally get infected in a direct or indirect tant site for molting of Anseriformes. contact with the urine of the infected animal. Our goal Methods: Since 2006, we have collected 3950 feces sam- was to display the clinical manifestations in 150 hospital- ples and 150 tissue samples from wild birds during the active ized patients, treated at the Clinic for infectious diseases in surveillance in Mongolia. Viruses isolated by the egg inoc- Novi Sad during the past ten years. ulation method, and RT-PCR, qRT-PCR and Neuraminidase Methods: A retrospective study of the clinical manifesta- inhibition test were used for subtyping. The confirmation of tions in patients diagnosed with leptospirosis, hospitalized the isolated highly pathogenic avian influenza virus(HPAIV), on the Clinic for infectious diseases from the year 1999 to and intravenous pathogenicity index(IVPI), phylogenetic year 2000. analysis were performed by the OIE Reference Laboratory Results: Non icterous form of leptospirosis was found in for HPAI at Hokkaido University, Japan. The confirmation 21,33% (32/150) patients; high body temperature with a gen- of the low pathogenic avian influenza virus (LPAIV) isolates eralized infectious syndrome was present in 43,75%; 8,33% and phylogenetic analysis were carried out in the National of the patients had a high body temperature followed with Veterinary Research and Quarantine Service of Korea. severe hemolitical anemia; aseptic meningitis was present Results: In 2005 and 2006, 2 HPAIV(H5N1) were iso- in 28,1%; gastroenteritis in 15,6%; bronchopneumonia in lated from wild birds (whooper-swan, bar-headed-goose 6,25%; nephritis in 6,25% and pneumonia, aseptic menin- and common-goldeneye) at Erkhel and Khunt Lakes. These gitis and gastrointestinal bleeding joined simultaneously in viruses were classified into the clade 2.2 so-called Qinghai 14th International Congress on Infectious Diseases (ICID) Abstracts e165

Lake-type. In May and August, 2009, 2 HPAIV(H5N1) were iso- H1N1, H2N2, H3N8, H7N7, and Newcastle disease virus lated from wild birds (whooper-swan and bar-headed goose) (NDV). Neuraminidase ativity (NA) assay was performed to at Doitiin tsagaan and Duruu Lakes. These viruses were clas- characterized the isolates. Were perfomed a RT-PCR to pro- sified into the clade 2.3.2. The IVPI was high /2.97-3.00/. tein M of Influenzavirus and L protein of broadly range of Also we isolated 21 LPAIVs in 2007 and 2008. The sub- Paramyxovirus. types were H3N8(11), H4N6(4), H7N7, H7N9, H3N1, H3N2, Sample FMP(ua) FMi (ua) TI H4N2 and H10N6. The viruses were related with the Euro- Asia lineage. In 2009, 7 LPAIVs were isolated from wild NDV(+) 16394.46 444.89 41,34 56 23659,12 1273.81 18,57 birds (whooper-swan, ruddy-shelduck, Mongoliangull, mal- 60 25118,95 1893,23 13,26 lard and gadwall) in Central and Eastern Provinces. The 64 25248.39 1343.51 18,79 subtypes were H3N8(3), H10N6(3) and H4N6. 66 25018,11 610.98 40,94 Conclusion: We isolated 4 HPAIVs and 28 LPAIVs from wild 87 26148.81 2500 10,45 birds in Mongolia genetically related to the Euro-Asian AIVs. 119 23635.86 1494,16 15,B1 All HPAI outbreaks were restricted to the wild birds in north- 129 26903.40 1890 14,23 central Mongolia. The phylogenetic differences of the H5N1 439 25262.89 818.95 30,84 isolates from 2005, 2006 and 2009 indicate that the role of the migratory birds in Mongolia in the AIV mutation should be NA activity and inhibition by DANA of penguins isolates. clarified. Therefore, it is necessary to continue the research Results: Our results shown that 9 samples (12%), were on avian influenza in Mongolia. positive by haemaglutination test, but no inhibition by influenza sera observed. Partial inhibition by NDV serum was observed in all samples. All samples presents NA activ- doi:10.1016/j.ijid.2010.02.1846 ity. All samples amplified L protein gene of Paramyxovus 34.025 (Avulavirus), demonstrating a strong band of 500 bp on Virological studies on migratory penguins captured in agarose gel. Brazilian southeast coast Conclusion: Our results shown that Avulavirus is present on these birds and may cause diseases on this species, con- L.A. Fornells Arentz 1,∗, I. Bianchi 2, C.E.P.F. Travassos 2, tributing to clinical deterioration of the animals. M.H.T. Liberal 3, C.D.M. Andrade 1, J.N.S.S. Couceiro 1 1 Federal University of Rio de Janeiro, Cidade Universitária, doi:10.1016/j.ijid.2010.02.1847 Brazil 34.026 2 Unversidade do Norte Fluminense -, Campos dos Goyta- Poultry farmers’ response to AI outbreak and its control cazes, Brazil in Indonesia 3 PESAGRO-RJ, Niteroi, Brazil E. Basuno ∗, Y. Yusdja, N. Ilham Background: The migratory birds represent the main vector of Orthomixovirus and Paramyxovirus in nature, spread The Indonesian Center of Agriculture Socio Economic and among birds in temperate regions. They have been reported Policy Studies (ICASEPS), West Java, Indonesia circulating among Antarctic penguins through serological surveys, especially in Adelie penguins (Pysoscelis adeliae) Background: AI outbreak in Indonesia had started since of eastern Antarctica. The Magellanic penguins (Sphenis- August 2003 up to now. GOI continuously try to con- cus magellanicus) are distributed on the southern shores trol it by introducing 9 strategies on bio-security policies, of South America. Their breeding colonies were distributed for instance, vaccination, depopulation, transportation and from the coast of Chile to the Peninsula Valdez in Argentina, trading of poultry products. Poultry industry development on the southern tip of South America. This penguin performs provides employment for villagers and it is very important migration to the north, and such shift is an annual event for low income villagers, in particular poultry rearers in sec- considered characteristic of the species. The birds breed in tor IV. colonies north of its distribution, as in the southern coast of Methods: In order to observe socio economic impacts of Brazil, where they stay in the winter. Some individuals have AI outbreak in sector IV, survey had been implemented in demonstrated irregular movements that may occur with or three provinces in Indonesia in early 2008. in large numbers, causing errant individuals. It is believed Results: Results indicated that in general farmers did not that for this reason this species have reached the Northeast know the 13 symptoms as overall AI symptoms. Overall only of Brazil in 2008 and made an unusual situation. 2.6 percent of the respondents knew all of the AI symptoms. Methods: We analyzed the presence of Orthomixovirus This knowledge was very low and, therefore, they could not and Paramyxoviruses in penguins captured on the coast of deal with AI outbreak properly. Overall, only 25.1 percent the Espírito Santo state, Brazil, due to the increasing num- of the respondents knew all of the seven items relating with ber of species in the region in 2008. Were inoculated into control measures as (i) stamping out, (ii) vaccination, (iii) the allantoic cavity embryonated fowl eggs suspensions of spraying disinfectant (iv) isolation, (v)) burning, (vi) com- 73 cloacal swabs taken from live migratory penguins at pensation and (vii) provide antibiotic, while the rests knew Brazilian Southeast Coast, between September - October only some of the items. The higher the disease attack the 2008. The allantoic fluids were tested for haemagglutination smaller the percentage of the respondents knew all items of activity (HA). In samples with positive HA, we performed AI outbreak prevention. Most farmers conducted vaccination hemagglutination inhibition (HI) test against antibodies to (65.3 percent). Only few smallholders in West Java applied e166 14th International Congress on Infectious Diseases (ICID) Abstracts vaccination (27.1 percent). Almost all farmers said that all cultures additional spa and MLST typing of the strain was of the methods of controlling AI outbreak did not give eco- performed, matching the results of the four cats (spa type nomic benefit. Survey also revealed that location of poultry 739, ST 45 with clonal cluster 45). enterprise is always sticking to and extend according to the Conclusion: A specific human MRSA cluster in humans and pattern of residential areas. cats was found and successfully treated in humans. This may Conclusion: In densely populated Java, it is almost impos- decrease future new infections in cats. Veterinary clinics sible to differentiate between areas to rear poultry and should implement guidelines for dealing with MRSA, and be residential areas. In one hand, such situation hardly can aware of increased risks for contracting MRSA. be excused considering environmental aspects for instance, but on the other hand, poultry in sector IV also need to be doi:10.1016/j.ijid.2010.02.1849 developed to provide employment for villagers. 34.028 doi:10.1016/j.ijid.2010.02.1848 An exploration of the knowledge, attitudes and perceptions of the local, adult, non-medically trained Grenadian 34.027 population about certain zoonotic diseases Cluster of MRSA in cats and staff of a veterinary clinic: S. Bidaisee Follow-up and possible implications for control ,∗ St. George’s University, Grenada, St. George’s, Grenada A.M. Tjon-A-Tsien 1 , M.C. Vos 2, E.V. Duijkeren 3, W.J. Wannet 4, H.M. Gotz 1, W. Schop 1, J.H. Richardus 1 Background: Zoonotic diseases represent a leading cause of illness and death from infectious diseases in humans. In 1 GGD Rotterdam Rijnmond, Rotterdam, Netherlands the Caribbean generally and in Grenada specifically, to the 2 Erasmus medical center, Rotterdam, Netherlands best of our knowledge, no reports on examining people’s 3 University of Urecht, Utrecht, Netherlands knowledge, attitudes and perceptions towards zoonotic dis- 4 National Institute of Public Health and Envrionment, eases have been published.The objective of this research Bilthoven, Netherlands study was to explore the knowledge, attitudes and percep- Background: At approximately 1% the prevalence of tions of the local, adult, nonmedically trained Grenadian Methicillin-Resistant Staphylococcus aureus (MRSA) in the population about certain zoonotic diseases. Netherlands is among the lowest in Europe. Voluntary noti- Methods: The study consisted of a quasi-experimental fication of a veterinarian of 4 successive but unrelated design consisting of 450 participants, selected using a con- cats with postoperative wound infections with an identi- venience sampling in the Grand Anse and the Carenage areas cal, human MRSA strain prompted this investigation. The of St. George’s, Grenada. A questionnaire was employed to prevalence rate of human MRSA carriage in all veterinary collect data on the knowledge, attitudes and perceptions staffmembers was measured, and subsequently we wanted towards five zoonotic diseases (Ringworm, Leptospirosis, to prevent MRSA infections in cats and MRSA carriage in this Creeping Eruptions, Rabies and Salmonellosis). clinic. Results: The overall level of distribution of Knowledge Methods: After informed consent all 44 veterinary of zoonotic diseases was 38.6%. Knowledge of Ring- staffmembers were questioned for MRSA risk factors. Cat worm (81.0%) was predominant among participants while case histories were reviewed (Result A). Hygienic procedures Leptospirosis and Creeping Eruption demonstrated the were updated (Result B). Staffmembers were screened for greatest deficiency in participants’ knowledge. Knowledge MRSA, and positives were treated. Posttreatment cultures of zoonotic diseases was found to have an effect on the were all sampled every 2 weeks during 8 weeks (Result C). attitudes and perceptions of persons towards the diseases. A selective broth was used for 24 hours, after which the IDI Education (p = 0.0000) and income (p = 0.0000) were found test was performed. Each positive sample was subcultured to be determinants of zoonotic disease knowledge while age on blood agar and an antibiogram was made using the Vitek-2 (p = 0.56) and gender (p = 0.97) had negligible influence on system (BioMerieux, Lyon, France) or E tests when appropri- the measure of knowledge, attitudes and perceptions. ate. Each detected strain was sent to the national reference Conclusion: The overall level of distribution for correct laboratory (RIVM) for pulse field gel electrophoresis (PFGE) knowledge towards zoonotic diseases was found to be less typing. MRSA carriage was treated using local and systemic than 50% (38.59%) among the study participants. Educa- antibiotics. tion and income assumed the role as confounders which Results: Result A: Professionals worked in individual together act to determine participants’ level of zoonotic (operation) rooms and had no catlle contact. No one had disease knowledge. Age and gender was found to have no MRSA risk factors or MRSA infections. One positive profes- effect on either participants’ attitudes towards pet care or sional had controlled skin eczema. The owner of the first cat their perceptions of zoonoses. Decisions on zoonotic safety and his family were MRSA negative. Result B: the updated involve consideration of a wide range of concerns to effec- hygienic protocol included improved hand hygiene, surface tively address the public health concerns of such diseases. cleansing and more extensive use of gloves and masks. Result Scientific advice is relevant to inform effective and efficient C: 7 persons (16%) were MRSA positive (nose, throat) with interventions that are environmentally specific and cultur- MRSA PGFE type 113 (national typing). Two of 7 professionals ally sensitive. spontaneously turned negative. Four were treated successfully, but the last one surprisingly had a positive culture doi:10.1016/j.ijid.2010.02.1850 in the second round.She stayed negative thereafter. On 5 14th International Congress on Infectious Diseases (ICID) Abstracts e167

34.029 and bird type associated with the presence of HPAI within Leishmaniasis in Albania markets. Methods: Pooled environmental swabs were taken from a S. Bino random sample of live-bird markets in 12 districts and subjected to H5 testing over a period of six months to determine Institute of Public Health, Tirana, Albania the presence of HPAI. Data on type of birds as well as origin Background: Different aspects of Leishmaniasis in Albania of birds were gathered in order to assess risk associated with has been described in different research papers. Leishma- HPAI infection in markets. niasis is mandatory notified near public health services. Results: Our results show that markets were continuously From 1960-2001 an average of 80 cases per year has been infected with HPAI, with 33.3% of market samples testing describbed in the literature. Also other studies of vectors positive over the study period. HPAI infection was concen- as well as stuies of seroprevalence in dogs has been per- trated in markets in the northeast and central regions of the formed recently. Data from echological survey, reservoirs study area where more than 60% of markets tested positive. and vectors were analysed in different geografical areas. Conclusion: HPAI due to H5 avian influenza appears to be Methods: A retrospective analysis of cases admitted in widespread within markets and concentrated in the north- district and tertiary care hospitals from 1997-2008 east and central areas of the study region. Knowledge about Also such analysis has inlcuded confirmed Visceral Leish- marketlevel prevalence in each district provides indication maniasis (VL) cases notified to the the national surveyance of the level of HPAI circulating within the commercial poul- center try industry, information that is currently not available from VL cases were reported from 35 out 36 districts, char- other sources. acterised by different levels of morbidity. Mortality and co infection data were also analysed. doi:10.1016/j.ijid.2010.02.1852 ELISA and IFAT were use dfor diagnosis. Results: A total of 1439 cases of Visceral Leishmaniasis 34.031 cases were analysed. The incidence rate ranked from 3.4 - Ancylostoma spp. on beaches of Elota, Sinaloa, México 4.3 cases/10000 population. M.C. Rubio Robles ∗, S.M. Gaxiola Camacho, N. Castro del About 89% percent of the disctricts are infected with Campo VL. The most affected areas are: Shkodra 1.4, Lezha 1.6, Berat, 1.1, Elbasan 0.7, Tirana 0.3 and. Vlora Universidad Autonoma de Sinaloa, Culiacan, Sinaloa, Mex- 0.4cases/10.000population. ico A high proportion of cases occurred among infantile population: especially children below 5 years, and 79.6% below Background: Eggs and larvaes of Ancylostoma spp. can 10 years of age. disseminated in the soil of public areas, and resist to P.neglectus and P. papatasi are the common while P.tobi adverse environment conditions, capable of surviving for is concntrated only in one grographic area. many months. Humans and pets can infect that have con- The seroprevalence in 340 dogs collected from 7 regions tact with contaminated soil of parks and sand of beaches. show a rate of 5.8%. Ancylostomiasis can be a zoonotic infection with hook- Conclusion: VL in Albania represents a serious health worm species that do not use humans as a definitive host, problem. Paedriatic cases are exceeding 80%. It is present the most common being A. braziliense and A. caninum. all over the country. A control program needs to be The normal definitive hosts for these species are dogs and established. cats; humans may also become infected when filariform larvae penetrate the skin With most species, the larvae cannot mature further in the human host, and migrate aim- doi:10.1016/j.ijid.2010.02.1851 lessly within the epidermis, causing cutaneous larva migrans 34.030 (also known as creeping eruption), sometimes as much Prevalence of HPAI in live-bird markets in the Jabo- as several centimeters a day. Some larvae may persist in databek region of west Java, Indonesia in 2009 deeper tissue after finishing their skin migration. Occasion- ally A. caninum larvae may migrate to the human intestine, ,∗ C. Lockhart 1 , E. Wuryaninggsih 2, E. Brum 1, P.R. Barrios 1 causing eosinophilic enteritis. Ancylostoma caninum larvae have also been implicated as a cause of diffuse unilateral 1 Avian Influenza Control Programme, Indonesia, Jakarta, subacute neuroretinitis. The objective was determine the Indonesia presence of Ancylostoma spp in sand of beaches of Elota 2 Campaign Management Unit, Jakarta, Indonesia municipality of Sinaloa, México. Background: Outbreaks of highly pathogenic avian Methods: The composite samples of sand of three influenza (HPAI) due to H5N1 began in October 2003 and beaches, were determined for representative samples have affected poultry in 31 of 33 provinces in Indonesia. described by the technique of Thrusfield (2005) was used: Very little is known about the HPAI in commercial poultry. n = [t*SD/L]2. Where n = sample size, t = value of the normal The objectives of this study were to determine the preva- distribution (Student t) for a 95% confidence level (t = 1.96), lence of HPAI due to H5 avian influenza viruses in live-bird L=accepted error or precision (5%), and SD=weighted dis- markets that trade in commercial poultry located in the ease prevalence (%); the total of composite sample of sand greater Jakarta metropolitan area on Java Island, Indone- determined by the double W samplings was 225, took surface sia. Secondary objectives were to identify geographic origin moist sand scraping of 100 grams of sand for each sample e168 14th International Congress on Infectious Diseases (ICID) Abstracts and deposited it in plastic bags; transferred to the labora- 34.033 tory of parasitology of the FMVZ-UAS to be analyzed by the Discovery of reverse zoonotic transmission of pandemic sedimentation technique. H1N1 influenza virus infection in cats following the initi- Results: 45 (20%) of the 225 composite samples of sand ation of a real time sero-molecular epidemiological study and in two of the three beaches were positive to Ancy- ,∗ lostoma spp. J. Trujillo 1 , B. Sponseller 1, A. Jergens 1, T. Pearce 1,E. Conclusion: The contamination with Ancylostoma spp. Strait 1, K. Harmon 1, S. Ramamoorthy 1, C. Prior 2, A. West 3, represent risk for the pets and public health, yet residents as P. Nara 1 visitors ignore about parasitic diseases that dogs can trans- 1 Iowa State University, Ames, IA, USA mit them it is necessary implement control strategies and 2 Park City Animal Clinic, Park City, UT, USA education for the prevention of the infections. 3 Park City Animal Clinic, Park City, UT, USA doi:10.1016/j.ijid.2010.02.1853 Background: Influenza viruses remain the most significant infectious disease One Health concern entering into 34.032 2010. The highly infectious pH1N1 virus is a human host Characterization of Venezuelan field strains of EEEV by adapted virus with unknown host susceptibly that remains RT-PCR and SSCP problematic for pandemic influenza preparedness plans. Atypical hosts provide an opportunity for endemic influenza V.M. Bermudez G. ∗, M.C. Gonzalez, J.M. Ruíz, J. Rivero, F. evolution, a new reservoir host, or a site for future muta- Herrera tional events. Following the discovery of the index case for Central University of Venezuela, College of Veterinary feline pH1N1 infection, we are employing a sero-molecular Medicine, AP-4563, Aragua, Venezuela epidemiological study to monitor infection rates and evolution of this virus at the human-animal contact interface Background: Genetic characterization of three field to advance the understanding of influenza virus evolution in strains of VEEE, by RT-PCR and SSCP shows difference in populations and predict, prevent or curtail emergent events. virulence, antigenic variation and immune response. Two Methods: This study utilizes molecular testing; real time genetic regions of the virus: No Trasnducible RNAm 26S and RT-PCR differential pH1N1 detection assays; virus isolation, a region of the gen nonstructural protein P4 03 (nsP4) might gene sequence analysis for virus detection, typing and viral relate to heterogeneity and behavior of the strains. genomics. Host immune responses are assessed via differen- Methods: EEEV field virulent strains were isolated from tial H1N1 ELISA, and specific hemagglutinin inhibition assays epizootic outbreaks in equines and named: Strain 1 or PAO and virus neutralization assays. from Cojedes State in 2002. Strain 2 or MERCEDES Guárico Results: Our epidemiological study discovered the first State in 1996. Strain 3 or TUCACAS from Falcón State in 1984. two feline cases of pH1N1 infections following apparent Primers from known EEEV were used to copy and to amplify reverse zoonosis from humans. Both cases include cats a fragment of 542 pb of the region No Transducible RNAm older than 10 yrs, clinical signs includ reespiratory dis- 03 26S and another 532 pb fragment of the gen nsP4. Once ease, lethargy and inappetance, 3-5 days following influenza amplified a RT-PCR was run and DNAc of both fragments from like illness in humans. One cat was moderately febrile. each of the three strains were verified and compared by Both cats developed lower respiratory disease character- SSCP. The doble chains of DNAc obtained were denatured ized by a bilateral dorsal alveolar pattern on radiography and turned into single chains by quick heat and cold stress and had lymphopenia. Bronchoalveolar lavage or possibly to promote in chain reassortments or accessory chains. The deep ora-pharyngeal swaps were sufficient for PCR based end products were separated by low amperage PAGE. viral detection. The power of serology in diagnosis will be Results: SSCP of the three strains of EEEV studied showed emphasized. As the study continues, additional cases will be a wide range of band patterns with marked difference in the also be presented. migratory pattern of the reassorted singlets (RSS) reveal- Conclusion: Here we report on the discovery and a diag- ing and showed difference in the migratory patterns of nostic approach of the first pH1N1 virus infection in the the denatured singlet (DSS). This results uncovered that atypical domestic cat which was associated with signif- insertions or deletions of nucleotides took place in the gen icant lower respiratory disease which is similar to more sequence of these strains of EEEV. recent human cases possibly suggesting the discovery of Conclusion: The three field strains of EEEV showed a relevant animal model for future experimental trials genetic polymorphisms in the genome regions studied which with pH1N1 viruses. Moreover these atypical index cases characterize EEEV variants of South America. demonstrate the possible development of new endemic infections of influenza virus in close household or community doi:10.1016/j.ijid.2010.02.1854 human/animal contacts complicating prepardness plans and reinforcing the need for expanding professionally trained comparative clinical scientists via the One Health initiative.

doi:10.1016/j.ijid.2010.02.1855 14th International Congress on Infectious Diseases (ICID) Abstracts e169

Plenary 5 (Invited Presentation) Strategies for Expanding Global Impact of Immuniza- tion Programs (Invited Presentation) Richard K. Root Memorial Lecture 36.001 35.001 Growing burden of dengue in Latin America: A public Transmission and Prevention of Transmission of HIV: Clues health challenge from the Early 21st Century J. Mendez Galvan M. Cohen Hospital Infantil de Mexico Federico Gomez, Mexico City, UNC Chapel Hill, Chapel Hill, NC, USA Mexico HIV is transmitted by blood and blood products, from HIV The evolution of dengue fever and dengue hemorrhagic infected mothers to babies (before and during birth, and fever in the world in the last 50 years shows the lack to through breast milk) and by anal and vaginal intercourse. effective vector control. The re-emergence of dengue fever The sexual transmission of HIV has lead to the majority and the new dengue hemorrhagic form in The Americas has of infections worldwide and this route of transmission has epidemiological, clinical, ecological, political and socioe- great variability in efficiency (∼1/10-1/1000 transmission conomic implications. Insufficient political commitment, events/sexual exposure). Transmission variability reflects inadequate financial resources, increased globalization and viral concentration in the genital secretions of the infected urbanization growth have contributed to change the dengue host, inflammation in the index case or partner, and the sex- situation after 19 Latin American were certified to have ual acts chosen. HIV prevention depends on complimentary eradicated Aedes aegypti. Difficulties begin with diagno- behavioral and biological strategies. Condoms and male cir- sis (clinical and laboratory), which includes asymptomatic cumcision reduce the risk of HIV acquisition. No preventive infections, undifferentiated febrile illness and differential vaccine has been developed, but a recent trial in Thailand diagnosis with other hemorrhagic diseases. Collection of has suggested potential limited protection from infection, appropriate epidemiological data and a true appreciation albeit for a brief period of time. To date all first and sec- of the social and economic impact of dengue are essen- ond generation topical vaginal microbicides have failed to tial to securing social, political and economic commitment provide reliable and significant protection from HIV infec- for dengue control efforts, as well as increased scientific tion, but trials with antiretroviral agents are in progress. and social awareness. In addition, the estimation of cost- The use of oral or topical antiretroviral agents for HIV pre- effectiveness is necessary in order to define the optimal vention is considered pre-exposure prophylaxis (PrEP). More division of resources between traditional dengue vector than 20,000 study subjects are enrolled in trials with oral control and the eventual introduction of dengue vaccines. antiviral agents, especially the combination of tenofovir Furthermore, anticipating the coordination of all the efforts and emtricitabine. It is likely that HIV infected patients to facilitate the regulatory requirements and to develop receiving antiretroviral therapy are less contagious and a vaccination strategies is essential. large randomized controlled trial (HPTN052) has enrolled more than 1500 HIV discordant couples to address this ques- doi:10.1016/j.ijid.2010.02.1857 tion directly. The enthusiasm for ART as prevention has 36.002 led to a ‘‘seek, test and treat strategy’’ now called ‘‘TLC PLUS’’...which requires wider HIV testing (T), linkage (L) Clinical development of tetravalent dengue vaccine for to medical care and delivery of ongoing care (C), PLUS endemic areas emphasis on combined behavioral and biological preven- M. Saville tion strategies for HIV positive people. Several pilot studies designed to implement TLC PLUS are underway worldwide. Sanofi pasteur, Marcy L’Etoile, France HIV transmission has been well-studied and prevenntion A vaccine to protect against dengue disease is sorely strategies are likely to be increasingly successful in the com- needed, particularly for children living in endemic areas ing years. who are most affected by the disease. The safety and immunogenicity of a tetravalent live attenuated dengue vac- doi:10.1016/j.ijid.2010.02.1856 cine containing 5 log10 TCID50 of chimeric yellow fever (YF)/DEN1,2,3,4 viruses (TDV) was tested in children in the Philippines, where dengue is endemic, and in a region of Mexico, where dengue is non-epidemic. In each of two randomized controlled blind-observer phase 1 trials (one per country), 126 subjects 2-45 years old were enrolled, including 72 2-11 yr olds/study. Sub- jects were divided into two groups receiving 1) 3 doses of TDV 2) 1 dose of either Stamaril® YF vaccine (Mexico) or Typhim Vi® (Philippines) followed by 2 doses of TVD. Vac- cines were administered at months 0, 3—4, and 12. Baseline flavivirus serostatus was determined. Vaccine safety and immune response were evaluated after each vaccination. e170 14th International Congress on Infectious Diseases (ICID) Abstracts

No related serious adverse events were observed. The in both developed and developing countries. Improved dis- reactogenicity profile was comparable to that of the con- ease prevention strategies are imperative. In countries with trol vaccines. No increase in reactogenicity was observed: established childhood vaccination programs, studies have in children compared with adults, or after the second or shown that adults are the predominant source of infec- third dose compared with the first. In both non-endemic and tion for infants. Therefore strategies to protect infants now endemic populations, immune responses increased incre- emphasise vaccination of adults, particularly those (eg, par- mentally after each of the 3 doses of TDV and were balanced ents, close household contacts and health-care workers) at against the 4 serotypes after 3 doses. high risk of transmitting infection to infants. A cocoon strat- TDV was well tolerated and immunogenic in children in egy, in which all potential adolescent and adult contacts of both endemic and non-endemic areas with a 3 dose sched- infants are vaccinated, is probably the most cost-effective ule. solution. Postpartum vaccination program of new mothers are doi:10.1016/j.ijid.2010.02.1858 ongoing in the US. The introduction of booster doses in adolescents has been an important step toward decreas- 36.003 ing disease burden. For example, in areas of Canada where Pertussis surveillance and testing: Recommendations Tdap vaccine has been administered to 14- to 16-year- from the GPI olds, marked reductions of pertussis have been observed in adolescents and younger age groups, possibly due to herd C.H. Wirsing von König immunity. HELIOS Klinikum Krefeld, Krefeld, Germany Adult disease in itself is a concern, with the true adult burden estimated at more than 600,000 cases annually in The Global Pertussis Initiative (GPI) was established in the United States. Adults commonly have a persistent cough 2001 to evaluate the ongoing problem of pertussis worldwide for up to 4 months, often requiring medical treatment for and to recommend appropriate pertussis control strategies. the associated morbidity and to reduce the risk of infec- In addition to primary vaccinations, the GPI currently recom- tion to others. Furthermore, it can have significant financial mends pertussis booster vaccination to pre-school children, implications for the patient and society. Evidence suggests adolescents, and those adults at risk of transmitting Bor- that implementation of adult vaccination programs could be detella pertussis infection to infants. The GPI actively highly cost-effective and even cost-saving. This presentation encourages efforts toward global standardization of pertus- will review available data on pertussis vaccination of adults sis disease clinical definitions and diagnostics. At a meeting and adolescents, and assesses the potential impact of such in Paris in January 2010, GPI members discussed pertussis vaccination, both now and in the future. surveillance and testing, and prepared recommendations on the implementation and utilization of these activities. Issues doi:10.1016/j.ijid.2010.02.1860 and projects discussed included: Infectious Disease and Vaccines Development - Advantages and limitations of various national surveil- (Invited Presentation) lance systems; - Seroprevalence studies; 37.001 - Ideal surveillance methodologies; Meningococcal C in Latin America - Ongoing efforts in standardization of real time PCR, culture, serology and sample treatment; E. Berezin - Likely future advances (eg, antibody detection in saliva). Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo SP, Brazil Previous regional meetings of the GPI have confirmed NO ABSTRACT RECEIVED that many countries have limited laboratory facilities for the detection of pertussis. The GPI hopes that the future doi:10.1016/j.ijid.2010.02.1861 introduction of increased laboratory capabilities and greater harmonization of clinical definitions and detection methods 37.002 will lead to enhanced surveillance and a better estimate of Tick-borne encephalitis: Clinical Development of vaccines the burden of pertussis infection worldwide. for Children and Adults ∗ doi:10.1016/j.ijid.2010.02.1859 E.M. Pöllabauer , A. Löw-Baselli, P.N. Barrett, H.J. Ehrlich 36.004 Baxter BioScience, Vienna, Austria Adolescent and adult Pertussis vaccination programs: Are Tick-borne encephalitis virus (TBEV), a member of the they having an impact? family Flaviviridae, causes substantial morbidity and even mortality in endemic areas. The distribution of TBEV cov- T. Ta n ers many countries in Europe and large parts of central and eastern Asia. Although most infections with TBEV are Northwestern University, Chicago, IL, USA asymptomatic, more than 10,000 severe cases are reported Pertussis disease in infancy remains a significant prob- annually, and the incidence has increased considerably dur- lem, with a high risk of serious morbidity and mortality ing the last few decades. Up to 46% of patients are left 14th International Congress on Infectious Diseases (ICID) Abstracts e171 with permanent sequelae such as cognitive or neuropsy- Control of intracellular pathogens has not been achieved, chiatric complaints, dysphasia, hearing defects and spinal except partly with the BCG vaccine against tuberculosis, paralysis. The severity of the disease and the lack of causal and modern efforts are directed towards pathogens against therapy emphasize the need for prevention of tick borne which cellular immune responses are critical. encephalitis (TBE) by vaccination. Inactivated, whole virus Newer approaches in vaccine production such as nucleic TBE vaccines (FSME IMMUN, Baxter and Encepur, Novartis) acid immunization, vectors, reverse genetics and additional are widely used in Europe. In recent years a full clini- routes of administration may circumvent prior difficulties. cal development program, including safety, immunogenicity The target of vaccination will shift towards adolescents, and seropersistence studies has been conducted for FSME- adults, patients in hospital and those with chronic diseases IMMUN in all age groups. Antigen doses of 2.4 ␮g and 1.2 ␮g and possibly will extend to therapy as well as prevention. were identified as optimal for adults and children, respec- The major scientific problems to be solved are maintenance tively. In an ongoing study, the safety and immunogenicity of of immune memory, immaturity and post-maturity of the FSME-IMMUN 0.25 ml Junior and Encepur 0.25 ml Children are immune system, and adjuvants capable of stimulating selec- being investigated in children 1 to 11 years of age. A total of tive cell types. 150 and 152 subjects were enrolled in the FSMEIMMUN and Encepur group, respectively. Immunogenicity was assessed doi:10.1016/j.ijid.2010.02.1863 by two different ELISA assays using antigens homologous to the TBEV strains of either FSME IMMUN (IMMUNOZYM1), or 37.004 Encepur (Enzygnost2). Four weeks after the second vacci- New Technology Update: Cell Culture derived seasonal nation, in the FSME-IMMUN group, 100% of subjects were and pandemic flu vaccine seropositive in both the IMMUNOZYM- (>126 VIEU/ml) and Hartmut J. Ehrlich ∗, P. Noel Barrett the Enzygnost ELISA (>10.32U/ml) compared with 94.0% and 96.7% respectively, in the Encepur group. Geometric Baxter Innovations GmbH, Vienna, Austria mean concentrations (GMC) measured by IMMUNOZYM ELISA were 3026 in the FSME-IMMUN and 678 in the Encepurgroup. The Vero cell line is the most widely accepted contin- GMCs measured with the Enzygnost ELISA were 163.3 (FSME- uous cell line by regulatory authorities and has been used IMMUN) and 93.7 (Encepur). Local reactions after the 1st since decades for the production of, e.g. polio-, rabies- and vaccination occurred in 12.7% with FSME-IMMUN and in 28.9% rotavirus vaccines. Here we report on the clinical charac- with Encepur. The rate of systemic reactions was compara- terization of Vero cell derived inactivated pandemic- and ble: 9.3% (FSME-IMMUN) and 11.8% (Encepur). The presently seasonal influenza vaccines. marketed TBE vaccines represent highly effective tools for A whole virus H5N1vaccine based on (Viet- the prevention of this continuously spreading disease. nam/1203/2004/H5N1, clade 1) was demonstrated to be safe and had an excellent tolerability profile. A dose of 7.5 $g of a non-adjuvanted vaccine formulation was doi:10.1016/j.ijid.2010.02.1862 highly immunogenic and induced antibodies neutralizing 37.003 homologous strains as well as viruses from other H5N1 Strategies for the Development of New Vaccines clades. A booster dose of a heterologous (clade 2) H5N1 vaccine 12-17 months later resulted in enhanced antibody S.A. Plotkin responses against both the original (clade 1) and the booster (clade 2) strain, indicative of .cross-protective memory. University of Pennsylvania and Vaxconsult, Doylestown, PA, A vaccine against the current pandemic H1N1 strain is USA being studied in adults and children. In adults, two doses of The reputation of vaccination rests on a two hundred 7.5$g antigen induced seroprotective HA antibody titers in year old history of success against major infectious dis- 89% - 91% of subjects. An ongoing pediatric study demon- eases. In general, two achievements have been crucial to the strated that after the second dose 100% seroprotection (HI success of vaccines: the induction of long-lasting immunoassay) was attained in the 3-8 and 9-17 year old cohorts. logical memory in individuals and the stimulation of a herd Vero cell derived trivalent seasonal influenza vaccines immunity that enhances control of infectious diseases in (split virion), using wildtype virus seed stocks were devel- populations. However, when one reviews the vaccines now oped and extensively tested in human studies. Their available it is apparent that most successes have been immunogenicity met all licensure criteria, clinical efficacy obtained when the microbe has a bacteremic or viremic was demonstrated and safety profile was comparable to egg phase during which it is susceptible to the action of neu- derived vaccines1. tralizing antibodies, and before replication in the particular organ to which it is tropic. Success has also been achieved against some agents repli- cating on respiratory or gastrointestinal mucosae, against which it has been possible to induce immune responses act- 1 This Project has been funded in whole with Federal (United ing locally as well as systemically. States Government) funds from the Office of the Assistant Secre- tary for Preparedness and Response, Office of Biomdical Advanced Research and Development Authority, under contract NUMBER HHS0100200600013C to DynPort Vaccine Company LLC, a CSC 1 IMMUNOZYM FSME IgG, Progen. company, under No.:S1008307 awarded to Baxter Healthcare Cor- 2 Enzygnost TBE, Dade Behring. poration. e172 14th International Congress on Infectious Diseases (ICID) Abstracts

These data indicate that flexible and versatile Vero cell lems in returned travelers. Some destinations have a higher platform can successfully be in the production of pandemic risk of cutaneous diseases in travelers, such as the Caribbean and seasonal influenza vaccines. and Latin America. The origin of most of these dermatological disorders is due to infection, but some of them are due doi:10.1016/j.ijid.2010.02.1864 to solar allergies and envenomization. The main cutaneous diseases observed in travelers are cutaneous larva migrans, The ill returnee from Latin America (Invited Presen- phytophotodermatitis, complicated mosquito bites, pyoder- tation) mas, miyasis and tungiasis. Risk factors like country of acquisition, age, reason for 38.001 travel, duration of the travel, gender vary according to Febrile Illnesses the disease. Countries within Latin America with higher risk are Jamaica, Dominican Republic, Brazil, Belize and Bolivia. I. Tellez Some risk groups that have been determined for dermato- Emory University, Atlanta, GA, USA logical conditions include short term travelers, those with tourism as the purpose of travel, male and young travelers. Roughly 10% of travelers to developing countries expe- Evaluation of an ill traveler with skin lesions includes very rience a febrile illness during travel or on return. The detailed questions to evaluate the history of exposure, pre- likelihood of developing a medical condition during travel vention measures, immunization, previous treatment and a relates to an individual’s past medical history, travel complete physical examination. Very rarely further diagnos- destination, duration of travel, level of accommodation, tic studies are needed such as blood tests, serology, skin immunization history, adherence to indicated chemopro- biopsies, cultures and imaging techniques. Many cutaneous phylactic regimens, activities during travel, and history of diseases related to travel can be prevented wearing closed exposure to infectious agents prior to and during travel. The shoes, avoiding skin contact with some fruit juices and using risk for acquiring a tropical infection is primarily affected by repellents to avoid insect bites. Use of anti rabies and anti the activities of the traveler. For example, immigrants from tetanus vaccines is also recommended for some destinies developing countries return home to visit friends and rel- and adventure travels. atives (VFR) in their place of birth and usually don’t take preventive therapy for malaria. Long-term expatriates, on doi:10.1016/j.ijid.2010.02.1866 the other hand, have unique risk profiles. Fever is a leading reason for post travel consultation. Careful questioning of 38.003 patients about the pattern of fever and associated symptoms Non-Enteric Helminths Including Cysticercosis is useful. Several papers around the world have reported data about returning travelers with fever. The Geosentinel R. Isturiz has reviewed its data on 24,920 travelers from 1997 to 2006. Centro Medico de Caracas, Caracas, Venezuela They reported that 28% of returned travelers seen at clinics presented with fever as their chief reason for seeking Segmented tapeworms of clinical importance range in medical care. Fever was a marker of a serious illness requir- size from a few centimeters (H. nana and H. diminuta) ing hospitalization. In this report, causes of fever varied by to several meters (T. solium and T. saginata) and utilize region visited and by time of presentation after travel. The humans as definitive hosts, intermediate hosts or both. Gen- exposure history is crucial to the formulation of a differ- erally, adult organisms reside and may produce disease in ential diagnosis. Knowledge of infectious disease outbreaks the gastrointestinal tract and larvae can inhabit and produce like the novel H1N1 Influenza pandemics in a specific region disease in any human tissue. Teniasis results from ingestion where the patient has traveled is very helpful. Travelers of viable metacestodes of either T. solium or T. saginata) to Latin America can be exposed to different infectious and is often asymptomatic, but occasionally serious, life agents that can give a systemic febrile illness. The most threatening illness can result. Cysticercosis is the infection common ones include respiratory tract infections, mononu- by Cysticercus cellulosae, the larval stage of T. solium. Neu- cleosis, dengue, malaria, and typhoid fever. Sometimes no rocysticercosis is the invasion to CNS structures that results specific cause is reported. Laboratory diagnosis has to be in a variety of neurological illness. Echinococcosis is the done promptly and efficaciously to avoid delays in treat- infection by larvae of E. granulosus Cystic), E. multilocularis ment. (Alveolar) and related species (E. vogeli, E. oligarthus, poly- cystic). Major epidemiologic and clinical differences exist. doi:10.1016/j.ijid.2010.02.1865 Diphyllobotriasis (D. latum) is frequent and is transmitted by uncooked freshwater fish. Hymenolepiasis is common in 38.002 warm climates. Dipylidiasis (D. caninum) and sparganosis Cutaneous Diseases in Returnee Travellers from Latin (Spirometra) are much less common. Advances in diagno- America sis, treatment and prevention of these neglected diseases will be reviewed with emphasis in neurocysticercosis. C. Perret Pontificia Universidad Catolica de Chile, Santiago, Chile doi:10.1016/j.ijid.2010.02.1867 Cutaneous diseases are very frequent in travelers. They are ranked in the three most common causes of health prob- 14th International Congress on Infectious Diseases (ICID) Abstracts e173

38.004 39.002 Risks of getting HIV infections and STIs when traveling to Neglected tropical diseases in Latin America and the Latin America Caribbean: Prospects for Control and Elimination G. Lopardo S. Ault FUNCEI, Buenos Aires, Argentina PAHO, Washington, DC Sexually transmitted infections (STIs) including HIV infec- In Latin America and the Caribbean, 180 million people tion are responsible for a variety of acute and chronic live in poverty, and carry most of the burden of neglected medical problems. Travel may interfere with human sexual tropical diseases (NTDs) like soil-transmitted helminthia- practices by splitting fixed sexual partnerships and remov- sis, schistosomiasis, Chagas disease, lymphatic filariasis, ing social taboos. Increased sexual promiscuity and casual onchocerciasis, leishmaniasis, trachoma, rabies, and other sexual relationships are likely to occur during travel because infections of poverty like neonatal tetanus and congenital people have the opportunity to escape from standard behav- syphilis. iors. These neglected diseases are often restricted to the rural In Latin-American countries (LAC) the prevalence of STIs and urban poor and vulnerable and excluded groups like is extremely high. Syphilis has a variable prevalence rate women and children, and indigenous communities. They among sex workers in LAC, ranging from 7% in Panama to 29% adversely affect school attendance, children’s physical and in Santos, Brazil. The same applies for gonococcal infections cognitive development, pregnancy outcome, labor produc- and other STIs. Resistance rates of Neisseria gonorrhoeae to tivity, and/or income-earning capacity, and create social different antibiotics vary according to different countries. stigma. Regarding chronic hepatitis B, seroprevalence for different A comprehensive integrated approach with access to LAC varies between high-endemicity regions like the Ama- diagnostic and treatment tools and an agenda to address zon basin, and low and intermediate areas like Argentina their social determinants. Political commitment from mul- and South Brazil, respectively, determining different risks of tiple sectors is needed to ensure resource availability exposure to travelers. There are no vaccines for STIs, with and international support. To facilitate development of the exception of those for HBV. It is estimated that in the this commitment, the Pan American Health Organization Latin American area there are 2 million people living with (PAHO)/WHO with its partners have recently taken several HIV and AIDS. Brazil accounts accounts for more than 40% major actions. Ten neglected diseases have been mapped of total infections. In some Brazilian cities, more than 60% by PAHO in 14 countries for ‘‘hot spots’’. PAHO partnered of drug users are HIV positive. The most severe epidemics with the Inter-American Development Bank and the Global are found in smaller countries such as Belize, Guyana and Network for Neglected Tropical Diseases to develop a new Suriname, with HIV prevalence rates of 2.1%, 2.5% and 2.4% Regional Fund for control and elimination of NTDs and other respectively. The majority of countries in the region have infectious diseases of poverty. PAHO’s Directing Council prevalence rates of less than 1%, but the prevalence among passed Resolution CD49.R19 (2009) in which Member States specific groups, such as men who have sex with men and sex committed by 2015 to eliminate or reduce those neglected workers, is often very high. Primary resistance rates of HIV diseases for which adequate tools and strategies exist, to vary according to the visited area. levels in which they are no longer public health problems. Screening of asymptomatic travelers who had casual sex PAHO and partners will complete mapping of the distribu- abroad should be encouraged. tion and overlap of neglected diseases in the Region; develop evidence-based guidelines and demonstration projects for doi:10.1016/j.ijid.2010.02.1868 integrated control; develop models to address social determinants; strengthen, scale up and intensify existing Neglected tropical diseases: Present need and programs of control and elimination through technical coop- present action (Invited Presentation) eration; and plan for certification of elimination of diseases like onchocerciasis and lymphatic filariasis which are close 39.001 to elimination in the Region. The WHO global plan to map and combat neglected tropical diseases doi:10.1016/j.ijid.2010.02.1870 L. Savioli 39.003 WHO, Geneva, Switzerland Chagas disease research: Advances and needs NO ABSTRACT RECEIVED Z. Yadon Pan American Health Organization, Washington DC, DC, USA doi:10.1016/j.ijid.2010.02.1869 American trypanosomiasis — a zoonotic disease caused by Trypanosoma cruzi (Protozoa, Kinetoplastida) — is transmitted to humans by blood-sucking triatomine bugs, blood transfusion and congenital transmission. Successful regional vector control programs based on the residual application of insecticide and improved screening of blood donors have e174 14th International Congress on Infectious Diseases (ICID) Abstracts achieved important reductions in the incidence of Chagas in life. The availability of rapid diagnostic tools and dona- disease in many Latin American countries. However, this tions of several drugs from pharmaceutical companies, and approach has been ineffective in some geographic areas the reduced price of other essential antihelminthic drugs such as the Gran Chaco. As a result, the development of has catalysed the rapid expansion of chemotherapy-based effective new tools in these areas to prevent house rein- control programmes for NTDs. The main challenges to PTC festation by triatomine bugs is a high research priority. No in Africa include poor health service infrastructure in post less important is the need of innovative approaches includ- conflict countries and cost-effective approaches for inte- ing those generated from genomics to improve upon existing grating the individual vertical programmes targeting specific diagnostic tests and to develop new parasitological tests diseases. for the early diagnosis of congenital infection in the newborn and in immunocompromised patients, as well as for doi:10.1016/j.ijid.2010.02.1872 the assessment of treatment response (PCR; antigenemia, recombinant antigens,synthetic peptides etc.). There is also Viral diseases (Oral Presentation) a pressing need of developing new anti-T. cruzi agents with high activity in both the acute and chronic phases, and epi- 40.001 demiological methods that me may be used to estimate the Unusual clinical profile of Dengue Infection in patients prevalence of infection, subclinical disease and treatment attending a tertiary care teaching hospital in north India needs in endemic and non-endemic countries. J. Agarwal ∗, G. Kapoor, S. Srivastava, K.P.Singh, R. Kumar, doi:10.1016/j.ijid.2010.02.1871 A. Jain 39.004 C S M Medical University, Lucknow, Uttar pradesh, India Integrated control of neglected tropical diseases in Africa Background: Major outbreaks of dengue virus have been reported from many parts of North India including Luc- M.J. Bockarie know, at regular intervals since 1996. We have carried out a Centre for Neglected Tropical Diseases, Liverpool, United detailed investigation of the Dengue cases occurring in year Kingdom 2008. Methods: Clinically suspected patients attending Pedi- Neglected tropical diseases (NTD) are the ‘other dis- atrics and Medicine outpatient or inpatient Departments and eases’ of Millennium Development Goal 6 that have received referred to Microbiology Department for serological diagno- little attention from policy-makers and politicians who sis of dengue, were prospectively enrolled after obtaining over focus on HIV, tuberculosis and malaria. They include verbal consent. Detailed clinical history and examination many medically diverse diseases that are strongly associ- findings were recorded in a pre designed questionnaire from ated with poverty. NTDs include bacterial, viral, protozoan 398 such patients between Jan 2008 to Dec 2008. Dengue and helminth infections that have plagued humanity since specific antibodies were detected using commercial Mac- antiquity. Globally, over one billion people suffer from one ELISA kit (IVD, USA). Results of hematological and other or more NTDs and about 500,000 people die from them every investigations were noted from medical records. year. Results: Mean age of patients’ was10.25 ± 10.9 years and Neglected Tropical Diseases are widespread in Africa due, 328/398 were in pediatric age group (%12 yrs age). A total of in part, to the low socio-economic status of rural popula- 53.26% (212/398) patients were positive for dengue IgM and tions. Many countries are endemic with of 5 or more NTDs 93% of these were admitted patients. Male: Female ratio including schistosomiasis, soil-transmitted helminths (STH), was1.8:1 and ∼74% belonged to rural area. Overwhelming lymphatic filariasis, onchocerciasis and trachoma, as well majority (92%) of dengue cases were seen between July as zoonotic disease such as human African trypanosomiasis, to November, which are the post monsoon months in this rabies, tick borne relapsing fevers, echinococcus (hydatid), part of world. Frequent clinical features included fever taeniosis (cysticercosis), brucellosis and plague, with a large (100%) with mean duration of 14.07 ± 9.2 days, edema (50%), part of the population at risk of co-infection with 2 or more altered sensorium (39%), rash (31.84%). Mucosal bleeding, of these diseases. hepatomegaly and splenomegaly were present in 31.84%, Fortunately, control strategies as well as diagnostic tools 57.29% and 56.25% respectively. Thrombocytopenia (58.74%) and the availability of safe and effective drugs exist for the was common laboratory finding. Liver enzymes SGPT and NTDs responsible for the greatest burden in Africa: lym- SGOT were raised in 72.55% and 78.43% of positive cases, phatic filariasis, onchocerciasis, STH and schistosomiasis. respectively. Presentation varied between adults and pedi- The World Health Organization has developed a strategy, atric populations, while among adults, seizure (p=0.029), Preventive Chemotherapy and Transmission Control (PCT), skin rash (p=0.029), abdominal pain (p=0.005) and hemo- which is geared towards the implementation of large-scale concentration (PCV > 36; p=0.063) were significant findings; mass drug administration. The objective of PCT is to pro- however in children, headache (p=0.029), serum sodium vide national programmes with technical guidelines that and calcium levels (p=0.022 and p=.0006) were signif- emphasize a coordinated, cost-effective approach to the icantly raised. Logistic Regression analysis found serum implementation of national elimination and control activ- SGOT>40 U/L and presence of splenomegaly as independent ities where preventive chemotherapy is the main tool, i.e. predictors for dengue infection. Only 3 cases met the WHO regular anthelminthic drug administration to all people at criteria for dengue haemorrhagic fever (DHF), however clin- risk of morbidity due to helminthic diseases, starting early ically ∼20% of the dengue positive cases were labelled and 14th International Congress on Infectious Diseases (ICID) Abstracts e175 managed as DHF. Mortality rate amongst dengue IgM posi- Conclusion: This is one of the first recognized civil- tives was 6.02% (5/83). ian community outbreaks of HAdV-14 since the virus first Conclusion: The unusual clinical profile necessitates appeared in California in 2003. Demographic characteristics continuous sero surveillance and monitoring for changing and illness patterns in case-patients were similar to those clinical presentationof dengue infection. observed in other HAdV-14 outbreaks in Oregon and Wash- ington State in 2007, with disease mostly occurring in adult doi:10.1016/j.ijid.2010.02.1873 male smokers. In this setting, HAdV-14 appeared to have spread mostly among close contacts in the home or within 40.002 a certain social network whose members often reported An outbreak of pneumonia associated with emergent smoking or sharing smoking materials with other HAdV-14 human adenovirus serotype 14 - Southeast Alaska, 2008 case-patients. Lack of HAdV-14 infection in controls and their household contacts suggests wide-spread transmission D. Esposito 1,∗, T.J. Gardner 2, E. Schneider 1, L.J. did not occur, either previously or during this pneumonia Stockman 1, J. Tate 1, C.A. Panozzo 1, C.L. Robbins 1, outbreak. S.A. Jenkerson 2, L. Thomas 3, C.M. Watson 4, A. Curns 1, D.D. Erdman 1,X. Lu1, T. Cromeans 1, M. Westcott 5, doi:10.1016/j.ijid.2010.02.1874 C. Humphries 5, J. Ballantyne 5, G.E. Fischer 1, J.B. McLaughlin 2, G. Armstrong 1, L.J. Anderson 1 40.003 1 Centers for Disease Control and Prevention, Atlanta, GA, Uptake and impact of Rotavirus vaccines in US Children USA J. Cortes 1, D. Esposito 1, M. Cortese 2, D. Bartlett 2,J. 2 Alaska Department of Health and Social Services, Anchor- Tate 2, D. Payne 2, M. Patel 2, A. Curns 2, J. Gentsch 2,U. age, AK, USA ,∗ Parashar 1 3 Alicia Roberts Medical Center, Klawock, AK, USA 4 Craig Public Health Center, Craig, AK, USA 1 CDC, Atlanta, GA, USA 5 Alaska State Public Health Virology Laboratory, Fairbanks, 2 CDC, NCIRD, Atlanta, GA, USA AK, USA Background: In 2006 and 2008, two new vaccines were Background: In September 2008, an outbreak of pneumo- recommended for routine vaccination of US infants against nia associated with a rare human adenovirus (serotype-14 rotavirus. We assessed vaccine uptake and its impact on [HAdV-14]) occurred on a rural island in Southeast Alaska. rotavirus disease in US children. To determine risk factors for disease and household trans- Methods: To measure vaccine uptake, we examined data mission characteristics, we investigated pneumonia cases in from sentinel immunization information system (IIS) sites three affected island communities. in eight different US locations. Coverage with at least 1 Methods: Case-patients were island residents who pre- dose of rotavirus vaccine was measured at age 5 months, sented to one of two medical clinics with clinical or and compared with coverage of other established child- radiological evidence of pneumonia between September 1 hood vaccines, DTaP and pneumococcal vaccine, given at the and October 27, 2008. Controls from the community were same age. To measure vaccine impact, we examined data matched 1:1 to case-patients based on age, sex, and com- from 2000-2009 on laboratory detections of rotavirus from munity of residence. Case-patients, controls, and household a national network of ∼70 laboratories to assess trends and contacts were interviewed for information on demograph- timing of rotavirus activity. Data from a subset of 29 labo- ics, recent illnesses, medical history, ill contacts, and other ratories that consistently reported for ≥30 weeks for each possible exposures. Serum and respiratory specimens were season during 2000-2009 were used to measure national and also collected. Risk factors for pneumonia were determined regional changes in rotavirus test results. using exact multivariate conditional logistic regression. Results: By March 2009, coverage with 1 dose of rotavirus Household HAdV-14 attack rates were calculated. at age 5 months has reached about 60%-70% across most Results: Thirty-two pneumonia case-patients and 32 of the IIS sites, a level that is about 10%-20% lower than matched controls were interviewed. Among case-patients, that of DTaP and pneumococcal vaccine. Concurrent with the median age was 47.5 (range, 2-95 years), 75% were increasing rotavirus vaccine coverage, rotavirus activity dur- male, and 74% were Alaska Native. Nine cases resulted ing the 2007-2008 and 2008-2009 rotavirus seasons declined in hospitalization and there was one death. Twenty-one by 64% and 60%, respectively, compared with pre-vaccine (66%) case-patients and no controls were infected with years during 2000-2006. In addition, compared with prevac- HAdV-14 (p < 0.001). Independent risk factors for pneu- cine years, the onset of both the 2007-2008 and 2008-2009 monia were contact with a known HAdV-14 pneumonia rotavirus seasons was delayed by 11 weeks and 6 weeks, case-patient (OR = 18.3, 95%CI = 2.0-&), current smoking respectively, and the seasons were shorter, lasting 14 and 17 (OR = 6.7, 95%CI = 0.9-&), and having neither traveled off- weeks, respectively, compared with 26 weeks in 2000-2006. island nor attended at a large public gathering (OR = 14.7, Regional differences in rotavirus activity were observed, 95%CI = 2.0-&). Fourteen (67%) of the 21 HAdV-14-infected with the West census region having a lower reduction and case-patients belonged to a single network of people who less delayed onset than all other regions in 2007-2008 and a socialized and often smoked together and infrequently trav- greater reduction and more delayed onset than other regions eled off-island. HAdV-14 infection occurred in 43% of case- in 2008-2009. versus 5% of control-household contacts (p = 0.005). Conclusion: Uptake of rotavirus vaccine in US children has increased since vaccine implementation. However, e176 14th International Congress on Infectious Diseases (ICID) Abstracts rotavirus vaccine coverage remains slightly lower than that 2008 season. Although many factors must be considered by a of other established childhood vaccines and factors that country prior to the decision to introduce vaccine nationally, might account for this difference should be examined. Fol- these data underscore the substantial burden of rotavirus lowing rotavirus vaccine introduction, rotavirus activity in disease on the Guatemalan healthcare system.This active US children has declined and disease seasonality has been population-based surveillance system will provide a solid altered compared with prevaccine years. Factors that might platform for the assessment of rotavirus vaccine impact explain the regional differences in changes in rotavirus after introduction. activity after vaccination should be explored. doi:10.1016/j.ijid.2010.02.1876 doi:10.1016/j.ijid.2010.02.1875 40.005 40.004 Surveillance for epidemic of enterovirus infections in Tai- The epidemiology of rotavirus disease among children <5 wan in 2008 years of age - Santa Rosa, Guatemala, 2007-2009 S.-K. Lai, C.-C. Huang, C.-H. Jiang, Y.T. Tsai, H.-L. Chang, J. Cortes 1,∗, W. Arvelo 1, B. lopez 2, L. Reyes 3, B. Gordillo 4, J.-H. Chuang ∗ U. Parashar 5, K. Lindblade 1 Centers for Disease Control, Taipei City, Taiwan, R.O.C 1 Centers for Disease Control and Prevention, Atlanta, GA, Background: The emergence of enterovirus 71 (EV71) in USA Taiwan in October, 2007 resulted in a large epidemic of 2 Centers for Disease Control and Prevention, Guatemala hand-foot-and-mouth disease (HFMD) or herpangina in young City, Guatemala children in 2008. EV71 patients may suffer from serious neu- 3 Guatemala Ministry of Public Health and Social Assistance, rological complications or even deaths. The aims of this Guatemala City, Guatemala study were to describe the framework of the surveillance 4 Ministry of Public Health and Social Assistance, Guatemala systems for enterovirus infections and to characterize this City, Guatemala epidemic in Taiwan in 2008. 5 CDC, Atlanta, GA, USA Methods: At Taiwan Centers for Disease Control (Tai- Background: Diarrhea is the second leading cause of wan CDC), there were four systems established for the death in Guatemalan children <5 years of age. To evalu- surveillance of enterovirus infections. First, we used the ate the potential health benefits of new vaccines against sentinel surveillance with more than 650 clinics for report- rotavirus, we assessed the burden of rotavirus diarrhea in ing the number of HFMD or herpangina in outpatient weekly. Guatemalan children. Second, the National Notifiable Disease Surveillance Sys- Methods: We examined data from an active population- tem (NNDSS) was used for reporting the hospitalized cases based surveillance system in Santa Rosa, Guatemala from with severe complications. Third, the laboratory surveil- October 2007 through September 2009 among children <5 lance consisted of 13 contract laboratories and 286 clinics years of age presenting to the hospital or ambulatory clinics. for testing and collecting samples, respectively. Fourth, Tai- Specimens were collected from patients with acute diar- wan CDC cooperated with the University of Pittsburgh to rhea (≥3 loose stools in 24 hours during last seven days) develop a syndromic surveillance, which is called the Real- and tested for rotavirus via enzyme immunoassay. Geno- time and Outbreak Surveillance (RODS) system, covering 80% typing via reverse-transcriptase polymerase chain reaction of the emergency visits nationally. The Taiwanese RODS sys- was performed on rotavirus positive specimens. Results were tem used the ICD-9-CM code of 074.0 and 074.3 to monitor stratified by age group and setting. enterovirus infections. A web-based decision support sys- Results: 906 patients identified with diarrhea during the tem for this epidemic was also developed for displaying the study period provided a fecal specimen for rotavirus testing. statistics and epidemic curves of the four systems in real Of the specimens tested, 291(35%) were hospitalized and time. 615 (74%) were ambulatory patients. Rotavirus accounted Results: The epidemic started in week 11, peaked in for 90 (33%) hospitalizations and 57 (9%) ambulatory vis- week 25, and was subsiding gradually. The sentinel physi- its for diarrhea annually. Rotavirus confirmed episodes had cians reported 72,610 visits in one epidemic wave, which a marked seasonality as 80% (N = 72) of cases occurred represents 18% of the ones nationally. 373 cases of severe in January and February. During these months, rotavirus complications (including 14 deaths) were reported through accounted for 59% of hospitalizations and 31% of ambula- the NNDSS. Among those, 347 cases (93%) were EV71. A tory visits for diarrhea. More than 85% (N = 123) of children web-based system with automated updates daily for the with rotavirus were <24 months. During the 2008 rotavirus public to browse the statistics and epidemic curves of the season, the predominant rotavirus genotype identified in 15 reported cases in the NNDSS was also released then. There of 27 (56%) samples tested was G1P8. Less common strains were 11,150 specimens tested and 3,724 (33%) enterovirus including 5 (19%) of the G12 genotype were also observed. isolated in the laboratory surveillance. The three most iso- Conclusion: This analysis highlights the prominent role of lated types were Coxsackie A2 (CA2), EV71 (B5 was the rotavirus as a cause of severe diarrhea in children <5 years of major subtype), and Coxsackie B4 (CB4). The real-time data age in Santa Rosa, Guatemala. Currently available vaccines from the RODS helped us better track the trend of the against rotavirus have demonstrated high effectiveness in epidemic. preventing severe disease caused by the predominant cir- During the large epidemic of enterovirus infections, our culating strain (G1P8) identified in Guatemala during the established surveillance systems are helpful for informing 14th International Congress on Infectious Diseases (ICID) Abstracts e177 decisions about control measures, resource allocation, and 40.007 risk communication in real time. Dengue fever outbreak in Lima, Peru 2009: Epidemiolog- ical changes in urban areas doi:10.1016/j.ijid.2010.02.1877 M. Loayza ∗, G.A. Cisneros, L. Loro, G. Yale 40.006 Ministerio de Salud, Lima, Peru Epidemiology of varicella among passengers and crew on international conveyances, United States, 2005-2008 Background: Dengue fever is endemic in Peru. The epidemic potential for dengue transmission north of Lima city P. Szymanowski 1,∗, H. Lipman 2, D. Fishbein 3, C. Chandra 4 has spread alarmingly in the last four years. A dengue out- 1 SRA International Contractor to CDC, Atlanta, GA, USA break occurs during March to June 2009 in three districts 2 Centers for Disease Control and Prevention, Atlanta, GA, of Lima. The 2005 and 2007 outbreaks of dengue fever USA occurred in these districts only one circulating serotype in 3 Centers for Disease Control and Prevention, 30333, GA, each outbreak. Epidemiological investigation was conducted USA to determine the distribution of cases, serotype circulation, 4 CDC Internship Program, Atlanta, GA, USA symptoms and signs of dengue fever in order to identify transmission and epidemic control measures. Background: Although the incidence of varicella in the Methods: Analysis of cases of the outbreak investigation United States has decreased markedly since a national conducted by the network of epidemiology at the Depart- vaccination program was implemented in 1995, CDC Quar- ment of Health V Lima City. The information was collected antine Stations continue to receive frequent reports of and processed through software NotiSp. Suspected case was varicella among international travelers. However, few pub- considered a person with a history of fever for 2 to 7 days lished reports are available on the the epidemiology of and two or more of the following symptoms: headache, varicella in travelers. Our objective was to describe the epi- retroocular, myalgia, arthralgia, rash and hemorrhagic man- demiology of varicella on international conveyances and to ifestations residing in the districts of Carabayllo, Comas and identify risk factors associated with illness. Independence. The cases were registered in epidemiological Methods: We reviewed reports of varicella captured by records, blood samples were taken to determine seroconver- the CDC Quarantine Activity Reporting System (QARS) from sion and identification of circulating serotypes. June 2005 - December 2008. A stepwise backward elimi- Results: Of 552 cases suspects, 148 (26.8%) were positive nation logistic regresion model (inclusion criterion: alpha for IgM antibody detection of specific dengue indicating pri- <0.05) was used to compare risk factors for varicella with mary infection and 99 cases were obtained by PCR serotypes: those for all other illnesses in travelers during the same DEN-3 (74%), DEN-1 (24%) and DEN-4 (2%). Most cases (45%) time period, including demographic characteristics, con- were adults between 20 and 59 years of age. The median age veyance time (maritime versus air or land [pedestrian, car, was 34 years. Women were more affected than men (56% and bus, train]), season and year of report, and type of traveler 44% respectively). The most frequent symptoms were fever (passenger or crew). (95%), headache (90%), body ache (86%), bone pain (75%) and Results: Of 3908 illness reports during the study period, pain retroocular (70%). The outbreak investigation revealed 446 (11.4%) met the case definition for varicella. Odds of a cluster of four clusters that could be because they have reported varicella were higher on maritime conveyances areas favourable for breeding of the vector, such as pres- (odds ratio [OR] = 38.3; 95% confidence interval [CI], 22.0 ence of disposable plastic containers, clearing rocks, water - 66.5) and in travelers born in tropical countries (OR = 2.3; shortages and the migration of people to Lima from dengue CI, 1.4 - 3.6), males (OR = 1.5; CI, 1.02 - 2.3), and younger endemic areas. travelers (for a 1-year decrease in age, OR = 1.08; CI, 1.06 Conclusion: The outbreak investigation confirmed the - 1.10). Odds of varicella reporting were lower in the fall presence of dengue as an emerging public health problem (OR = 0.30; CI, 0.16 - 0.54). There were no statistical differ- in Lima, identifying the co-circulation of three serotypes, ences between varicella and non-varicella illnesses by type demonstrating dengue epidemiological changes, so it is of traveler (crew member, passenger), race and ethnicity important to strengthen surveillance actions epidemiolog- (Hispanic, non-Hispanic), or year of report. ical and vector control in these areas during the coming Conclusion: The higher incidence of varicella reporting years. by maritime conveyances compared with other conveyances may be due to the large number of unvaccinated crew doi:10.1016/j.ijid.2010.02.1879 members originating from tropical countries where varicella commonly occurs in adults. Maritime vessels, compared with other conveyances, may also achieve more complete case finding because of the extended periods of time crew live aboard the vessels. The availability of a vaccine for varicella means that most cases could be prevented, and vaccination should be considered for crew members on maritime conveyances without documented immunity to varicella. doi:10.1016/j.ijid.2010.02.1878 e178 14th International Congress on Infectious Diseases (ICID) Abstracts

40.008 the different occurrence of infections with the high risk HPV Risk of being seropositive for multiple HPV types among types in Finland and Uganda. Finnish and Ugandan women doi:10.1016/j.ijid.2010.02.1880 P.B. Namujju 1,∗, H.-M. Surcel 1, P. Koskela 1, E.K. Mbidde 2, M. Muwanga 3, R. Byaruhanga 4, C. Banura 5, M. Kaasila 1,R. 40.009 Kirnbauer 6, M. Lehtinen 7 A phase 3 study of a short, two dose regimen of an investigational Hepatitis B vaccine 1 National Institute for Health and Welfare, Oulu, Finland 2 Uganda Virus Research Institute, Entebbe, Uganda J. Martin 1,∗, S. Halperin 2, F. Diaz-Mitoma 3 3 Entebbe Hospital, Entebbe, Uganda 1 4 St. Francis Hospital, Nsambya, Kampala, Uganda Dynavax Technologies, Berkeley, CA, USA 2 5 Makerere University, Kampala, Uganda Dalhousie University, Halifax, NS, Canada 3 6 Medical University Vienna, Vienna, Austria Herridge Clinic, Ottowa, ON, Canada 7 University of Tampere, Tampere, Finland Background: Achieving rapid protection against hepatitis TM Background: Although infections with multiple HPV types B can be critical for travellers. HBsAg-ISS (HEPLISAV )isan have been readily reported, more information is needed for investigational vaccine containing Hepatitis B surface anti- occurrence of the different types at individual or at the gen (HBsAg) and 1018 Immunostimulatory Sequence (ISS), a population level, e.g., across countries Objective: We deter- Toll-like Receptor 9 (TLR9) agonist adjuvant. A Phase 3 study mined the distribution of seroprevalences to multiple HPV of subjects 18-55 years of age demonstrated non-inferiority types in Finland and Uganda to compare epidemiology of the of a short, 2 dose regimen of HBsAg-ISS to a 3 dose reg- different HPV types in the two populations. imen of a licensed vaccine. This analysis in subjects >40 Methods: Cross-sectional seroprevalence study of ante- years of age compares the seroprotection rate (SPR), mea- ≥ natal clinic attendants. In Finland serum samples were sured by antibody to HBsAg [anti-HBsAg] 10 mIU/mL, and randomly drawn from a subset of samples collected between anti-HBsAg geometric mean concentration (GMC) of HBsAg- 1995 -2007 for the Finnish Maternity cohort and in Uganda, ISS with licensed vaccine (Engerix-B, 20 mcg). This study samples were collected (between 2004-2008) from women demonstrated that the SPR of a short, 2 dose regimen of enrolled after consenting. The serum samples were stored HBsAg-ISS in subjects 18-55 and in subjects over 40 is supe- and analysed for HPV antibodies against seven HPV types; 6, rior to the standard regimen of Engerix-B. This vaccine could 11, 16, 18, 31, 33, and 45 using direct VLP ELISA. provide a better solution for clinicians needing rapid, safe Results: Sera were analysed for 2 784 Finnish and 1 964 and effective protection against hepatitis B disease for trav- Ugandan women (mean ages 22 and 25 years) of whom 44% elers. and 57% had antibodies to at least one of the seven HPV Methods: A randomized observer-blind study comparing types (6/11/16/18/31/33/45) tested (p < 0.001). Multiple 2 doses of HBsAg-ISS at months 0 and 1 with saline placebo HPV antibody positivity was common. Finnish women, who at month 6 to 3 doses of licensed vaccine at months 0, 1, were HPV45 seropositive (F-HPV45), had higher adjusted and 6. Anti-HBsAg were measured at months 0, 1, 2, 3, 6, risk estimates of having antibodies to most of the other and 7. Safety, including local and systemic reactogenicity HPV types (HPV18, 31 and 33) than comparable Ugan- and adverse events was assessed. dan women (U-HPV45): F-HPV45:HPV18 (OR = 10.9, 95% CI Results: 2101 subjects, including 1188 subjects over age 5.3-23) vs. U-HPV45:HPV18 (OR = 3.4, 95% CI 2.3-5.0), F- 40, were included in the per-protocol analysis in a 3:1 ran- HPV45:HPV31 (OR = 6.1, 95% CI 2.8-13.4) vs. U-HPV45:HPV31 domization of HBsAg-ISS to Engerix-B. The primary endpoint (OR = 2.2, 95% CI 1.6-3.0), and F-HPV45:HPV33 (OR = 12.2, SPR for all subjects was statistically signiﬁcantly higher for 95% CI 5.8-26) vs. U-HPV45:HPV33 (OR = 3.3, 95% CI 2.4- HBsAg-ISS (95% at month 3) vs. Engerix-B (81% at month 4.5). This was true also for antibodies to HPV31 and HPV33 7) [p < 0.0001]. For subjects over age 40 the primary end- among HPV18 seropositive Finnish women (F-HPV18) vs. point SPR was 92% for HBsAg-ISS and 75% for Engerix-B) HPV18 seropositive Ugandan women (U-HPV18) albeit with [p < 0.0001]; the GMC (mIU/mL) at month 7 was 236 for somewhat overlapping conﬁdence intervals: F-HPV18:HPV31 HBsAg-ISS and 218 for Engerix-B. HBsAg-ISS was safe, well- (OR = 5.2, 95% CI 3.0-9.0) vs. U-HPV18:HPV31 (OR = 3.1, 95% tolerated and comparable to Engerix-B with regard to local CI 2.2-4.4), F-HPV18:HPV33 (OR = 6.9, 95% CI 4.1-11.7) vs. U- and systemic adverse events and serious adverse events. Two HPV18:HPV33 (OR = 3.3, 95% CI 2.3-4.6). In general, among cases of ANCA-associated vasculitis were observed; one in an the HPV16 seropositives increased risk estimates for being HBsAg-ISS subject and one in an Engerix-B subject. A review seropositive for a second HPV type were observed but major of AEs potentially associated with autoimmune conditions differences were not observed between the Finns and the revealed no difference between groups. Ugandans. Conclusion: This study demonstrated that the SPR of a Conclusion: We observed remarkably increased risk esti- short, 2 dose regimen of HBsAg-ISS in subjects 18-55 and mates for being double HPV antibody positive among HPV45 in subjects over 40 is superior to the standard regimen of and HPV18 seropositive Finns as compared to the Ugandans. Engerix-B. This vaccine could provide a better solution for In conclusion, biological, behavioral factors, iatrogenic and clinicians needing rapid and safe protection against hepatitis societal factors (screening vs no screening) may result in B disease for travelers.

doi:10.1016/j.ijid.2010.02.1881 14th International Congress on Infectious Diseases (ICID) Abstracts e179

Carbapenemase-producing bacteria: The threat of 41.002 ‘Panresistance’ (Invited Presentation) Clinical Impact and Current Epidemiology of Carbapene- 41.001 mase producers Detecting Carbapenemase Producers in the Clinic K. Thomson C. Giske Creighton Unviversity School of Medicine, Omaha, NE, USA Karolinska University, Stockholm, Sweden Carbapenemase-producing pathogens have become a major and increasing infectious disease threat. Their most Carbapenem resistance among Klebsiella pneumoniae,is serious impact is the lack effective therapies for the infec- increasing in many parts of the world, and the treatment tions they cause. Given that laboratory detection is often options for such strains are very limited. The mechanisms poor, our understanding of their epidemiology is incom- are mainly transferable carbapenemases of K. pneumoniae plete. Some types of carbapenemase producers are already carbapenemase (KPC) or metallo-betalactamase (MBL) type ubiquitous. For other types, there are known hotspots of (mainly VIM), but also OXA-48 carbapenemases, as well as occurrence. KPC producers are mostly detected in the extendedspectrum beta-lactamases or AmpC in combination eastern USA and Israel, but have also been detected in with porin loss. Infection control is of crucial importance for some European and Asian countries. Metallo-␤- lactamase combating such resistance, and depends on adequate detec- (MBL) producers mostly occur in Asia, Europe, Australia tion of carbapenemase-producing isolates. Several authors and South America. OXAcarbapenemase have been detected have reported on problems of detecting such isolates, and worldwide. The most rapidly spreading pathogens are the reasons and possible solutions are discussed. probably Acinetobacter baumannii that produce OXA car- Carbapenem-producers have carbapenem MICs below the bapenemases and KPC-producing Klebsiella pneumoniae. current clinical breakpoints of EUCAST and CLSI. However, However, these enzymes also occur in species that are EUCASTs epidemiological cut-offs (ECOFFs) values, the limit less closely monitored, e.g. OXA-producing Enterobacteri- of the wild-type populations, have been found useful to aceae and KPC-producing A. baumannii and P. aeruginosa. identify such carbapenemase-producers. Disk diffusion cor- There appears to be less rapid spread of Enterobacteriaceae, relates to the current MIC ECOFFs are under development, Pseudomonas aeruginosa and Acinetobacter that produce and seem to be working equally well with the tentative transmissible MBLs, but this observation may be a reflection zone ECOFFs. In particular meropenem and ertapenem proof suboptimal laboratory testing rather than reality. Prompt duce a good separation between wild-type isolates and and accurate laboratory detection is critical. Outbreaks carbapenem-producers. Automated antimicrobial suscepti- and therapeutic failures have resulted from testing prob- bility testing (AST) systems will in most cases detect all lems. Another problem is that carbapenemase producers, carbapenemaseproducers when using ECOFFs actively when especially K. pneumoniae and A. baumannii, are efficient reading the quantitative AST results. scavengers of additional resistance mechanisms and, as a Phenotypic tests for confirmation of carbapenemase- consequence, are constantly changing. In this sense, they production comprise the modified Hodge test (MHT), and are a ‘‘moving target’’ and contemporary understandings in-house combination disks containing carbapenems in com- may have reduced relevance to the therapeutic, diagnostic, bination with boronic acid (for KPC detection) or zinc and infection control challenges of the future. The current chelators (for MBL-detection). The MHT has high sensitiv- needs are for effective therapies, effective infection control ity for detection of KPC, but lower for MBL. Also, there are based on better detection, education of health care profes- problems with specificity, mainly with AmpC hyperproduc- sionals, and for research to provide better understandings ers. The combination disk method has recently been updated of the biology of these pathogens. with the addition of cloxacillin as a third inhibitor,in order to separate AmpC hyperproduction plus porin loss (synergy with doi:10.1016/j.ijid.2010.02.1883 cloxacillin and boronic acid) from KPC (synergy with boronic acid only). Further, dipicolinic acid has better specificity for 41.003 MBL-detection than EDTA. Controlling the Spread of Carbapenemase-Producing Bac- Although the above mentioned recommendations seem teria to identify carbapenemase-producers among K. pneumoniae, it is still uncertain whether they will be adequate M. Schwaber for detection of carbapenemases in other species of Enter- National Center for Infection Control, Tel Aviv, Israel obacteriaceae. Further, there are still concerns regarding detection with automated AST-systems. Detection depends Background: During 2006, Israeli hospitals faced a on the carbapenems included in the test. clonal outbreak of carbapenem-resistant Klebsiella pneumoniae, producing the serine carbapenemase KPC-3. doi:10.1016/j.ijid.2010.02.1882 Locally-implemented infection control measures in affected hospitals failed to contain spread. A nationwide intervention was launched to contain the outbreak and introduce a strategy to control future dissemination of antibiotic-resistant bacteria in hospitals. Methods: In March 2007, the Ministry of Health issued guidelines mandating physical separation of hospitalized e180 14th International Congress on Infectious Diseases (ICID) Abstracts carriers of carbapenem-resistant Enterobacteriaceae (CRE) tions caused by VIM-producing K. pneumoniae, the lowest and dedicated staffing, and appointed a professional task mortality was observed in the group of patients who had force charged with containing spread of the epidemic strain. received combination therapy with two active drugs, one The task force paid site visits at acute care hospitals, eval- of which was a carbapenem and the other either colistin or uated infection control policies and laboratory methods, an active aminoglycoside, whereas therapy with one active supervised adherence to the guidelines via daily census drug resulted in a mortality similar to that observed in reports on carriers and their conditions of isolation, provided patients who had received therapy with no active drug. regular feedback on performance to hospital directors, and Based on this experience, it remains doubtful whether intervened additionally when necessary. During 2008, the monotherapy with a carbapenem would be effective in the intervention was extended to long-term care facilities, and treatment of such infections. On the other hand, carbapen- in June 2008 national guidelines for active surveillance were ems in combination with another active agent may provide issued. The primary outcome measure was the incidence some therapeutic benefit against MBL-positive carbapenem- of clinically diagnosed nosocomial CRE cases in acute care susceptible Enterobacteriaceae. In this respect, the issue of hospitals. either reporting such isolates as fully resistant to carbapen- Results: By March 2007, over 1200 patients were affected ems or consider the respective MICs at face value should in acute care hospitals. Prior to the intervention, the remain open. In conclusion, information about how to treat monthly incidence of noscomial CRE climbed steadily, peak- infections caused by CPGN is surprisingly scarce. ing at over 180 cases. Crude 30-day mortality was > 30%. With the intervention, the continuous rise in incidence of doi:10.1016/j.ijid.2010.02.1885 CRE acquisition was halted, and at the end of the 14-month initial intervention period the number of new monthly cases Session: Plenary 6 (Invited Presentation) was 46. Following the introduction of active surveillance guidelines, monthly incidence fell further, reaching a low 42.001 of 24 as of October 2009. A direct correlation was observed Malaria Eradication between compliance with isolation guidelines and success in containment of in-hospital CRE transmission. C.V. Plowe Conclusions: A centrally-coordinated public health inter- University of Maryland School of Medicine, Baltimore21201, vention has succeeded in containing a nationwide outbreak MD, USA of CRE in Israeli hospitals after local measures failed. The intervention demonstrates the importance of strategic A global campaign to eradicate malaria in the middle planning and national oversight in combating antimicrobial of the last century relied chiefly on two powerful tools, resistance. insecticide spraying of mosquitoes to interrupt transmission and chloroquine treatment to reduce the human reservoir doi:10.1016/j.ijid.2010.02.1884 of infection. While this effort, led by the World Health Organization, did succeed in eliminating malaria from some 41.004 areas on the edges of the malaria map, it was aban- Treatment Options for Carbapenenam Resistant Infections doned as a failure after little more than a decade. The emergence of insecticideresistant Anopheles mosquitoes G. Daikos and drug-resistant Plasmodium falciparum parasites, failure University of Athens, Athens, Greece to understand and adapt to local differences in mosquito ecology and malaria epidemiology, and donor fatigue, all Carbapenemase producing Gram-negative bacteria contributed to the demise of the campaign, which never (CPGN) become increasingly prevalent and cause serious included Africa, the region with by far the greatest malaria infections resulting in high fatality. These organisms are burden, then and now. In the ensuing decades, the focus resistant, not only to almost all available !-lactam antibi- shifted from eradication to control, and worldwide malaria otics but also to other classes of agents, leaving tigecycline deaths increased in the face of chloroquine resistant falci- and colistin as the only therapeutic options. None of parum malaria and weak health care systems. these agents, however, is ideal; tigecycline produces low The development and deployment of two new tools, blood levels and colistin has questionable performance in long-lasting insecticide-treated nets and artemisinin-based serious infections owing to poor pharmacokinetics. More combination drug treatments, have led to dramatic reduc- worryingly, resistance to both of these compounds has been tions in malaria in several countries, including some developed. The newer !-lactamase inhibitors, NXL 104 and in Africa. Malaria has even been completely eliminated BAL 30376, show promises for infections caused by CPGN. A recently from some endemic areas with low levels of trans- proportion of carbapenemase-producing Enterobacteriacae mission and relatively good health infrastructure. These has MICs of carbapenems within the susceptible range success stories have generated such optimism that Bill raising the critical question of whether carbapenems might and Melinda Gates and other donors and, following their be effective in the treatment of infections caused by such lead, malariologists, are talking again about eradication. To organisms. achieve a better outcome than the first campaign, malaria Anecdotal reports claim microbiological and clinical eradicators in the 21st century will need to learn and apply response in patients infected with MBLpositive carbapenem- lessons from both past and recent failures and successes. susceptible organisms after treatment with a carbapenem. If a renewed malaria eradication effort is started with the In a prospective study of 67 patients with bloodstream infec- tools in hand now, it will be essential to keep the pipeline 14th International Congress on Infectious Diseases (ICID) Abstracts e181

ﬂowing with improved insecticides and drugs to replace 43.003 those that succumb to resistance, as well as to develop new Rational Use of Antibiotics in the Critically Ill Neonate and tools, including safe and effective drugs and vaccines that the Premature Infant block malaria transmission. Prospects for malaria eradication may be jeopardized by the apparent recent emergence C. Odio of artemisinin-resistant falciparum malaria in Southeast Hospital Nacional de Ninos and School of Medical Sciences, Asia. San Jose, Costa Rica doi:10.1016/j.ijid.2010.02.1886 NO ABSTRACT RECEIVED

A rational approach for the treatment and preven- doi:10.1016/j.ijid.2010.02.1888 tion of neonatal sepsis (Invited Presentation) 43.004 43.002 Strategies to Limit Infections in the Neonate and to Global Burden of Neonatal Sepsis Reduce Infection-related Mortality E.K. Mulholland 1,∗, E. Fenn 2, A. Zaidi 3 P. Sanchez 1 London School of Hygiene and Tropical Medicine, London, University of Texas Southwestern Medical Center, Dallas, United Kingdom TX, USA 2 Menzies School of Health Research, Darwin, Australia Health-care associated infections remain a major prob- 3 Aga Khan University, Karachi, Pakistan lem in the neonatal intensive care unit (NICU), resulting As infant and child mortality declines in many developing in significant morbidity and mortality. Specifically, blood- countries, neonatal mortality becomes the dominant com- stream infections have been associated with adverse ponent of all child mortality, now constituting about 40% of neurodevelopmental outcomes among preterm infants with child deaths. As attention is focused on this problem, it is birth weight <1000 grams. In addition, these infections are becoming clear that, in the high mortality countries, neona- associated with prolonged duration of hospitalization among tal mortality rates are being systematically underestimated, survivors and increased cost of neonatal health care. It is especially in the poorest, most marginalized communities. clear that preventive strategies are urgently needed. Data on the causes of neonatal deaths in the community are Many bloodstream infections in the NICU are associated seriously inadequate, as deaths occur outside the health ser- with the use of central venous catheters, and implemen- vice, and post mortem questionnaires are very difficult to tation of evidence-based measures as well as bundles interpret in this age group. Studies that examined the inci- has reduced their occurrence. Nevertheless, much work dence and mortality due to neonatal sepsis were reviewed. remains. Candidal infections have become more prevalent We sought to determine the relationship between the neona- in the NICU, and fluconazole prophylaxis is being recom- tal mortality rate and the proportion of neonatal deaths mended and used to prevent candidiasis among infants with due to infection. From a review of 32 community based birth weight <1000 grams. Although fluconazole prophylaxis studies published since 1990, between 8% and 80% of all has reduced invasive candidal infections, the underlying risk neonatal deaths in different regions of the developing world factors that result in Candida becoming a more common are reported as being due to infectious causes. Similar wide pathogen remain, namely the overuse of antibiotics espe- variability is seen in the incidence of clinical neonatal sep- cially the third generation cephalosporins. In addition, the sis, with reported rates varying from 49 per 1000 live births use of H2 blocker also has contributed to Candidal coloniza- in rural Guatemala to as high as 170 per 1000 live birthsin tion and late onset sepsis. Recent results of randomized rural India. The field of neonatal mortality, and specifically clinical trials have shown beneficial effects of probiotics neonatal sepsis, in developing countries is obscured by a for prevention of necrotizing enterocolitis and lactoferrin lack of credible data. Neonatal sepsis rates are confounded for prevention of late onset sepsis. Finally, the need to by lack of clear clinical definitions, and even neonatal mor- vaccinate not only our preemies but also staff and family tality rates are very unclear. Without any clear means of members of babies in the NICU will further reduce the like- determining the cause of community neonatal deaths, the lihood of introducing community-associated pathogens into contribution of sepsis to overall mortality is equally unclear. the NICU. The need for new and innovative research in this field is overwhelming. doi:10.1016/j.ijid.2010.02.1889 doi:10.1016/j.ijid.2010.02.1887 e182 14th International Congress on Infectious Diseases (ICID) Abstracts

Bacterial infections following influenza (Invited Pre- cination to induce protection against secondary bacterial sentation) infections will be discussed in the context of both seasonal and H1N1 influenza infection. 44.001 Secondary bacterial infections - The other side of doi:10.1016/j.ijid.2010.02.1891 influenza pathogenesis 44.003 J. McCullers Alteration of the Innate Immune Rheostat and Suscepti- St. Jude Children’s Research Hospital, Memphis, TN, USA bility to Secondary Bacterial Superinfections Secondary bacterial infections are a major cause of mor- T. Hussell bidity and mortality following influenza. This was especially National Heart and Lung Institute, London, United Kingdom true during past pandemics, where 50-95% of all deaths were complicated by or attributed to bacterial pathogens. The Infection of mucosal surfaces culminates in long term emergence in 2009 of a new pandemic strain has increased modifications that impact on future inflammatory events. the urgency for us to understand how bacteria work together These modifications do not necessarily depend on per- with influenza viruses to cause pneumonia. Several mecha- sistence of the original pathogen but on the altered nisms have been postulated to explain this interaction. The microenvironment which occurs upon resolution. This viral neuraminidase has been shown to enhance adherence ‘‘imprinting’’ by the first pathogen involves subtle alter- of bacteria and increase the incidence of bacterial pneu- ations of epithelial cells, resident mucosal macrophages, monia. The lack of glycosylation of the surface proteins of production of mediators that recruit immune cells and viruses emerging from the avian reservoir contributes to importantly, an alteration in the local microbial commensal both primary virulence and secondary bacterial infections community. by preventing viral clearance. Recent work has implicated Bacterial super-infections are common following the influenza A virus protein PB1-F2 as a virulence factor influenza and lead to a worse prognosis often resulting which enhances secondary bacterial pneumonia. Although in death. Analysis of post-mortem specimens from the the novel H1N1 swine-origin influenza virus has molecular 1918-19 pandemic shows a bacterial prevalence greater signatures that predict viral virulence in humans including than 95%. Control of initial bacterial growth relies on high neuraminidase activity and low glycosyltation, it does multiple components of innate immunity, many of which not possess a functional PB1-F2 protein. In the context of a are disrupted following influenza virus infection in murine pandemic, it is likely that secondary bacterial complications models. One key determinant that limits bacterial growth and overall mortality will be lower because of this absence. is the responsiveness of airway macrophages to bacteria in However, reassortment or mutation to restore PB1-F2 func- the airspaces. We show that influenza virus limits respon- tion to this virus could herald greatly expanded virulence. siveness by enhancing an innate immune negative regulator (CD200 receptor) during resolution of adaptive immunity. doi:10.1016/j.ijid.2010.02.1890 Removal of this single receptor limits bacterial burden in the airway and lung and completely prevents peripheral 44.002 dissemination, sepsis and mortality. Adjustment of innate The role of mucosal antiviral immunity in bacterial sec- reactivity may therefore provide a novel opportunity to ondary lung infections prevent life-threatening consequences of lung influenza virus infection. D. Metzger Albany Medical College, Albany, NY, USA doi:10.1016/j.ijid.2010.02.1892 Bacterial co-infections are typically a major cause of 44.004 mortality following influenza infection, including infection Lessons from 1918 and the current H1N1 pandemic on the with the pandemic H1N1 Cal/04/09 virus, but the reason role of bacterial infections during pandemic influenza for this increased susceptibility is only poorly understood. We have found that alveolar macrophages are the first K. Klugman line of defense against pulmonary pneumococcal and MRSA Emory University, Atlanta, GA, USA infection, and can very rapidly (within 4 hr) clear almost all bacteria after in vivo challenge with a relatively low The current pandemic of H1N1 influenza has features dose (up to 105 CFU of pneumococci). However, prior reminiscent of 1918 including infections and excess morbid- influenza virus infection inhibits this clearance mechanism ity in young adults. The impact in terms of mortality has and causes normally sublethal doses of bacteria to be 100% however been far less severe. This is in part due to lesser lethal. This is due to production of interferon (IFN)-gamma virulence of the virus, but also to the introduction of antibi- during pulmonary T cell responses to influenza infection, otics and most recently to the introduction of conjugate which inhibits scavenger receptor expression by alveolar pneumococcal vaccines in some countries that have reduced macrophages and in turn, leads to decreased bacterial clear- the morbidity of influenza associated pneumonia. During the ance from the lung. Thus, the increased anti-viral immune 1918 pandemic, post mortem data suggest that the major- response causes decreased protection against pulmonary ity of deaths were associated with bacterial superinfection bacterial infection. These results and the potential of vac- leading to pneumonia following4-6days after influenza. A 14th International Congress on Infectious Diseases (ICID) Abstracts e183 re - analysis of contemporary blood culture findings suggest Information is of paramount importance in prevention of that most of these infections were pneumococcal, followed HAI. Informed travelers are likely to comply with recom- by hemolytic (probably Group A) streptococcal infections, mendations, recognize symptoms, and avoid complications. and a minority of infections were due to Staphylococcus A gradual slow ascent, when possible, is as important for aureus. Attempts were made at that time to reduce infec- prevention. Other non-pharmacological measures are avoid- tion and mortality by killed bacterial vaccines. These trials ing exertion, dehydration, or use of respiratory suppressing were poorly controlled, but an analysis restricted to the substances. AMS/HACE pharmacologic prevention consists of prevention of pneumonia and mortality among influenza acetazolamide or dexamethasone. Nifedipine, tadafil, and patients who received these vaccines, suggests that vac- inhaled !-agonists are used for HAPE prevention. cines against hemolytic streptococci and pneumococci, but Descent is effective to treat all HAI but is not always not Haemophilus influenzae, may have had some protec- possible in remote areas or desirable for milder cases. tion against pneumonia and death. In a randomised trial of Alternatives like rest, oxygen, medications, positive air- 9 valent conjugate pneumococcal vaccine in children who way pressure and hyperbarics devices provide support until subsequently developed seasonal influenza in 1998 - 2000, descent is possible or acclimatization ensues. hospitalization for pneumonia was reduced by 45%. In the current pandemic, postmortem data suggest that staphy- doi:10.1016/j.ijid.2010.02.1894 lococcal infections are more common than in 1918, but pneumococcal infections remain predominant. Where con- 45.002 jugate pneumococcal vaccination of children has led to herd Risks on Common Cruise Itineraries immunity, vaccine serotypes have been largely absent as a A. Rísquez Parra cause of fatal pneumonias. The great majority of individuals hospitalized with H1N1 pneumonia have received antibiotics Centro de Vacunaciones, Caracas, Venezuela and it is probable that widespread availability of antibiotics has contributed to the reduction in mortality associated with Cruise travel has become one of the most popular ways to this pandemic, by reducing bacterial superinfections in sus- visit different places and is increasing in terms of cruise pas- ceptible individuals. sengers, voyages and region destinations. Most passengers, voyages and cruises are considered from low to medium health risks. A cruise offers a wide spectrum of services and doi:10.1016/j.ijid.2010.02.1893 is oriented to different customers with clearly different life styles risks from children, families up to elderly. Tradition- Travelers to Latin America with special risks (Invited ally, about one third of travelers are above 65 years old and Presentation) other adults have some special conditions. However, dur- 45.001 ing last few years the number of cruises oriented to young adults and visiting different regions and very peculiar envi- High Altitude Itineraries ronments such as the Amazons may increase the health risk M. Cabada significantly. Although, exposition to a mixture of people from different countries and diverse environments visited University of Texas Medical Branch, Infectious Diseases Divi- tend to change usual lifestyle or behaviors in terms of look- sion, Galveston/TEXAS, Lima, Peru ing for adventures and new activities during vacations. In Several countries in Latin America double their tourist terms of travel health risks, the age of the cruise member is arrivals in the last 10 years. The Andes Mountains are the extremely related to the chance to suffer an event (sickness common denominator for most countries in South America. or accident) due mainly to underlying chronic health prob- Many peaks in this mountain range attract mountaineers and lems. Most common health problems are associated with trekkers which may be aware of the risks at high altitude. movement (sea-sickness) and gastrointestinal diseases. Of importance are the Andean cities and tourism attractions Communicable diseases are easily disseminated because over 2,400 meters above sea level luring millions every year. a lot of activities for long hours made in semi-enclosed cab- Significant numbers of travelers to these destinations are ins and many times very crowded. And as in crowded places unaware of the health risks of altitude or come unprepared. and high interactive communities, cruise passengers are not The diseases related to high altitude ascend are referred an exemption for airborne diseases, as flu infections and to as high altitude illnesses (HAI). These comprise acute other acute respiratory illnesses. Injuries account for an mountain sickness (AMS), high altitude cerebral edema important number of infirmary visits. Medical care aboard (HACE), and high altitude pulmonary edema (HAPE). AMS is important for preventive and caring passengers and crew affects 20% to 50% of travelers to altitudes up to 4000 for health and medical issues. Pre-travel consultation is a meters. HACE and HAPE are less common affecting 0.01% to great opportunity for advising and providing health educa- 2% of travelers to similar altitudes. The risk factors can be tion for main risks and preparing passengers for a healthy classified as intrinsic (not modifiable), which include age, and safety itinerary. preexisting medical conditions, prior history of HAI, and probably genetic factors. Modifiable risk factors include rate doi:10.1016/j.ijid.2010.02.1895 of ascend, sleeping altitude, altitude attained, degree of exertion, and medications. The hypoxic ventilatory response is an individual risk factor that can be suppressed or stimulated. e184 14th International Congress on Infectious Diseases (ICID) Abstracts

45.003 immunologic changes that must be considered when giving Immunocompromised Travelers immunizations. These and related matters are discussed in this presentation on pregnancy and travel. Also discussed E. Jong are practical comfort and safety measures for the pregnant traveler, insurance issues and assistance in finding medical University of Washington, Seattle, WA, USA care. In the future, increasing numbers of travelers may have While immunization and prophylactic medications are compromised immune systems due to advanced age, medi- the topics that raise the most concern among providers, cations taken for chronic conditions, infection with human these are not the most common problems encountered by immunodeficiency virus, and immune deficits associated pregnant travelers. with congenital syndromes, systemic diseases, and/or treat- Attention to these few basic principles will greatly reduce ments. A complete medical history is necessary during the the anxiety that patient and provider are both apt to feel pre-travel health evaluation. Recommendations for travel when travel is combined with pregnancy. vaccines, malaria chemoprophylaxis, and care of common travel ailments such as traveler’s diarrhea must be tailored doi:10.1016/j.ijid.2010.02.1897 to the individual’s health status. Required (e.g. yellow fever, meningococcal disease) and Infectious diseases surveillance systems in practice recommended (e.g. influenza, hepatitis A and B, typhoid, (Invited Presentation) rabies) travel vaccines may be contraindicated or be less efficacious in the immunocompromised (IC) traveler. In 46.001 some cases, timing or adjustment of vaccine doses may ProMED and HealthMap: Collaboration to improve emerg- optimize the immune protection elicited. Drugs for preven- ing disease surveillance tion of malaria may interact with medications taken on a ,∗ regular basis, necessitating additional laboratory testing, L. Madoff 1 , J. Brownstein 2 dosage changes, and/ or the selection of alternate pre- 1 ProMED-mail and ISID, Boston, MA, USA vention strategies. Some IC travelers may have increased 2 Childrens Hospital, Boston, USA susceptibility to gastrointestinal pathogens, and may warrant consideration of prophylactic antibiotics as well as Unofficial or informal sources (also called ‘‘rumors’’ or specific instruction on food safety at destination. The risk of ‘‘unstructured data’’) of emerging disease outbreaks such geographically focal infections such as visceral leishmania- as media reports and firsthand accounts have become an sis, certain fungal infections transmitted through inhalation important mechanism for detecting these outbreaks. These (Penicillium marneffei in Southeast Asia and coccidiomy- sources are disseminated by a variety of human-based and cosis in the Americas) and tuberculosis in some developing automated biosurveillance networks that are now routinely countries must be considered because of the increased pos- monitored by public health authorities at all levels. The 2005 sibility of severe disease in IC persons. revisions to the International Health Regulations recognize Travelers with specific needs, such as the IC traveler, that these sources often appear in advance of official notifi- should seek travel health advice months in advance of depar- cation of disease threats and are important in allowing the ture, so that the travel health specialist and the primary timely response to emerging diseases. Early media reports care provider have adequate time to communicate about of respiratory illness in Mexico were among the first signs of and coordinate the medical aspects of the trip preparation. the H1N1 pandemic and unofficial information sources are a Identification of medical resources at destination, how to critical mechanism for following the pandemic. ProMED-mail obtain special drugs and medical supplies in case of need, (the Program for Monitoring Emerging Diseases of the Inter- and emergency medical evacuation are additional important national Society for Infectious Diseases) has used largely pre-travel topics for these travelers. humanbased reporting to detect and report outbreaks of emerging infectious diseases since 1994. doi:10.1016/j.ijid.2010.02.1896 HealthMap, based at Boston Children’s Hospital and Har- vard Medical School, uses automated mining of open sources 45.004 in multiple languages to detect emerging disease outbreaks Pregnant Travelers in and place them on a world map. ProMED and HealthMap have begun to collaborate to exploit the strengths of human- D. Carroll based and automated detection and reporting systems. The Pregnant Traveler, Spring Lake, MI, USA Studies to evaluate the use of informal sources and to improve the detection of emerging disease outbreaks are in Pregnancy is not an illness, but it is an altered state of progress and have found differences in timeliness of report- health during which many physiologic changes occur. These ing depending on disease type and geographic location. changes need to be considered when advising a pregnant These differences are being used to target the development woman regarding international travel, especially to remote of new regional and disease specific reporting networks as locations. well as the deployment of new mobile tools for capturing Some examples are changes in renal and metabolic sta- and disseminating news of emerging threats. tus that affect pharmacokinetics, cardiorespiratory changes that need to be considered in high altitudes, gastrointesti- doi:10.1016/j.ijid.2010.02.1898 nal changes that predispose to traveler’s diarrhea, and 14th International Congress on Infectious Diseases (ICID) Abstracts e185

46.002 The Caribbean animal health network (CaribVET) is Google Flu Trends: Mapping Influenza in Near Real Time a collaboration among veterinary services, laboratories, research institutes, and regional/international organiza- C. Conrad tions to improve animal and veterinary public health in the Caribbean. Its specific objectives are to promote a regional google.org, San Francisco, CA, USA approach for emergency preparedness and diseases con- Google.org uses Google’s strengths in information and trol especially for emerging and zoonotic diseases, reinforce technology to build products that address global challenges. regional diagnostic capacities, and strengthen national epi- Infectious diseases are responsible for millions of deaths demiological surveillance systems. around the world each year. Influenza, in particular, affects Meetings, trainings, skills building and development of 3-5 million people per year, and kills 250-500 thousand. regional tools for information and data exchange are the With this in mind, a small group of engineers, working main strategies used. The Steering Committee of CaribVET closely with medical professionals at Google.org and exter- is responsible for the regional strategy while seven Work- nally, began to investigate what innovations Google could ing Groups organize the collaboration on specific diseases bring to this issue. By some estimates, there are more than (Tick and Tick Borne Diseases, Avian Influenza, Classical 1.6 billion people on the planet with access to the Swine Fever, Salmonellosis, Rabies) or activities (Epidemi- Internet and Google receives more than a billion searches ology, Laboratory quality assurance). daily. By analyzing influenza-like illness (ILI) data from The epidemiology working group has developed crite- the U.S. Centers of Disease Control and Prevention, and ria for the definition of priority diseases, core surveillance anonymized, aggregated search query data, we discovered databases, an evaluation of national surveillance systems that a rise in the frequency of certain influenza-related and risk analysis of regional interest. It participates in the search terms in a place corresponds with a rise in actual updating of a participatory website (www.caribvet.net), flu activity for that area. In November 2008, we introduced with information and data on surveillance systems, diag- Google Flu Trends for the United States, an online tool that nostic laboratories, conferences, and major diseases of the tracks and analyzes search terms to provide flu activity esti- region. The Working Group for avian influenza has developed mates. Now for 20 countries, Google Flu Trends generates a regional surveillance protocol, a diagnostic network, sur- estimates that are automatically updated daily, providing a veys of wild birds and on risk posed by fighting cocks trade. timely indicator of influenza activity. Our hope is that Google Research on West Nile first developed in Guadeloupe, iden- Flu Trends be a complementary surveillance tool for health tified risk factors which were used to implement risk based officials, as well as a source of useful information for the surveillances in the region. general public. The interaction between surveillance and research within We continue to receive feedback from health officials CaribVET facilitates the access to surveillance data and field worldwide regarding the tool’s use, helpfulness and lim- samples for the development of research studies. Research itations. We have also learned about the positive impact results are used for emergence prediction, improvement of that Google Flu Trends has had on public awareness of the surveillance and control of diseases. timing and intensity of flu season, as well as preventative measures like hand washing and vaccination. Now entering its second year, Google Flu Trends will continue to adapt in response to a growing body of information regarding its practical application and potential. doi:10.1016/j.ijid.2010.02.1899 46.003 CaribVET: A Model for Surveillance of Zoonotic Diseases T.Lefrancois 1,∗, M. Petit-Sinturel 1, M. Kalloo 2, J. Shaw 3,K. Herbert-Hackshaw 4, M. Trotman 5, V. Gongora 6 1 CIRAD Guadeloupe, Petit Bourg, Guadeloupe 2 CARICOM Secretariat, Georgetown, Guyana 3 USDA-APHIS-IS, Santo Domingo, Dominican Republic doi:10.1016/j.ijid.2010.02.1900 4 Veterinary Services, Kingstown, Saint Vincent and the 46.004 Grenadines 5 Veterinary services, Bridgetown, Barbados GeoSentinel: Provider-based Surveillance of International 6 Belize Agricultural Health Authority, Cayo, Belize Travelers The Caribbean region is considered to be at risk for D. Freedman zoonotic diseases because of widespread backyard breed- Birmingham, Alabama, AL, USA ing system, diverse disease surveillance systems, legal or illegal human and animal movements. Several zoonosis are 80 million individuals from industrialized nations travel to reported including Influenza, West Nile, Rabies, Leptospiro- the developing world each year. Provider-based surveillance sis. of travelers is increasingly sophisticated. One such network, e186 14th International Congress on Infectious Diseases (ICID) Abstracts

GeoSentinel monitors disease trends among travelers and (acute and convalescent phase) from patients with febrile can inform both pre-travel advice and post-travel manage- syndroms negative to malaria by direct blood-smear test. ment and defines the spectrum of illness and the relation to Indirect Immunofluorescence (IFI), was used to detect rick- place of exposure for the most significant health risks that ettsial infection in humans and rodents. Additionally, PCR face travelers. was performed in liver-DNA from rodents searching for spe- Founded in 1996, the communications and data collection cific genetic sequences of Rickettsia genus (Citrate Synthase network currently comprises 50 travel/tropical medicine gene, gltA) and pathogenic Rickettsias (OmpB gene). ISTM (International Society of Travel Medicine) clinics on Results: We obtained 23 rodent DNA samples positive to 6 continents operating in cooperation with the US CDC. gltA but only 6 of them, positive for the OmpB gene, result- Returning travelers seen at relatively few sentinel sites ing on a 6.8% DNA frequency of infection to Rickettsias by provide a sample of disease agents in over 230 different PCR. Some PCR products for the gltA gene, were sequenced countries. As of December 1, 2009, over 114,000 patient and showed 98% similarity with the Rickettsia Prowazekii records increasing by 20,000/yr, track trends against a 12- species, but the phylogenetic analysis suggests that these year long baseline for over 500 diagnoses in order to monitor sequences form a separated cluster indicating that these anomalies that might herald disease emergence. Rickettsias could represent a new specie or sub specie. 89 Real time data entry via internet onto a central server of the 220 human sera were tested by IFI and 11 came allows monitoring of alarming sentinel events to generate up positive in dilution 1:64 (10 of the samples were posi- immediate network wide queries and enhanced surveil- tive in the convalescence period M2, and one in the acute lance during focal or widespread outbreak situations. The phase, M1). Most of the ectoparasites collected were iden- GeoSentinel response arm disseminates alerts and advisories tified as hard ticks (Amblyomma sp, Ixodidae family,) soft through CDC, ProMedMail, ISTM, ASTMH, and other partner ticks (Ornithodoros Alectorobius puertoricensis, Argasidae networks and agencies. family) and fleas (Xenospsilla sp genus). These samples still Examples have included: imported traveler-related remain to be tested for rickettsial infection using both gltA cases/outbreaks of SARS, 2009 H1N1 influenza, leptospirosis and OmpB. from Borneo, Hantavirus from Chile, Hajj meningitis from Conclusion: This is the firs of a serie of studies that Singapore, firstever dengue from Easter Island, and schisto- will allow us to characterize ecologically this endemic site somiasis from Tanzania. and contribute to recomend the measures to prevent future The presentation will include advances, observations, human cases in this important risk area. lessons and limitations from the experience of the global GeoSentinel surveillance network. Data from sentinel doi:10.1016/j.ijid.2010.02.1902 travelers upon their return to medically sophisticated environments can also benefit local populations in resource- 47.002 limited countries. Distinct pathological signatures after lethal avian H5N1 and swine H1N1 influenza infections suggest variable doi:10.1016/j.ijid.2010.02.1901 pathogenesis M.-M. Garigliany 1,∗, A. Habyarimana 2, B. Lambrecht 2,E. Advances from the laboratory (Oral Presentation) VandePaar1, A. Cornet 1, T. Van den Berg 2, D. Desmecht 1 47.001 1 Faculty of Veterinary Medicine - University of Liège, Liege, Epidemiological description of infection with agents of the Belgium Rickettsia genus in rodents, ectoparasites and humans in 2 Veterinary and Agricultural Research Center, Brussels, Bel- the northern coast of Antioquia, Colombia gium J.C. Quintero Vélez 1,∗, A. Londono˜ 1, V. Quiroz 2, F. Díaz 2,P. Background: Influenza annual epidemics result in up to Agudelo 3, M. Arboleda 3, J. Rodas 2 500,000 deaths in human population, and different pandemics occurred over the 20th century, among which the 1 Universidad de Antioquia, Medellin, Colombia 1918 pandemic was accountable for more than 50 millions 2 Universidad de Antioquia, Medellín, Colombia deaths. Lethal seasonal or pandemic influenza infections 3 Instituto Colombiano de Medicina Tropical-CES, Sabaneta, are all associated either to secondary bacterial infec- Colombia tions or acute respiratory distress syndrome (ARDS). Since Background: Rickettsia is a worldwide usually rodent- antibiotics will help in treating bacterial pneumonias, it is carried tick, flea or lice-borne bacteria. In Colombia, few crucial for public health to understand the pathogenesis of reports have beed performed, first in the mids thirties caus- influenza-associated ARDS in order to fight it or to prevent ing an outbreak in the population of Tobia Cundinamarca, its occurrence. Descriptions of the lung alterations in fatal and from the years 2006 to 2008 in the Northern region of influenza infections in human and mouse all depict similar Colombia known as Urabá. Our main goal was to perform an lung dysfunctions and lesions. Here we describe the ARDS epidemiological description of the infection in the endemic associated with the inoculation of identical doses of two mentioned area in Colombia. influenza strains highly pathogenic for mice. Methods: Samples were obtained from the municipal- Methods: A clade 1 avian H5N1 virus ities of Apartadó, Turbo y Necoclí, where 335 rondents (A/crested eagle/Belgium/1/2004) and a porcine H1N1 were captured and parasites were collected from 33 of virus (A/swine/Iowa/4/1976) were rendered highly them. 220 double-blood human samples were also taken pathogenic for mice by serial lung-to-lung passaging in 14th International Congress on Infectious Diseases (ICID) Abstracts e187 mice. Two series of mice were inoculated intranasally with accession number: EU552928). Protein expression revealed 10 MLD50 of virus. Body and lung weights were monitored ∼15 kDa molecule with biological activities similar to the daily and several organs were sampled at selected time cultured supernatants of splenocytes obtained directly from intervals for histopathological / immunohistochemical parasite-inoculated animals. Antibodies raised against the evaluation or for viral titration. protein blocked the activities of both the protein and Results: MLD50 s were similar for both viral strains (3.2 the supernatant and also recognized a band in the active PFUs for the H1N1 and 6.4 TCID50 for the H5N1 strain). The supernatant with the same molecular mass as the protein. course of the infection was much faster for H5N1 than for Furthermore, the protein was able to reactivate experimen- H1N1, the endpoint days being days 4 and 8 post-inoculation, tally immunosuppressed cells by regaining their ability to respectively. Typically, H1N1-infected lungs were charac- proliferate. terised by a progressive extension from the airways to the Conclusion: A nervous system-induced Immune System- lung parenchyma, resulting in a massive mononuclear cellu- Released Activating Agent (ISRAA) was identified and may lar infiltrate. For H5N1, the lung parenchyma was rapidly have a potential therapeutic benefit in immunocompromised diffusely involved, the airways being almost unaffected, situations and in further understanding the mechanism for with a very low density of inflammatory cell infiltrates and, innate immunity commencement and action. at the end-point day, with massive alveolar edema. Influenza antigens were detected in lungs, brain, liver, spleen, heart, doi:10.1016/j.ijid.2010.02.1904 pancreas, kidneys and pervisceral fat of H5N1-infected mice, while H1N1 antigens were only found in the lungs. 47.004 Conclusion: The clearly distinct histological pictures Variable expression of alpha haemolysin and Panton shown here refute the hypothesis of a single universal Valentine leucocidin in clinical isolates of Staphylococcus pathogenesis beyond all influenza-associated fatal ARDS aureus are linked to agr-dependent quorum sensing and suggest that the treatment should be tailored to the T. Sloan 1,∗, R.O. Jensen 2, A. Cockayne 2, L.G. Durrant 3,P. influenza pathotype. Williams 2, R. James 2 doi:10.1016/j.ijid.2010.02.1903 1 Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom 47.003 2 University of Nottingham, Nottingham, United Kingdom A novel nervous-to-immune signalling mechanism medi- 3 University of Nottingham, Nottingham, United Kingdom ating innate responses to infections Background: Considerable controversy exists over the ,∗ M. Bakhiet 1 , S. Taha 2 relative importance of alpha haemolysin (Hla), Panton Valentine leucocidin (PVL) and phenol-soluble modulins 1 Arabian Gulf University, Bahrain, Bahrain (PSMs) in the pathogenesis of the different types of infec- 2 Arabian Giulf University, Manama, Bahrain tions that can be caused by CA-MRSA and PVL positive MSSA Background: Substantial communications between the strains. We have investigated factors that affect Hla and PVL nervous and the immune systems were well established, expression in S.aureus clinical isolates. but the effect of the nervous system in directing the innate Methods: Recent isolates of Staphylococcus aureus which immunity is not known. Accordingly, we hypothesized that were confirmed to be positive for PVL by PCR were obtained opening innate responses to infections are mediated via from diagnostic clinical samples (swabs, pus, blood culture, nervous-to-immune signalling pathway. lung tissue) from Nottingham University Hospitals NHS Trust. Methods: To explore the factor(s) involved in this 25 strains were grown in CYGP medium for 24 hours at 37 ◦C nervous-to-immune signaling pathway, splenicdenervated with shaking, before exoproteins were prepared from the and non-denervated Sprague-Dawley rats were inoculated culture supernatant, separated using SDS-PAGE before West- with Trypanosoma brucei brucei (T.b.brucei) followed by ern blotting with anti-LukF and anti-Hla antibodies. immediate dissection of the spleen and culture of spleno- Results: A variable level of expression of both the LukF cytes. ELISPOT and cell proliferation assays were used to subunit of PVL or HLA was observed between clinical iso- assess cellular and biological activities. Using the fluores- lates, with some correlation being observed between the cent differential display technology the gene involved in this level of expression of both in an individual isolate. The level process was identified and further cloned. of expression was not related to the agr subtype of the clin- Results: Supernatants of cultured splenocytes prepared ical isolate. The presence of the type specific auto-inducing from subcutaneously trypanosomeinoculated rats and mice peptide (AIP) in supernatants of the clinical isolates was con- spleens obtained immediately after inoculation and added firmed by bioassays using specific reporter strains. Clinical to naïve cells significantly stimulate IFN-’ production and isolates expressing very low levels of LukF all produced their cell proliferation compared to PBS-inoculated animals. This type specific AIP,however the addition of 100 nM of type spe- action was abrogated by surgical denervation of the spleen. cific AIP induced the expression of LukF and Hla (Fig. 1). LukF The fluorescent differential display technology depicted the and Hla expression in clinical isolates was inhibited by the gene involved in this process which was further cloned universal S. aureus agr inhibitor, ala5-AIP-1 (Fig. 2) [McDow- and its sequence was mapped to chromosome 14 (GenBank ell et al., (2001) Mol Microbiol 41: 503-512] e188 14th International Congress on Infectious Diseases (ICID) Abstracts

respectively in HepG2 cells when compared with pcDNA3.1 empty vector cotransfected cells. There was no change in relative luciferase activity when HBs wild plasmid was cotransfected with hfgl2p(-1334)LUC in either CHO or HepG2 cells. Conclusion: These results suggest that HBs mutations related with YMDD mutation induce hfgl2 promoter activity in both CHO cells and HepG2 cells. It provides new insights in the interaction between HBV mutation and host gene Fig. 1 Clinical isolate TS12 +/-AIP-3. hfgl2 expression and the mechanism of hepatitis flare fol- Fig. 2 Clinical isolate TS6 +/- AIP-1 (Ala5). lowing YMDD mutation. This work was supported by NSFC Conclusion: PVL positive Staphylococcus aureus clinical No. 30972606 and National Key Basic Research Program of isolates express variable levels of LukF and Hla when cul- China 2007CB512904. tured in vitro. Modification of agr activity by the addition of synthetic AIPs suggests that agr has a major role in regulat- doi:10.1016/j.ijid.2010.02.1906 ing PVL expression in these clinical isolates. Some strains, despite having both lukS and lukF genes and producing AIP, 47.006 expressed little LukF unless additional synthetic AIP was Enteric virus detection and identification with a universal added. Upregulation of agr could explain the high levels of virus discovery assay LukF expression in some isolates. C. Uhlenhaut 1,∗, S.D. McClenahan 1, S. Sosnovtsev 2,K. These findings reveal surprising variation in the in vitro Bok 2, A.Z. Kapikian 2, K.Y. Green 3, P.R. Krause 1 expression of PVL in clinical isolates and indicate the potential for attenuating the virulence of S.aureus. 1 FDA Center for Biologics Evaluation and Research, Bethesda, MD, USA doi:10.1016/j.ijid.2010.02.1905 2 National Institutes of Health, Bethesda, MD, USA 3 National Institute of Allergy and Infectious Diseases, 47.005 Bethesda, MD, USA HBs mutations related with YMDD mutation induced the expression of hfgl2 gene Background: Detection and identification of known and unknown viruses can be challenging, especially for those M. Han 1,W.Li2,Y.Li3, D. Chen 4,W.Yan5, X. Wang 3,X. with substantial genetic divergence, e.g. caliciviruses. To Luo 6, Q. Ning 7,∗ address this issue, we developed a universal virus detection assay combining virus capsid enrichment with a generic 1 Tongji Hospital, Tongji medical collge, Huazhong university PCR. We analyzed stool and cell culture samples with our of Science and Technology, Wuhan, China degenerate oligonucleotide primer (DOP) PCR. Caliciviruses 2 Tongji hospital, Tongji medical college, Huazhong Univer- are small, non-enveloped (+)ssRNA viruses. The family Cali- sity of Science and technology, Wuhan, China civiridae is comprised of four genera, Norovirus, Sapovirus, 3 Tongji Hospital, Tongji medical college, Huazhong Univer- Vesivirus and Lagovirus. Vesiviruses and lagoviruses infect a sity of Science and Technology, Wuhan, China wide range of animal hosts; noroviruses and sapoviruses are 4 Tongji Hospital, Tongji medical college, Huazhong univer- recognized as human pathogens, causing acute gastroenteri- sity of Science and Technology, Wuhan, China tis. Human noroviruses and sapoviruses cannot be cultured 5 Tongji Hospital, Wuhan, China which impedes the research of these viruses considerably. 6 Tonji Hospital, Wuhan, China Methods: The first step of the assay is the physical and 7 Tongji Hospital, Tongji Medical College, Huazhong Univer- biochemical purification by targeted digestion of contami- sity of Science and Technology, Wuhan, Hubei, China nating host nucleic acids followed by DOP PCR. The primer Background: Mutations in the highly conserved tyrosine- population is optimized for the detection of virus-sized methionine-aspartate-aspartate (YMDD) motif are fre- genomes. Products can be identified by cloning and sequenc- quently associated with resistance to antiviral treatment ing or by high throughput sequencing. Various DNA viruses and often followed with hepatitis flare, representing a major (including HSV, VZV, SV40, AAV, EBV, parvoviruses, and hep- concern in the treatment of hepatitis B virus (HBV) infection. atitis B) and RNA viruses (including HTLV-1, HTLV-2, several Previous studies showed that highly expression of hfgl2 gene animal retroviruses, poliovirus, hepatitis A, human corona is related with necrosis of hepatocytes and development of virus, human metapneumovirus, and influenza virus) were fulminant hepatitis. detected in previous studies in cell cultures and clinical Methods: To characterize the interaction between HBs samples. mutations resulted by YMDD mutation and the expression of Results: Human norovirus (stool) and feline calicivirus hfgl2 gene, HBs mutation expression plasmids, I195 M and (vesivirus, cell culture) were identified with our univer- W196S were cotransfected with a hfgl2 promoter luciferase sal assay. Approximately 35% of the virus genomes were report construct into CHO cells and HepG2 cells respectively. obtained with a single assay. We also identified enterovirus Results: Cotransfection of I195 M or W196S with hfgl2p(- sequences from an asymptomatic individual. 1334)LUC resulted in a significant increase in relative Conclusion: The findings presented here demonstrate the luciferase activity with an average increase of 3.3-fold and ability of the DOP-PCR assay to not only detect and iden- 3.7-fold in CHO cells, and 3.5-fold and 4.9-fold increase tify viruses in clinical and cell culture samples but to also 14th International Congress on Infectious Diseases (ICID) Abstracts e189 provide a large portion of the sequence information with increment of erythropoiesis in the host as a compensatory a single assay. Human diarrheal diseases cause a significant mechanism for the haemolysis brought about by the metal disease burden; an estimated 1.8 million deaths in children ion-scavenging activity by Candida tropicalis. under the age of five are caused by gastroenteritis annually. Gastroenteritis is the third leading cause of death due to infection, yet, about 40% of cases are of unknown etiology. Universal detection of viruses with an assay as it was described here could lead to the detection of known yet unsuspected viruses or the discovery of novel viruses. doi:10.1016/j.ijid.2010.02.1907 47.007 Conclusion: Our results suggest that gene expression profiling of this mouse model may provide new insights into Gene expression profilling of mouse host response to Can- Candida tropicalis induced systemic infection particularly dida tropicalis infection in finding molecular mechanisms and early biomarkers. P.P. Chong 1,∗, V.-C.P. Yong 1, H.F. Seow 2, R. Rosli 1 doi:10.1016/j.ijid.2010.02.1908 1 University Putra Malaysia, Selangor, Selangor, Malaysia 2 Victoria University, Melbourne, Victoria, Australia 47.008 Background: Candida tropicalis is an opportunistic Cytokines in experimental leptospirosis: Association with pathogen which can cause systemic candidiasis in immuno- severe disease and postimmunization immune response compromised hosts. Systemic infections caused by non- A. Chagas-Junior 1, D. Athanazio 2,∗, J. Macedo 1,M. albicans Candida species, especially C. tropicalis has seen a Menezes 1, M. Reis 1, F. McBride 2, A. McBride 2 rising trend. Nonetheless, studies on the global host immune and serologic responses towards the infection are lacking. 1 Oswaldo Cruz Foundation, Salvador, Brazil Methods: To further understand the effect of Candida 2 Federal University of Bahia, Salvador, BA, Brazil tropicalis induced systemic infection on the host gene tran- Background: Leptospirosis shares with bacterial sepsis scriptional profile, we carried out DNA microarray-based some clinical features, however, the leptospiral lipopolysac- gene expression profiling of lethal infection and sublethal charide is 10-12 times less toxic than its gram negative infection in a BALB-C mouse model. Three groups of mice counterparts. Severe leptospirosis has been associated with comprising control (non-infected), sublethal or low infec- serum levels of proinflammatory markers such as TNF-a, tion and lethal or high-infection (inoculated with 105 and PTX3, IL6, and IL8. In addition, data from bovine whole 107 C. tropicalis cells respectively) were sacrificed and cell antigen vaccines suggest that induction of strong Th1- total RNA isolated from the sera. The total RNA was type response is associated with protection. The aims of this reverse-transcribed and hybridized to the Illumina Mouse- study were to investigate: 1) gene expression of cytokines Ref8 Microarray BeadChip. The gene expression level was by peripheral blood mononuclear cells (PBMCs) in severe dis- normalized to !2-microglobulin. ease; and 2) gene expression of cytokines in PBMCs after immunization by whole cell vaccine and homologous challenge. Methods: Gene expression of IL2, IL4, TNF-a, and IFN- g by Real Time PCR. The virulent strain used in the study was L.interrogans serovar Copenhageni strain Cop 4.14. To evaluate gene expression in severe disease, 25 hamsters were infected by 250 leptospires (5x lethal dose 50%) and compared to 4 uninfected controls. Hamsters immunized by Results: The results showed that 1373 genes were differ- whole cell vaccine and controls were evaluated at 8 time entially expressed in the lethal infection group but lower points (n=3 in each group) from 0 h to 21 days. inoculum size of Candida tropicalis in the sublethal infec- Results: All infected hamsters developed lethal disease tion group had little effect on the host-response gene with typical target organ pathology. Gene expression was expression. For microarray data validation, multiplex RT- higher for all cytokines in infected animals at moribund PCR of 19 selected genes was carried out via GenomeLab state (7-8 days after infection) when compared to con- GeXP Genetic Analysis System. Confirmed upregulated genes trols. The difference was statistically significant for IFN-g included genes involved in host defense, pathogen recog- (p=0.01). Cytokines were not associated with bacterial nition, signal transduction, inflammation, chemokines and quantification in tissue or specific target organ lesions. cytokines, including Ltf, Pglyrp1, Ch13l4, syndecans, Marco Immunized hamsters survived and expressed higher levels and Ngp. Interestingly, we also observed differential expres- of TNF-a on the eighth day (145 vs 19) and IFN-g on the sion of Actb and Gapdh in the lethal infection group although third day after infection on the third day (32 vs 0.5) after both are house-keeping genes normally presumed to be challenge, when compared to the control expression of expressed at constant levels. From the expected functions HPRT. of the genes that were upregulated in the infection groups, we speculate that Candida tropicalis could possibly cause e190 14th International Congress on Infectious Diseases (ICID) Abstracts

Conclusion: Severe disease is associated with higher 47.010 expression of IFN-g in hamsters. The whole cell vaccine used E-gene variation with reference to neurovirulence in the in this study elicited strong IFN-g and TNF-a responses. Indian clinical isolates of Japanese encephalitis virus ∗ doi:10.1016/j.ijid.2010.02.1909 S.K. Pujhari , S. Prabhakar, R.K. Ratho, M. Modi, M. sharma, B. Mishra 47.009 Postgraduate Institute of Medical Education and Research, Prevalence of genes responsible for resistance to antimi- 160012, UT, India crobials in surface water Escherichia coli isolates Background: Japanese encephalitis (JE) is an important G. Singh ∗, P. Vajpayee, R. Shanker arboviral infection of public health concern. There is a sig- Indian Institute of Toxicology Research, Lucknow, India nificant variation in mortality (20-60%) in JE viral infection. It is possibly attributed due to the host genetic makeup Background: The resistance to antimicrobial agents is an or genomic variation in the JE virus. Various approaches important issue in both human and veterinary medicine. have allowed E gene sequences of flaviviruses to be related The excessive use of antibiotics is hastening the develop- to virulence in animal models and shows single amino ment of antibiotic resistance in bacteria augment health acid substitutions are sufficient to alter neurovirulence and risks to humans and animals. Lack of access to potable water neuroinvasiveness. The present study has looked for the has forced many inhabitants in developing countries to rely mutational analysis of E gene, in clinical isolates at amino on surface water resources for their daily water needs. acid positions at 176,177,227,244,264 and 279, which have Presently, these water resources have emerged as reservoirs been shown responsible for neuro-virulence in experimental of Escherichia coli pathotypes harboring virulence as well animals. as multi-drug resistant genes which could play an impor- Methods: A total of 95 patients with suspected viral tant role in the diarrheal disease outbreaks. The river Ganga encephalitis were enrolled. JEV conformation was done by and its tributaries meet 40% of the water requirement for MAC ELISA and RT-PCR. The RT-PCR positive samples were drinking and irrigation in India. further subjected to sequencing using ABI PRISM BigDye Ter- Methods: In this study, E. coli isolates (n = 65) retrieved minator cycle sequencing ready reaction kit in ABI PRISM from the river Ganga and Gomti (a major tributary of 310 genetic analyzer. The drafting of sequences was per- the river Ganga) were screened using Polymerase Chain formed using BioEdit software. Neighbor joining algorithm Reaction for prevalence of genes (blaTEM, blaSHV, aac(3)- was implemented for phylogenetic inference using MEGA IIa, aac(3)-IV , aph(3’)-Ia, aph(3’)-IIa,ant(3)-Ia (aadAI), 4.0.2.The DNA sequences were translated insilico and muta- ant(3 )-If (aadA6), tetA, tetB, tetC, catI, floR, sul1, sul2) tion analysis was performed. Re-confirmation of mutations responsible for resistance to antimicrobial agents of five was done using BLAST tool in NCBI website antimicrobial families (!-lactams, Aminoglycosides, Tetracy- Results: Among confirmed cases 70% belonged to the cline, Phenicols, Sulfonamides). pediatric age group, with a male to female ratio of Results: Our observations indicate that 67.2, 32.3, 55.3, 3:1.Patients presented with moderate to high-grade fever 72.3 76.9, 63.0, 75.3, 43.0, 44.6% E. coli isolates exhibit (41%); convulsions and rigidity (65%), extra pyramidal fea- tetA, tetB, tetC, blaTEM, blaSHV, catI, floR, sul1, sul2 tures (35%). Convulsion was often the presenting symptom. genes, respectively. A mortality of 27% was observed among JE positive cases. Conclusion: The prevalence of E. coli isolates harboring JE virus specific RNA was detected in 7 cases. Phylogeneti- multiple antimicrobial resistance genes points to the inher- cally all our isolates belonged to genotype-III. Interestingly ent health risks associated with the use of surface water a novel mutation of S227T at amino acid level was detected by inhabitants of the planned and temporary settlements corresponding to the domain II of E gene in JEV compared along the banks of these rivers. This will require formulation to both Indian and overseas isolates. of strategies for preemptive monitoring of surface water to Conclusion: Genotype III was found to be circulating in prevent diarrheal outbreaks. this part of India. With the present available limited number of cases no significant correlation was found between E gene doi:10.1016/j.ijid.2010.02.1910 mutation and disease severity. However, the observation of novel mutation S227T of E protein in this geographical area has given the impetus to explore its role in JE pathogenesis and vector competency

doi:10.1016/j.ijid.2010.02.1911