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Archive for the ‘Outbreaks’ Category

Pertussis: Global Trends in Incidence and Vaccine Uptake

Recent pertussis outbreaks are of concern, but should not overshadow a dramatic decrease in disease rates documented during the past three decades. [1] In the following chart, I’ve compared regional trends in pertussis reporting and W.H.O. estimates of vaccine uptake [2] Note that vaccine coverage has changed little since 1990.


2. Berger S. Pertussis: Global Status, 2013. 353 pages, 511 graphs, 648 references. Gideon e-books,

Trichinosis: Cross-border Episodes

A recent trichinosis outbreak in Belgium related to Spanish boar meat reflects the continued high incidence of trichinosis in Spain. In fact, trichinosis rates in Spain are comparable to those which have not been encountered in the United States for more than 50 years [1,2] – see graph.

Cross-border incidents of trichinosis are relatively uncommon. The following chronology, including cases related to importation or human travel, is abstracted from Gideon (primary references available on request)

1975 – An outbreak (125 cases) of trichinosis in France was traced to horse meat imported from Poland.
1976 (publication year) – An outbreak (6 cases) in Paris was associated with travel to Egypt.
1985 – Outbreaks (1,073 cases, 2 fatal) in France were caused by horse meat imported from Germany and the United States.
1986 (publication year) – An outbreak (20 cases) among Gurkha soldiers serving in Hong Kong was associated with a barbecue.
1986 – An outbreak (2 cases) was reported among French-Vietnamese nationals who had eaten pork sausages at a diplomatic reception in Laos.
1990 – An outbreak (90 cases) among Southeast Asian refugees in the United States and Canada was associated with uncooked commercial pork served at a wedding in Des Moines, Iowa. This was the fourth outbreak reported since 1975 among Southeast Asian refugees in North America.
1992 – The world’s first case of human infection by Trichinella pseudospiralis was reported in New Zealand – probably acquired in Tasmania, Australia.
1982 – An outbreak (1,000 cases or more) was reported in the southern region of Lebanon – including six cases hospitalized in Israel.
1993 – An outbreak (538 cases) in France was traced to the meat of a single horse imported from Canada.
1994 – An outbreak (7 cases) in France was associated with horsemeat imported from Mexico.
1995 (publication year) – An outbreak (8 cases) in Germany and the former Yugoslavia involved family members who had shared smoked ham.
1995 to 1996 – A single case of trichinosis was reported in Japan – acquired during travel to Poland.
1997 – A Japanese traveler acquired trichinosis from smoked bear meat while in China.
1998 – An outbreak (404 cases, 37 hospitalized) in the France was related to consumption of meat from horse which had been imported from Yugoslavia.
1998 – An outbreak (92 cases, 0 fatal) in Italy was ascribed to imported Polish horsemeat.
1998 to 1999 – An outbreak (44 cases) in Germany was ascribed to raw smoked sausage (mettwurst) imported from Spain.
1999 – An outbreak (8 cases) among Yugoslavian immigrants in the United Kingdom was ascribed to salami imported from Serbia.
2000 (publication year) – An outbreak (25 cases) was reported among travelers returning to Singapore from a neighboring country.
2000 – An outbreak (8 cases) in England and Wales was ascribed to ingestion of imported meat products.
2001 – An outbreak (7 cases, none fatal) among Eastern European immigrants living in Rome was ascribed to imported pork sausage.
2002 – An outbreak (3 cases) in Germany was caused by infested smoked wild boar meat imported by travelers from Romania.
2002 – An outbreak (30 cases, 0 fatal) was reported among Thai workers in the Israel who had ingested the meat of a wild pig.
2003 (publication year) – An outbreak in Germany was reported among members of a family from Bosnia.
2003 (publication year) – A Japanese national acquired trichinosis in Kenya.
2004 – An expatriate developed Trichinella britovi infection in France from barbecued leg of jackal (Canis aureus) eaten in Algeria.
2004 – Two of the three cases of Trichinosis reported in the Czech Republic had been acquired in Poland and Macedonia.
2004 – An expatriate from New Zealand acquired trichinosis in Laos.
2004 – An outbreak (7 cases) of trichinellosis was reported Danes who had eaten home-made sausage purchased in Romania.
2004 (publication year) – An outbreak (2 cases) was reported in the Netherlands among family members who has consumed infested pork in Montenegro.
2005 – An outbreak (9 cases) of Trichinella nativa infection among French hunters in Canada was caused by contaminated bear meat. Eight additional cases were reported among persons in France who shared imported meat.
2006 – An outbreak (49 cases) in China was related to meat imported from Laos.
2007 – An outbreak (214 cases) in Poland was ascribed to contaminated raw sausage. Five cases in Germany, two in Ireland and 1 in Denmark were related to travel in the area of the outbreak.
2007 – An outbreak (21 cases) of Trichinella britovi infection among persons in Spain and Sweden was related to Spanish wild boar sausage.
2007 – An outbreak (3 cases) in Germany was caused by contaminated cured sausage eaten in Romania.
2008 – An outbreak (4 cases, 0 fatal) of trichinosis in Italy was reported among persons who had ingested infested pork in Romania.
2008 – An outbreak (8 cases) of human trichinosis associated with ingestion of raw soft-shelled turtles (Pelodiscus sinensis) was reported in Taiwan, including two cases exported to Japan. The pathogen in this case may have been Trichinella papuae.
2009 – An outbreak (3 cases) of trichinosis was reported among French nationals who had ingested warthog ham in Senegal.
2009 – An outbreak (5 cases) was reported among French tourists who ingested the meat of a grizzly bear while on a boating trip in Canada.
2009 – An outbreak of trichinosis among boar hunters in Bosnia was associated with a case hospitalized in Switzerland.
2010 – A case in Scotland was ascribed to ingestion of meat imported from France.
2011 (publication year) – A Thai worker acquired Trichinella papuae trichinosis from wild boar meat in Malaysia.

1. Berger SA. Infectious Diseases of Spain, 2014. 623 pages, 194 graphs, 3,844 references. Gideon e-books.
2. Berger SA. Trichinosis: Global Status, 2014. 90 pages, 73 graphs, 894 references. Gideon e-books.

Diagnosis Support for Ebola through GIDEON

The Diagnosis module of Gideon is designed to generate a ranked differential diagnosis list for any Infectious Diseases scenario. In recent weeks, we’ve been running simulations of Ebola. The following link will access a Power Point “show” demonstrating one such scenario. Ebola case (Powerpoint)

Ebola Deaths in Perspective

Recent events in West Africa have largely eclipsed several other ongoing outbreaks on the global stage. For example, over 780,000 cases of Chikungunya have been reported in the western hemisphere in recent months, including 1,371 cases in the United States (vs. only 4 of Ebola). Obviously, the severity of Ebola far outweighs that of Chikungunya; thus, the ratio of reported Chikungunya cases to Ebola cases (772,069 / 10,141) is 76-to-1, the ratio of Ebola deaths to Chikungunya deaths (4,922 / 118) is 73-to-1.

Sadly, one ongoing epidemic which is more severe than Ebola in both disease numbers and mortality, receives little notice from the lay media. The last available publication on cholera in Haiti reported 780,541 cases (8,562 fatal) as compared to 10,041 (4,922 fatal) of Ebola. As of October 28, cases of both diseases had been reported in nine additional countries.

The following graph illustrates mortality figures for some ongoing Infectious Disease outbreaks (I’ve added SARS for historic impact). The lower row records the number of countries which reported cases originating in the outbreak epicenter.

Outbreak Deaths

Chikungunya – Coming to America ?

Chikungunya and Zika: Global Status

Chikunguna is hardly a “household” word in the United States; but we may all be talking about the disease very soon! This viral infection, transmitted by mosquitoes, is associated with high fever, rash and severe joint pains. Even after recovery, the pains may persist for many months. Originally described in Africa, the disease spread to Asia, causing an epidemic of over 1.5 million cases in India during 2006 to 2007. At one point, an Indian traveler carried the infection to Italy, resulting in hundreds of cases in the region of Ravenna.

During the first half of 2014, new outbreaks were reported in the South Pacific; and in a period of only five months, over 660,000 cases have occurred in the Caribbean, involving essentially all regional islands and several mainland countriues. Once a “rare tropical disease”, Chikungunya is now endemic to at least 75 countries. Few realize that the mosquitoes which transmit Chikungunya in Africa, India, Italy and the Caribbean are also found in Florida and Texas. 750 imported cases have already been reported on the U.S. mainland during 2014, and it may be only a matter of time until a mosquito bites one such case, and begins a chain of transmission to the local population (as occurred in Italy in 2007).

Chikungunya and Zika – Global Status, 2014 is the most up-to-date book on the subject of Chikungunya. (The volume also covers Zika, another emerging mosquito virus disease). The book presents a thorough review of global and country-specific epidemiology, as well as complete background information on the history and clinical features of Chikungunya, including 22 graphs and 1,626 linked references. The next updated version will be released in early 2015. Further specs are available at

Ebola – The Book

Ebola: Global StatusA disease which was relatively unknown to most people – and even most health care professionals – has suddenly become a household word throughout the world. As of September 2014, over 2,000 people have died in the largest recorded outbreak of Ebola. Ebola: Global Status, 2014, the most up-to-date book written on the disease, examines the history, clinical features and epidemiology of Ebola virus infection. A country-by-country chronology presents all aspects of Ebola, including a relatively obscure outbreak which occurred among monkeys in the Philippines, and later spread to Texas.

For further specs on Ebola: Global Status, 2014, see The next yearly update of the book will be released in early 2015.

Correction: The original text inadvertently stated that this was the only book on the subject. This has been re-edited to state that this is “the most up-to-date book written on the disease.”

Campylobacteriosis in Iceland

A recent posting in ProMED belies the fact that Iceland reports the lowest rates of campylobacteriosis in that region of Europe. [1-2] See graph [3] Note that an earlier outbreak (436 cases) was reported in 1999.


1. Berger SA. Infectious Diseases of Iceland, 2014 371 pages, 75 graphs, 1,455 references. Gideon e-books,
2. Berger SA. Campylobacteriosis: Global Status, 2014 104 pages, 96 graphs, 1,073 references. Gideon e-books,
3. Gideon graph tool at

Outbreaks of Non-tubercuous Mycobacterial Infection in the United States

The following chronology of nosocomial mycobacteriosis outbreaks in the United States is abstracted from Gideon and the Gideon e-book series. [1,2] Primary references available on request.

1987 – An outbreak (17 cases) of Mycobacterium chelonae otitis media was caused by contaminated water used by an ENT practice in Louisiana.
1988 – An outbreak (8 cases) of foot infections due to Mycobacterium chelonae subspecies abscessus infections were associated with a jet injector used in a podiatric office.
1989 to 1990 – An outbreak (16 cases) of sputum colonization by Mycobacterium fortuitum was reported among patients on an alcoholism rehabilitation ward in Washington, D.C.
1991 (publication year) – An outbreak (6 cases) of Mycobacterium fortuitum infection in Washington was associated with contaminated electromyography needles.
1995 to 1996 – An outbreak (87 cases) of postinjection abscesses due to Mycobacterium abscessus in several states was ascribed to an adrenal cortex extract.
1998 – An outbreak (6 cases) of Mycobacterium mucogenicum bacteremia among bone marrow transplant and oncology patients in Minnesota was related to contaminated water.
1999 – An outbreak (10 cases) of intra- and periarticular Mycobacterium abscessus infection in Texas was caused by contaminated benzalkonium chloride used for injection.
2000 to 2001 – An outbreak (110 cases) of skin infections due to Mycobacterium fortuitum was caused by contaminated footbaths in California nail salons.
2001 – An outbreak of Mycobacterium chelonae keratitis in California was associated with laser in situ keratomileusis (LASIK).
2001 to 2002 – An outbreak of Mycobacterium simiae in a Texas hospital was related to contaminated tap water.
2002 – An outbreak (14 confirmed and 11 suspected cases) of soft tissue infections due to Mycobacterium abscessus followed injections of cosmetic substances administered by unlicensed practitioners in New York City.
2002 – An outbreak (115 cases or more) of cutaneous infection by Mycobacterium fortuitum was associated with a contaminated footbath in a nail salon in California.
2002 (publication year) – An outbreak (34 cases) of Mycobacterium chelonae soft tissue infection in California was associated with liposuction.
2002 to 2003 – An outbreak (4 cases) of Mycobacterium chelonae infection among patients undergoing rhytidectomies in New Jersey was caused by a contaminated methylene blue solution.
2003 – An outbreak (3 cases) of Mycobacterium goodii infection was associated with surgical implants in a Colorado hospital.
2004 – An outbreak (12 cases) among Americans of soft tissue infections caused by Mycobacterium abscessus following cosmetic surgery performed at various clinics in the Dominican Republic.
2004 – An outbreak (143 cases) of mycobacterial skin and soft tissue infection (presumed M. fortuitum) was reported among persons attending nail salons in California.
2008 – An outbreak (4 cases) of Mycobacterium mucogenicum bloodstream infections was reported among patients with sickle cell disease, in North Carolina.
2009 (publication year) – An outbreak (6 cases) of Mycobacterium chelonae infection was associated with a tattoo establishment.
2009 – An outbreak (2 cases, 1 confirmed) of Mycobacterium haemophilum skin infection was associated with a tattoo parlor in Washington State.
2011 (publication year) – An outbreak (3 cases) of Mycobacterium bolletii/M. massiliense furunculosis was associated with a nail salon in North Carolina.
2011 (publication year) – An outbreak of Mycobacterium abscessus infection was associated with outpatient rhytidectomies.
2011 – An outbreak (2 cases) of Mycobacterium haemophilum infection was reported among persons receiving tattoos in the Seattle, Washington region. {m 201108122444}
2011 (publication year) – An outbreak (11 cases) of Mycobacterium porcinum infection in a Texas hospital was related to contamination of drinking water.
2011 to 2012 – An outbreak (19 cases) of Mycobacterium chelonae infection involving multiple states was associated with contaminated ink used in tattoo parlors.
2011 to 2012 – An outbreak (15 cases) of infection by rapidly-growing mycobacteria was reported among pediatric hematopoietic cell transplant in a Minnesota hospital.
2013 – An outbreak (2 cases) of non-tuberculous mycobacterial infection was associated with fractionated CO2 laser resurfacing procedures performed at a clinic in North Carolina.
2013 to 2014 – An outbreak (19 cases) wound infection was reported among Americans who had traveled to the Dominican Republic for cosmetic surgery – including 12 due to Mycobacterium abscessus and 2 Mycobacterium fortuitum
2014 – An outbreak (15 cases, 4 fatal) of Mycobacterium abscessus infection in a South Carolina hospital was associated with contact of equipment with contaminated tap water.

1. Berger SA. Infectious Diseases of the United States, 2014. 1145 pages, 478 graphs, 12,294 references. Gideon e-books,
2. Berger SA. Non-Tuberculous Mycobacteria: Global Status, 2014. 61 pages, 31 graphs, 584 references. Gideon e-books,

Note featured on ProMED

Bacterial Diarrhea in Australia

Notwithstanding recent outbreaks among men-who-have-sex-with-men, the incidence of shigellosis in Australia has remained remarkably constant for over eighty years. In the following graph I’ve contrasted disease rates in Australia and New Zealand with those reported in the United States. [1-3]


In fact, most other forms of bacterial diarrhea have become far more common than shigellosis in Australia – see graph:


1. Berger SA. Infectious Diseases of Australia, 2014. 575 pages, 163 graphs, 3,658 references. Gideon e-books,
2. Berger SA. Shigellosis: Global Status, 2014.
162 pages, 199 graphs, 1,076 references. Gideon e-books,
3. Gideon graph tool –

Hepatitis A in Asian Russia

Reported rates of Hepatiis A for Uzbekistan and bordering countries are strikingly similar, and somewhat higher of those for the Russian Federation. [1,2] See graph [3]:


1. Berger SA. Infectious Diseases of Uzbekistan, 2013. 354 pages, 74 graphs, 69 references.
2. Berger SA. Hepatitis A: Global Status, 2013. 169 pages, 182 graphs, 1274 references.
3. Gideon Graph Tool, see tutorial at Gideon-Graphs.pps

Note featured on ProMED