Traveler''s diarrhea at sea: two multi-pathogen outbreaks caused by food eaten on shore visits

In 1976 and 1981, two outbreaks of gastrointestinal illness aboard cruise ships occurred within 24 hours following onshore visits to Haiti and Mexico, respectively. Three hundred eighty-six of 600 (64 per cent) and 98 of 260 (38 per cent) passengers became ill following luncheons in Port-au-Prince, Haiti, and Cozumel, Mexico. No increase in illness was observed among those passengers who did not attend the onshore luncheons. In both outbreaks, unrefrigerated seafood dishes served at outdoor buffets were epidemiologically incriminated as the vehicles of transmission. Several species of Vibrion, Salmonella, and toxigenic Escherichia coli were recovered from stool specimens of ill passengers in both outbreaks. In addition, invasive Escherichia coli and Shigella were isolated from stool specimens of ill passengers who ate at the Haitian buffet. Previous investigations of outbreaks of gastrointestinal illness aboard cruise ships have implicated exposures on board as the source and have involved only a single pathogen.     

Passenger mortalities aboard cruise ships

OBJECTIVES: to study the epidemiology of passenger mortalities on cruise ships. METHODS, MATERIAL AND RESULTS: during six years (April 1995 to April 2001) deaths aboard two similar cruise ships (A & B) were registered and studied. Each ship had an average of approximately 800 passengers with median age about 65 years. Twenty five passengers died: 9 men and 3 women on ship A and 10 men and 3 women on ship B. There was an average of one death every six months per ship. More men than women died, although there were more female passengers on both ships (P<0.05). Eleven passengers were found dead in their cabins. Five deaths outside the medical centers were witnessed; four of them had asystole and one ventricular fibrillation when medical staff arrived. Nine patients died after 1/2 to 52 hours of intensive care in the medical centers aboard.     

Contacting passengers after exposure to measles on an international flight: Implications for responding to new disease threats and bioterrorism

On May 21, 2000, a passenger with measles traveled from Japan to Hawai'i on a seven-hour flight. When the flight landed, the U.S. Public Health Service (USPHS) Quarantine Station in Honolulu alerted passengers that a suspected case of measles had been identified, but they were not detained. The next day, to offer appropriate post-exposure prophylaxis, the Hawai'i Department of Health (HDOH) attempted to contact all passengers from the flight using information from the airline, U.S. Customs declaration forms, and tour agencies. Of 335 total passengers, 270 (81%) were successfully reached and provided complete information. The mean time from exposure to contact for all respondents was 61 hours (95% confidence interval 57, 66). A total of 202 (75%) of the responding passengers were contacted within 72 hours after exposure, the time period during which administration of measles vaccine would have provided protection for susceptible individuals. The time-to-contact was significantly longer for passengers who did not stay in hotels than for hotel guests. Customs forms proved to be of limited utility in contacting international travelers. This experience highlights the need for more complete and timely methods of contacting passengers potentially exposed to infectious agents aboard flights.     

Outbreak of influenza in highly vaccinated crew of U.S. Navy ship

An outbreak of influenza A (H3N2) occurred aboard a U.S. Navy ship in February 1996, despite 95% of the crew's having been appropriately vaccinated. Virus isolated from ill crew members was antigenically distinct from the vaccination strain. With an attack rate of 42%, this outbreak demonstrates the potential for rapid spread of influenza in a confined population and the impact subsequent illness may have upon the workplace.     

Epidemiology of influenza in the elderly: evidence of virus recycling.

During the Hong Kong influenza epidemic of 1968-1969 the attack rate among persons born prior to 1890 was about one-third the rate among persons born after 1899. During an Asian influenza epidemic in the same community two years earlier there was no apparent age effect. Most persons born before 1890 had detectable pre-epidemic antibody against A/Hong Kong/68 whereas most persons born after 1899 had no detectable pre-epidemic antibody. The lower attack rate in the older age group is consistent with the hypothesis that influenza A viruses with similar or identical hemagglutinins can reemerge over time and that remote previous experience with the same or a similar strain can be protective. Also, no age group born after 1890 was found to have a high prevalence of antibody against A/England/72 or A/Dunedin/73, the successors to A/Hong Kong/68, indicating that recycling of hemagglutinin antigens is not strictly ordered.     

Seafarers and passengers who disappear without a trace from aboard ships

It is a fact that not only ships, but also seafarers and passengers vanish without a trace at sea, be it in the past or in present times. Several examples for this phenomenon are given. A scheme of the ship conditions found after discovering that single persons or even whole crews had disappeared from board is provided as an orientation, before describing in detail the more than 18 reasons for vanishing from ships for good, giving examples where appropriate. These reasons are in their majority logical, but strange and bizarre reasons also exist. Causes may e.g. be the sea state, crimes, suicide, alcohol, piracy. A chapter concerning passengers lost from large modem cruise ships, especially in the Caribbean, follows. Finally, suggestions are made, for instance psychological aptitude tests, as regards how to maybe help decrease the number of disappearing persons, especially young seafarers, from aboard ships on the high seas.     

Flight-Associated Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 Corroborated by Whole-Genome Sequencing

To investigate potential transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during a domestic flight within Australia, we performed epidemiologic analyses with whole-genome sequencing. Eleven passengers with PCR-confirmed SARS-CoV-2 infection and symptom onset within 48 hours of the flight were considered infectious during travel; 9 had recently disembarked from a cruise ship with a retrospectively identified SARS-CoV-2 outbreak. The virus strain of those on the cruise and the flight was linked (A2-RP) and had not been previously identified in Australia. For 11 passengers, none of whom had traveled on the cruise ship, PCR-confirmed SARS-CoV-2 illness developed between 48 hours and 14 days after the flight. Eight cases were considered flight associated with the distinct SARS-CoV-2 A2-RP strain; the remaining 3 cases (1 with A2-RP) were possibly flight associated. All 11 passengers had been in the same cabin with symptomatic persons who had culture-positive A2-RP virus strain. This investigation provides evidence of flight-associated SARS-CoV-2 transmission.     

Epidemic campylobacteriosis associated with a community water supply.

In May 1983, an estimated 865 cases of epidemic gastrointestinal disease occurred in Greenville, Florida. Surveillance of pharmacy sales of antidiarrheal medicines suggested that the outbreak was confined to Greenville and its immediate vicinity. Surveys demonstrated that the gastrointestinal illness attack rates inside and outside the city limits were 56 per cent (72/128) and 9 per cent (7/77), respectively (relative risk (RR) = 6.2); consumption of city water was associated with illness (RR = 12); and as water consumption increased, the attack rate also increased (p less than 0.001). Four adults were hospitalized and one outbreak-related case of Guillain-Barre' syndrome was identified. Campylobacter jejuni was isolated from specimens from 11 ill persons; serologic studies showed the development of Campylobacter-specific antibodies. Fecal coliforms were found in water samples, but Campylobacter was not recovered from water. The city water plant, a deep well system, had numerous deficiencies including an unlicensed operator, a failure of chlorination, and open-top treatment towers. Birds were observed perching on the open-top treatment tower. Of 38 birds trapped seven weeks later, 37 per cent harbored C. jejuni; however, plasmid and serotyping studies showed that strains were not the same as the common strain from ill persons. This outbreak suggests that water systems that are unprotected from contact with birds may become contaminated and a source of outbreaks of human campylobacteriosis.     

Epidemiology of common-source outbreaks of shigellosis in the United States, 1961-1975.

In 1961-1975, there were 72 foodborne and 38 waterborne outbreaks of shigellosis reported in the United States. Foodborne outbreaks were most often caused by salads with contamination attributed to poor hygiene of a food handler. Waterborne outbreaks most often involved semipublic water systems, and were usually the result of inadequate chlorination of water contaminated by human feces. In 110 common-source outbreaks, 16,541 persons were ill. The attack rate for both food- and waterborne shigellosis was 47%, and the case-fatality ratio was 0.1% in foodborne outbreaks and 0.2% in waterborne outbreaks.     

Rabies risk assessment of exposures to a bat on a commercial airliner - United States, August 2011

On August 5, 2011, a bat flew through the cabin of a commercial airliner minutes after takeoff during an early morning flight from Wisconsin to Georgia, potentially exposing the passengers and flight crew to rabies virus. Three days later, the Wisconsin Division of Public Health (WDPH) requested assistance from CDC to conduct a rabies risk assessment for the passengers, flight crew, and ground crew members associated with the flight. No one was determined to have been exposed to rabies virus based on Advisory Committee on Immunization Practices guidelines for rabies prevention. An environmental assessment of the Wisconsin airport found a rigorous animal control and incident documentation program and no evidence of bat infestation. Although none of the persons assessed required postexposure rabies prophylaxis in this incident, bats active in daylight or found in areas where they are not normally found (e.g., aboard an aircraft) can pose risks for rabies transmission, and public health officials should be prepared to respond to such occurrences.     

Foodborne outbreaks of campylobacteriosis: the United States experience, 1980-1982

During 1980-1982, 23 foodborne outbreaks of diseases caused by Campylobacter were reported to the Centers for Diseases Control through the National Foodborne Surveillance Program, which collects reports from state and territorial epidemiologists throughout the United States. These outbreaks involved 748 ill persons, of whom 4% were hospitalized. For outbreaks with six or more ill persons, the median attack rate was 41%, the mean or median incubation periods ranged from 66 to 120 hours, and the mean duration of symptoms ranged from three to seven days. Raw milk was implicated or suspected in 14 outbreaks. In four of the other outbreaks, food handling errors were identified, and in five outbreaks, poultry, eggs, or beef were implicated or suspected. In three of four outbreaks in which Campylobacter was recovered from cows at the implicated dairies, some isolates from cows were serotypically identical to isolates from ill persons. In one egg-associated outbreak, one of the isolates of Campylobacter recovered from hens at the implicated egg farm was serotypically identical to an isolate recovered from an ill person. These findings underscore the hazard of eating undercooked or raw foods of animal origin such as raw milk. Raw milk contaminated by infected cows is a major cause of foodborne campylobacteriosis in the United States.     

Waterborne Gastroenteritis due to the Norwalk Agent: Clinical and Epidemiologic Investigation

An outbreak of gastroenteritis occurred at a Pennsylvania summer camp in July 1978. Symptoms included abdominal pain (81 per cent), nausea (72 per cent), and vomiting (53 per cent); upper respiratory infection symptoms occurred in 35 per cent of the campers. Illness was associated with consumption of five or more glasses of water or water-containing beverages. Stool cultures from affected persons were negative for bacterial pathogens; however, a fourfold or greater rise to the Norwalk agent was demonstrated in serum samples of three of three ill persons tested and in none of eight controls (p < .02). Campers ill during the first session who were also present during the second session did not become ill during the second session (p < .001). (Am J Public Health 1982; 72:72-74.)     

Umfassende Pflege und Betreuung Schwerkranker und Sterbender am Beispiel ausgewählter Symptome und Interventionen

The special care and attention due to terminally ill and dying patients will be demonstrated in this contribution with the help of specifically chosen paradigm cases and examples. The paper focuses on the needs of dying patients and their (nurs ing) relatives during the last days/hours of life (48-72 hours). Noisy, rattling breathing (death-rattle) and dry mouth (xerostomia) will be introduced as selected symptoms and phenomena together with basic stimulation and subcutaneous therapy as corresponding nursing interventions. Especially subcutaneous therapy has been shown to be a simple, non-invasive, and outstandingly effective option for easing symptoms and suffering of terminally ill people. Furthermore, this contribution wants to stimulate the critical reflection of carers within their own organizational structure in order to foster patient focused, competent, and comprehensive therapy, care, and attention of terminally ill and dying patients during their last days of life.     

A community waterborne outbreak of salmonellosis and the effectiveness of a boil water order.

OBJECTIVES: A 1993 large water-borne outbreak of Salmonella typhimurium infections in Gideon, Mo, a city of 1100 with an unchlorinated community water supply, was investigated to determine the source of contamination and the effectiveness of an order to boil water. METHODS: A survey of household members in Gideon and the surrounding township produced information on diarrheal illness, water consumption, and compliance with the boil water order. RESULTS: More than 650 persons were ill; 15 were hospitalized, and 7 died. Persons consuming city water were more likely to be ill (relative risk [RR] = 9.1, 95% confidence interval [CI] = 2.9, 28.4), and the attack rate increased with increased water consumption. S. typhimurium was recovered from samples taken from a city fire hydrant and a water storage tower. Persons in 31% (30/ 98) of city households had drunk unboiled water after being informed about the boil water order, including 14 individuals who subsequently became ill. Reasons for noncompliance included "not remembering" (44%) and "disbelieving" (25%) the order. CONCLUSIONS: Communities with deteriorating water systems risk widespread illness unless water supplies are properly operated and maintained. Effective education to improve compliance during boil water orders is needed.     

国营航班延误下旅客群体突发事件发生机理与风险控制策略研究

  目的  了解航空旅客焦虑情绪特征及其影响因素,为提高旅客服务质量及完善航空卫生保健机制提供借鉴。  方法  2015年1月 — 2016年12月,采用简单随机抽样法,分别对民航东北、华北、华东、中南、西南等地区的10个机场共计2 526名航空旅客进行特质焦虑量表、简易应对方式量表、自编基于心理需求的焦虑倾向量表调查。  结果  旅客特质焦虑为（38.85 ± 8.23）分、积极应对为（23.65 ± 5.44）分、消极应对为（15.77 ± 3.92）分、焦虑倾向为（70.33 ± 6.55）分。航班延误知情权为（4.01 ± 0.97）分,延误餐宿解决质量为（3.83 ± 0.92）分,航班正点率为（3.68 ± 1.12）分,起飞降落平稳性为（3.62 ± 0.86）分,行李完好性为（3.57 ± 0.91）分,是影响旅客焦虑的主要因素;行李安全与质量[4.43 ± 0.82分],通知及时性[4.28 ± 0.86分],餐宿安排质量[4.27 ± 0.99分],延误知情权[4.25 ± 1.13分],延误赔偿承诺[4.14 ± 0.80分],是旅客最期望解决的因素。不同年龄、飞行时间、出行去向的旅客的特质焦虑差异有统计学意义（均P < 0.001）,不同性别、年龄、飞行频率的旅客的积极应对差异均有统计学意义（均P < 0.05）,不同性别、年龄、飞行频率、飞行时间、出行方向的旅客的消极应对差异均有统计学意义（均P < 0.01）,不同性别、年龄、飞行频率、飞行时间、出行方向的旅客的焦虑倾向差异均有统计学意义（均P < 0.001）。特质焦虑、应对方式、焦虑倾向之间均呈明显相关关系。应对方式在特质焦虑与焦虑倾向间的多重中介效应显著,其效应量占总效应量的34.8 %;积极应对、消极应对的中介作用效应显著,其中介效应量分别占间接效应的60.5 %、39.5 %。61.8 %、41.6 %、35.9 %、32.3 %、31.8 %的旅客分别在航班延误、起飞、提取行李、候机、值机阶段产生焦虑情绪,41.8 %、32.5 %、31.8 %、21.9 %的旅客分别伴随有心跳加速、耳痛、头晕头痛、恶心等身体症状,51.5 %、44.2 %的旅客常以睡觉、听音乐/看报/看视频等方式来应对。  结论  航空公司、机场等运营管理部门可在航班延误应急处置、行李安全质量保障、客舱服务等方面制定针对性强的管理策略与服务模式,提升旅客卫生保健工作质量与效率。     

Epidemiological features of and public health response to a St. Louis encephalitis epidemic in Florida, 1990-1

A St. Louis encephalitis (SLE) epidemic in Florida during 25 weeks in 1990-1, resulted in 222 laboratory-diagnosed cases, an attack rate in the 28 affected counties of 2.25/100,000. Disease risk rose with advanced age, to 17.14/100,000 in persons over 80 years, and all 14 fatal cases were in persons over 55 years (median, 70 years). Community serosurveys in Indian River County, the epicenter of the outbreak (attack rate 21/100,000), showed acute asymptomatic infections in 3.6% of the persons surveyed, with higher rates in persons with outdoor occupational exposure (7.4%) and in clients of a shelter for the indigent (13.3%). A matched case-control study found that evening outdoor exposure for more than 2 h was associated with an increased risk for acquiring illness (odds ratio [OR] 4.33, 95% CI 1.23-15.21) while a number of recommended personal protective measures were protective. Four SLE patients were dually infected with Highlands J virus, the first reported cases of acute infection with this alphavirus. The case-control study provided the first evidence that a public education campaign to reduce exposure had a protective effect against acquiring the disease.     

Norwalk-related viral gastroenteritis due to contaminated drinking water

An explosive outbreak of gastrointestinal illness clinically compatible with infection by an agent serologically related to Norwalk virus agent occurred in an elementary school in May 1978. Seroconversion by radioimmunoassay to the Norwalk antigen was noted in two of three ill persons, but no viral particles were identified in stool. Illness developed in 72% of students and teachers at the school, and 32% of household contacts of these ill persons. Of household contacts of persons exposed at school but not clinically ill, 11% developed illness. This value, however, was not statistically different from the level of illness observed concurrently in household contacts of students at an unaffected school nearby. Epidemiologic investigation implicated water as the mode of transmission. Average consumption of one or more glasses per day was strongly associated with illness (p less than 0.00000001). Among soccer team members with limited school contact, water consumption at the school was associated with a 14-fold greater risk of illness (p less than 0.000001). Drinking water was most likely contaminated by back-siphonage through a cross-connection between the school's well and septic tank. This contamination occurred approximately 24 to 36 hours before the outbreak developed.     

Study of prevalence of chronic illness in a semiurban community in Pune Cantonment by household interview method.

A household interview survey of 200 households in a semiurban community in Pune Cantonment carried out during 1979 revealed a prevalence rate (persons, 109/1000 of chronic illness. Prevalence rate (No. of illnesses) was 140/1000. Multiple illnesses were found among 23.5 percent of ill persons. The present survey has been found to bring out the nature and extent of the problem of chronic illness as perceived by the community and relationship of chronic illness to social factors. The information, can be useful for public health and further research.     

Cruise-ship--associated Legionnaires disease, November 2003-May 2004

More than 9.4 million passengers traveled on pleasure cruises departing from North American ports in 2004, an increase of 13% since 2003 and 41% since 2001. Cruise ships typically transport closed populations of thousands of persons, often from diverse parts of the world. Travelers are at risk for becoming ill while on board, most commonly from person-to-person spread of viral gastrointestinal illnesses. Certain environmental organisms, such as Legionella spp., pose a risk to vulnerable passengers. During November 2003-May 2004, eight cases of Legionnaires disease (LD) among persons who had recently traveled on cruise ships were reported to CDC. This report describes these cases to raise clinician awareness of the potential for cruise-ship--associated LD and to emphasize the need for identification and reporting of cases to facilitate investigation.     

An outbreak of a food-related illness resembling boric acid poisoning

An outbreak of an illness suggestive of boric acid poisoning occurred among 51 persons who had eaten lunch at the cafeteria of the United States Agency for International Development in Islamabad, Pakistan, on February 11, 1990. Affected patients had headache and severe myalgias 2 to 4 hours after eating lunch. Fever, nausea and vomiting, red eyes, and photophobia were also reported. Among 25 patients (49%), a sunburn-like inflammation of the skin of the face developed, which subsequently desquamated. One patient required hospitalization for 1 day because of dehydration. Among all patients, the only symptoms remaining 72 hours after the meal were mild headache, fatigue, and peeling skin. Those persons who became ill were more likely to have eaten one particular food item (minestrone soup) for lunch than were those who did not become ill. A similar illness has been described following ingestion of boric acid. However, the results of an analysis of serum samples collected 3 days after the lunch from 24 patients did not show boron above normal background levels. Because of boron's short half-life, however, these data do not rule out the possibility that patients may have had higher boron levels at the onset of the illness.