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PubMed2005

Evaluation of school absenteeism data for early outbreak detection, New York City.

BACKGROUND: School absenteeism data may have utility as an early indicator of disease outbreaks, however their value should be critically examined. This paper describes an evaluation of the utility of school absenteeism data for early outbreak detection in New York City (NYC). METHODS: To assess citywide temporal trends in absenteeism, we downloaded three years (2001-02, 2002-03, 2003-04) of daily school attendance data from the NYC Department of Education (DOE) website. We applied the CuSum method to identify aberrations in the adjusted daily percent absent. A spatial scan statistic was used to assess geographic clustering in absenteeism for the 2001-02 academic year. RESULTS: Moderate increases in absenteeism were observed among children during peak influenza season. Spatial analysis detected 790 significant clusters of absenteeism among elementary school children (p < 0.01), two of which occurred during a previously reported outbreak. CONCLUSION: Monitoring school absenteeism may be moderately useful for detecting large citywide epidemics, however, school-level data were noisy and we were unable to demonstrate any practical value in using cluster analysis to detect localized outbreaks. Based on these results, we will not implement prospective monitoring of school absenteeism data, but are evaluating the utility of more specific school-based data for outbreak detection.

Absenteeism↗

PubMed2005

Using autoregressive integrated moving average (ARIMA) models to predict and monitor the number of beds occupied during a SARS outbreak in a tertiary hospital in Singapore.

BACKGROUND: The main objective of this study is to apply autoregressive integrated moving average (ARIMA) models to make real-time predictions on the number of beds occupied in Tan Tock Seng Hospital, during the recent SARS outbreak. METHODS: This is a retrospective study design. Hospital admission and occupancy data for isolation beds was collected from Tan Tock Seng hospital for the period 14th March 2003 to 31st May 2003. The main outcome measure was daily number of isolation beds occupied by SARS patients. Among the covariates considered were daily number of people screened, daily number of people admitted (including observation, suspect and probable cases) and days from the most recent significant event discovery. We utilized the following strategy for the analysis. Firstly, we split the outbreak data into two. Data from 14th March to 21st April 2003 was used for model development. We used structural ARIMA models in an attempt to model the number of beds occupied. Estimation is via the maximum likelihood method using the Kalman filter. For the ARIMA model parameters, we considered the simplest parsimonious lowest order model. RESULTS: We found that the ARIMA (1,0,3) model was able to describe and predict the number of beds occupied during the SARS outbreak well. The mean absolute percentage error (MAPE) for the training set and validation set were 5.7% and 8.6% respectively, which we found was reasonable for use in the hospital setting. Furthermore, the model also provided three-day forecasts of the number of beds required. Total number of admissions and probable cases admitted on the previous day were also found to be independent prognostic factors of bed occupancy. CONCLUSION: ARIMA models provide useful tools for administrators and clinicians in planning for real-time bed capacity during an outbreak of an infectious disease such as SARS. The model could well be used in planning for bed-capacity during outbreaks of other infectious diseases as well.

Bed Occupancy↗

PubMed2006

The time-course of a scrapie outbreak.

BACKGROUND: Because the incubation period of scrapie has a strong host genetic component and a dose-response relationship, it is possible that changes will occur during an outbreak, especially in the genotypes of cases, age-at-onset of disease and, perhaps, the clinical signs displayed. We investigated these factors for a large outbreak of natural scrapie, which yielded sufficient data to detect temporal trends. RESULTS: Cases occurred mostly in two genotypes, VRQ/VRQ and VRQ/ARQ, with those early in the outbreak more likely to be of the VRQ/VRQ genotype. As the epidemic progressed, the age-at-onset of disease increased, which reflected changes in the genotypes of cases rather than changes in the age-at-onset within genotypes. Clinical signs of cases changed over the course of the outbreak. As the epidemic progressed VRQ/VRQ and VRQ/ARQ sheep were more likely to be reported with behavioural changes, while VRQ/VRQ sheep only were less likely to be reported with loss of condition. CONCLUSION: This study of one of the largest scrapie outbreaks in the UK allowed investigation of the effect of PrP genotype on other epidemiological parameters. Our analysis indicated that, although age-at-onset and clinical signs changed over time, the observed changes were largely, but not exclusively, driven by the time course of the PrP genotypes of cases.

Aging↗

PubMed2004

Loss of paramedic availability in an urban emergency medical services system during a severe acute respiratory syndrome outbreak.

OBJECTIVES: To describe the loss of paramedic availability to Toronto Emergency Medical Services during a biphasic (SARS-1 and SARS-2) outbreak of severe acute respiratory syndrome (SARS). METHODS: During the SARS outbreak, a dedicated paramedic surveillance and quarantine program was developed. The authors determined the number of paramedics on quarantine each day, the type of quarantine (either home quarantine [HQ] or work quarantine [WQ]), and the development of SARS-like symptoms. RESULTS: During the SARS outbreak, there were five cases of probable SARS and three cases of suspect SARS. SARS-1 lasted 30 days, during which 234 paramedics were placed on HQ. The total number of HQ days was 1,615. During the five peak days of SARS-1, the total number of HQ days was 664. SARS-2 lasted 18 days, during which 292 paramedics were placed on either HQ or WQ, for a combined number of quarantine days of 1,637. During the five peak days of SARS-2, the combined number of quarantine days was 910. Of these, paramedics were available for duty on 708 days (78%) due to the WQ program. The primary reason for quarantine was unprotected exposure to a health care institution experiencing a SARS outbreak. Under quarantine, SARS-like symptoms developed in 68 paramedics, including cough (53 [78%]), myalgia (33 [48%]), fatigue (30 [44%]), headache (29 [43%]), fever (11 [16%]), and shortness of breath (7 [10%]). CONCLUSIONS: Paramedics were among the health care workers who developed SARS. During SARS-2, WQ optimized the number of days on which paramedics were available for duty. Many paramedics developed SARS-like symptoms without being diagnosed as having SARS. A dedicated paramedic surveillance and quarantine program provided a useful means to manage the paramedic resource during the SARS outbreak.

Absenteeism↗

PubMed2000

Economic aspects of food-borne outbreaks and their control.

This paper begins with a discussion of the definition of an outbreak. It considers the portion of outbreaks in the general pattern of food-borne infectious disease. The methods used to identify outbreaks are described and the importance of the potential benefits and the economic impact of outbreak recognition and control and are discussed. The paper concludes by illustrating the economic impact of intervention using three infectious diseases botulism, Salmonella and Escherichia coli O157 as case studies of outbreaks.

Costs and Cost Analysis↗

PubMed1992

Theoretical epidemiology on bovine ephemeral fever outbreaks in Tanegashima Island, Kagoshima Prefecture of Japan in 1988.

From the end of September to November 1988, a compact scale of bovine ephemeral fever (BEF) outbreaks occurred suddenly in Tanegashima island of Kagoshima Prefecture, southern part of Kyusyu island of Japan. The BEF outbreak pattern showed epidemical characteristics as follows; (1) outbreak spread from few foci to zone during one month, and (2) the disease might be transmitted in farms with a fixed probability of adequate contact. By using the above aspects, we attempted to analyze the disease theoretically with the application of Poisson distribution and Reed-Frost model. The BEF incidence in farms was in well accord with the Poisson distribution. As the very rare event occurred in unit time or in unit area in this epidemic, the cattle population at risk were equivalently susceptible to BEF virus in this island, due to the influence of no vaccination to BEF control before the first outbreak. Similarly, the epidemic curve of the Reed-Frost model was proved to fit well the incidence observed in a farm, and the probability of adequate contact was induced as p = 0.226. If the cattle population is less than 5 in this farm, the outbreak would not occur in the first instance.

Animals↗

PubMed2026

Outbreaks of fluconazole-resistant Candida parapsilosis are driven by low-biofilm-producing isolates that emerge under host selection.

Candida parapsilosis is a major human fungal pathogen, with recent global outbreaks driven by fluconazole-resistant (FLCR-Cp) isolates that are difficult to eradicate and associated with poor clinical outcomes. However, the microbial traits enabling persistence of these outbreak lineages remain poorly defined. Here, we show that FLCR-Cp isolates responsible for prolonged, multi-country outbreaks consistently exhibit a striking low-biofilm-producing (LBP) phenotype. Contrary to the prevailing view that robust biofilm formation promotes persistence, LBP strains displayed enhanced stress tolerance, increased cell wall masking, and reduced immune recognition. These traits conferred resistance to neutrophil and macrophage killing and enhanced survival in immune cell-rich organs during systemic infection. Genome-wide transcriptomic profiling revealed extensive metabolic and regulatory rewiring in LBP strains. Whole-genome sequencing (WGS) of a global isolate collection further demonstrated that the LBP phenotype has emerged independently multiple times, supporting convergent evolution under host selection. Functional genomic analyses suggest that biofilm attenuation arises through multigenic changes, and disruption of key biofilm-associated transcriptional regulators enhanced fitness during immune interactions. Together, our findings overturn the assumption that robust biofilm formation drives outbreak persistence and instead identify biofilm attenuation as an adaptive tradeoff that promotes immune evasion and long-term survival. These results redefine our understanding of C. parapsilosis adaptation during healthcare-associated outbreaks and shift attention toward host-driven evolutionary processes than environmental persistence alone.

Biofilms↗

PubMed2026

Methods for cost-efficient, whole genome sequencing surveillance for enhanced detection of outbreaks in a hospital setting.

INTRODUCTION: Outbreaks of healthcare-associated infections (HAI) result in substantial patient morbidity and mortality; mitigation efforts by infection prevention teams have the potential to curb outbreaks and prevent transmission to additional patients. The incorporation of whole genome sequencing (WGS) surveillance of suspected high-risk pathogens often identifies outbreaks that are not detected by traditional infection prevention methods and provides evidence for transmission. Our approach to real-time WGS surveillance, the Enhanced Detection System for Healthcare-Associated Transmission (EDS-HAT), has 1) identified serious outbreaks that were otherwise undetected and 2) shown the potential to be cost saving. METHODS: We describe our cost-efficient methods to perform WGS surveillance and data analysis of pathogens for institutions that are interested in expanding infection prevention surveillance. We provide an overview of the weekly workflow of EDS-HAT during two distinct phases over three years. RESULTS: In an average week at our tertiary healthcare system, we sequenced 60 samples at a cost of less than $100 each during Phase 1, and 80 samples for less than $70 each in Phase 2, inclusive of laboratory reagents and staff salaries. The average turnaround time, from sample collection to reporting data to infection prevention, was nine days. CONCLUSIONS: Performing EDS-HAT in real-time can be both feasible and time-efficient. Providing such timely information to aid in outbreak detection could identify transmission events sooner and thus could increase patient safety.

Disease Outbreaks↗

PubMed1997

Heterogeneous Serratia marcescens genotypes from a nosocomial pediatric outbreak.

OBJECTIVE: Define the applicability of a rapid molecular typing scheme to study the epidemiology of a Serratia marcescens outbreak. DESIGN: With the assistance of a simple bacterial lysis technique, isolates of S marcescens from a putative outbreak were genotyped with the polymerase chain reaction technology for which primers were chosen on the basis of previously defined enterobacterial repetitive intergenic consensus sequences. SETTING: Pediatric ICU. PATIENTS: Intensively monitored patients who were found to yield S marcescens from any body site during the epidemic period. RESULTS: Over an 8-month period, 12 ICU patients were either infected or colonized with S marcescens. All of these patients were transiently supported by artificial ventilation. During the epidemiologic investigation, a dilution error in a high-level glutaraldehyde disinfectant, which was being used for some ventilator components, was observed. Rectification of the error was associated with an abrupt termination of the outbreak. Enterobacterial repetitive intergenic consensus polymerase chain reaction was easily applicable to this setting and it defined 4 distinct genotypes among the 12 isolates. CONCLUSION: The typing method is easily implemented and offers great promise as an epidemiologic tool. The associated investigation served to emphasize that an outbreak may occur with more than one epidemic strain and that strain heterogeneity itself does not exclude an outbreak.

Bacterial Typing Techniques↗

PubMed2007

Protective measures and human antibody response during an avian influenza H7N3 outbreak in poultry in British Columbia, Canada.

BACKGROUND: In 2004 an outbreak of avian influenza of the H7N3 subtype occurred among poultry in British Columbia, Canada. We report compliance with recommended protective measures and associated human infections during this outbreak. METHODS: We sought voluntary participation by anyone (cullers, farmers and their families) involved in efforts to control the poultry outbreak. Recruitment was by advertisements at the worker deployment site, in local media and through newsletters sent directly to farmers. Sera were tested for antibody to H7N3 by microneutralization assay. A subset of 16 sera (including convalescent sera from 2 unprotected workers with conjunctivitis from whom virus had been isolated) was further tested by Western blot and routine and modified hemagglutination inhibition assays. RESULTS: A total of 167 people (20% to 25% of all workers) participated between May 7 and July 26, 2004. Of these, 19 had experienced influenza-like illness and 21 had experienced red or watery eyes. There was no significant association between illness reports and exposure to infected birds. Among 65 people who entered barns with infected birds, 55 (85%) had received influenza vaccine, 48 (74%) had received oseltamivir, and 55 (85%), 54 (83%) and 36 (55%) reported always wearing gloves, mask or goggles, respectively. Antibody to the H7 subtype was not detected in any sera. INTERPRETATION: During the BC outbreak, compliance with recommended protective measures, especially goggles, was incomplete. Multiple back-up precautions, including oseltamivir prophylaxis, may prevent human infections and should be readily accessible and consistently used by those involved in the control of future outbreaks of avian influenza in poultry. Localized human avian influenza infections may not result in serologic response despite confirmed viral detection and culture.

Adolescent↗

PubMed2005

Outbreak of osteomyelitis/septic arthritis caused by Kingella kingae among child care center attendees.

OBJECTIVE: Kingella kingae often colonizes the oropharyngeal and respiratory tracts of children but infrequently causes invasive disease. In mid-October 2003, 2 confirmed and 1 probable case of K kingae osteomyelitis/septic arthritis occurred among children in the same 16- to 24-month-old toddler classroom of a child care center. The objective of this study was to investigate the epidemiology of K kingae colonization and invasive disease among child care attendees. METHODS: Staff at the center were interviewed, and a site visit was performed. Oropharyngeal cultures were obtained from the staff and children aged 0 to 5 years to assess the prevalence of Kingella colonization. Bacterial isolates were subtyped by pulsed-field gel electrophoresis (PFGE), and DNA sequencing of the 16S rRNA gene was performed. A telephone survey inquiring about potential risk factors and the general health of each child was also conducted. All children and staff in the affected toddler classroom were given rifampin prophylaxis and recultured 10 to 14 days later. For epidemiologic and microbiologic comparison, oropharyngeal cultures were obtained from a cohort of children at a control child care center with similar demographics and were analyzed using the same laboratory methods. The main outcome measures were prevalence and risk factors for colonization and invasive disease and comparison of bacterial isolates by molecular subtyping and DNA sequencing. RESULTS: The 2 confirmed case patients required hospitalization, surgical debridement, and intravenous antibiotic therapy. The probable case patient was initially misdiagnosed; MRI 16 days later revealed evidence of ankle osteomyelitis. The site visit revealed no obvious outbreak source. Of 122 children in the center, 115 (94%) were cultured. Fifteen (13%) were colonized with K kingae, with the highest prevalence in the affected toddler classroom (9 [45%] of 20 children; all case patients tested negative but had received antibiotics). Six colonized children were distributed among the older classrooms; 2 were siblings of colonized toddlers. No staff (n = 28) or children aged <16 months were colonized. Isolates from the 2 confirmed case patients and from the colonized children had an indistinguishable PFGE pattern. No risk factors for invasive disease or colonization were identified from the telephone survey. Of the 9 colonized toddlers who took rifampin, 3 (33%) remained positive on reculture; an additional toddler, initially negative, was positive on reculture. The children of the control child care center demonstrated a similar degree and distribution of K kingae colonization; of 118 potential subjects, 45 (38%) underwent oropharyngeal culture, and 7 (16%) were colonized with K kingae. The highest prevalence again occurred in the toddler classrooms. All 7 isolates from the control facility had an indistinguishable PFGE pattern; this pattern differed from the PFGE pattern observed from the outbreak center isolates. 16S rRNA gene sequencing demonstrated that the outbreak K kingae strain exhibited >98% homology to the ATCC-type strain, although several sequence deviations were present. Sequencing of the control center strain demonstrated more homology to the outbreak center strain than to the ATCC-type strain. CONCLUSIONS: This is the first reported outbreak of invasive K kingae disease. The high prevalence in the affected toddler class and the matching PFGE pattern are consistent with child-to-child transmission within the child care center. Rifampin was modestly effective in eliminating carriage. DNA sequence analysis suggests that there may be considerable variability within the species K kingae and that different K kingae strains may demonstrate varying degrees of pathogenicity.

Anti-Bacterial Agents↗

PubMed2006

A tuberculosis outbreak in a private-home family child care center in San Francisco, 2002 to 2004.

BACKGROUND: Child care facilities are well known as sites of infectious disease transmission, and California child care facility licensure requirements include annual tuberculosis (TB) screening for on-site adults. In April 2004, we detected an adult with TB living in a private-home family child care center (child care center A). METHODS: We reviewed patient medical records and conducted a contact investigation. The investigation included all persons at the child care center, the workplace and leisure contacts of the adult patient with TB, and the household contacts of secondary case patients. Contact names were obtained through patient interviews. A positive tuberculin skin test result was defined as induration of > or =5 mm. DNA fingerprints of Mycobacterium tuberculosis isolates were analyzed. Outbreak cases were those that had matching DNA fingerprint patterns or were linked epidemiologically, if DNA fingerprint results were not available. RESULTS: Between August 2002 and July 2004, we detected 11 outbreak cases, including 9 (82%) among children (<18 years of age). All 11 outbreak patients lived or were cared for at child care center A. The 9 pediatric TB patients were young (<7 years of age), United States-born children of foreign-born parents, and 4 (44%) had positive cultures for M tuberculosis. Including isolates recovered from the 2 adult patients, all 6 M tuberculosis isolates shared identical, 7-band, DNA fingerprint patterns. The contact investigation identified 3 (33%) of the 9 pediatric cases; 2 (22%) presented with illness and 4 (44%) were detected by primary care providers during routine TB screening. Excluding case subjects, 36 (54%) of 67 named contacts had latent TB infection. CONCLUSIONS: Provider adherence to locally adapted pediatric TB screening recommendations proved critical to outbreak control. TB screening compliance by the child care center and more aggressive source-case investigation by the TB program might have prevented or abated this large pediatric TB outbreak.

Adolescent↗

PubMed1999

Two outbreaks of influenza A (H3N2) in a Japanese nursing home in the winter of 1996-1997, with differing vaccine efficacy.

Sixty of 128 (46.9%) residents of a nursing home were immunized with two doses of the trivalent split influenza vaccine. They developed 7.4-11.5-fold antibody increases, with a 69-82% protection rate, presenting good immune response rates to the influenza vaccine. Two outbreaks of influenza A (H3N2) occurred. There were no significant antigenic differences among the vaccine strain and the strains isolated from both outbreaks in haemagglutination-inhibition tests, suggesting that the second might have been a reoccurrence. There were no residents who were infected in both outbreaks. The vaccine efficacy against clinical illness in the first outbreak of typical influenza-like-illness (ILI) was 51% (relative risk: 0.49), and the febrile period was reduced significantly by vaccination. In the second outbreak, however, in which all patients had atypical ILI with a high fever but not respiratory symptoms, vaccine efficacy was not apparent for unknown reason.

Aged↗

PubMed2000

Epidemiological studies of coincidental outbreaks of enterohemorrhagic Escherichia coli O157:H7 infection and infectious gastroenteritis in Niimi City.

A sharp rise in the number of patients with infectious gastroenteritis was observed in the 25th week of year 1996 in the Takahashi-Ashin district by researchers with the Infectious Disease Surveillance Program for tuberculosis and other infectious diseases in the Okayama Prefecture. This sharp rise occurred coincidentally with an outbreak of enterohemorrhagic Escherichia coli O157:H7 (EHEC O157) infection in Niimi City of the Takahashi-Ashin district. However, this phenomenon of coincidental outbreaks was not observed during the outbreak of EHEC O157 infection in Oku Cho. By reviewing outpatients' charts in a sentinel hospital in Niimi City for the Infectious Disease Surveillance Program, it was noted that patients with acute gastrointestinal infection visiting the hospital during the increased incidence of infectious gastroenteritis may have been included as misclassified cases of EHEC O157 infection. On the other hand, the exponential probability plotting of symptomatic patients with EHEC O157 infection in Niimi City revealed a breaking point which suggested a dual exposure to contaminated food or an overlap with other acute gastrointestinal infections. The latter possibility was discounted, because stool culture-positive patients with EHEC O157 infection also exhibited a similar breaking point, and furthermore, the coincidental increase in infectious gastroenteritis in the same area was attributable to the EHEC O157 infection. The present study demonstrates the association between the sharp rise in gastroenteritis and the outbreak of EHEC O157 in the Takahashi-Ashin district. A careful analysis of the cases of infectious gastroenteritis by the Infectious Disease Surveillance Program would have predicted the outbreak of EHEC O157.

Disease Outbreaks↗

PubMed1993

Field and laboratory analysis of an outbreak of foot and mouth disease in Bulgaria in 1991.

In July 1991, an outbreak of foot and mouth disease (FMD) occurred near Stefan Karadjovo village in Boliarovo (south-east Bulgaria, close to the Turkish border). The virus isolated was identified in Bulgaria as serotype O and this was subsequently confirmed by the World Reference Laboratory for Foot and Mouth Disease in Pirbright (United Kingdom). Serological studies using bovine sera and monoclonal antibody analysis were made. In addition, the sequence of approximately 170 nucleotides at the 3' end of the 1D gene was determined for the field isolate and for vaccine strains used in Bulgaria. These were compared with other sequences of type O FMD viruses from outbreaks in the Middle East. Serum samples were taken from domestic animals in the region close to the outbreak and examined for anti-FMD virus antibodies to assess the extent (if any) of spread of the virus before or after the outbreak. No evidence of infection was found in these animals. The virus involved in the Bulgarian outbreak was antigenically similar to the O1 vaccine strains but probably did not originate from these strains. The virus was closely related genetically to a group of viruses isolated in the Middle East since 1987, suggesting that it may have been introduced into Bulgaria from an area in the Middle East by unidentified means.

Animals↗

PubMed1993

Epidemiological aspects of outbreaks of food-borne salmonellosis in Scotland between 1980 and 1989.

Between 1980 and 1989, 2,212 outbreaks of food-borne infection were reported in Scotland. Of 2,073 episodes for which a causative agent was established, 1,732 (84%) were caused by salmonellae. An average of 980 people were affected each year, while the average number of individuals infected per general outbreak was 16.8. The infected foods were consumed outside Scotland in 25% of the outbreaks. In 75% of 1,107 episodes where the location was specified, the implicated foods were consumed in the home; hotels and restaurants accounted for 15%. Specific food items were identified in 603 (35%) of the 1,732 outbreaks; poultry meat was responsible for 332 (55%) and milk 49 (8%), while eggs accounted for 23 (4%) outbreaks.

Animals↗

PubMed1993

Clinical evolution and diagnosis of an outbreak of European brown hare syndrome in hares reared in captivity.

The authors studied an outbreak of an acute form of European brown hare syndrome (EBHS) in captive hares. The farm involved had shown negative results in a previous serological test for EBHS conducted on approximately 8% of the animals. Hares which succumbed during the outbreak were submitted to an anatomo-pathological examination and the livers of these animals were collected for laboratory analysis. Examination by immunoelectron microscopy and enzyme-linked immunosorbent assay confirmed the diagnosis of EBHS virus (EBHSV). An initial serological survey conducted on the survivors twenty-two days after the outbreak demonstrated an immunological response against EBHSV. During the outbreak, data were collected on morbidity, mortality, incidence of the disease in various age groups, and also on the antigenic characteristics of the virus responsible for the outbreak.

Acute Disease↗

PubMed2000

Spatial risk factors related to outbreaks of contagious bovine pleuropneumonia in northern Italy (1990-1993).

In October 1990, an outbreak of contagious bovine pleuropneumonia (CBPP) was reported in Italy after an absence of approximately one century. Since October 1990, ninety-four outbreaks have occurred in Italy, of which forty-seven were concentrated in three areas of northern Italy (Lombardy region). The disease was eradicated in September 1993. The data used for the analysis were obtained from the epidemiological investigations undertaken during the outbreaks of 1990-1993. The unit of interest for the analysis is the farm. Spatial segregation of infected and uninfected farms within the study area was determined through the Pielou index of segregation. Data from herds within the same set of outbreaks were analysed through logistic regression to identify factors which could be used to discriminate between infected and uninfected herds. The study indicated a clear spatial segregation between infected and uninfected herds. The results of the analysis do not indicate the mode of disease spread. However, the study demonstrated that both aerosol and indirect transmission of the infection could have occurred, as previously documented in Africa. The possibility that indirect transmission played a prominent role in the spread of CBPP in the region of Lombardy is a completely new suggestion. Further studies are required to understand the epidemiology of CBPP in regions with intensive farming and a relatively cold climate. In particular, three aspects require consideration; firstly, animal movement among neighbouring herds could produce a pattern of disease similar to the one produced by indirect transmission (this possibility was excluded in the epidemiological outbreak investigations conducted by field veterinarians). Secondly, the methods of spatial analysis used in this study have not been previously used in the field of veterinary epidemiology. Further validation of the efficacy of these methods is thus required. Thirdly, the epidemiology of CBPP under conditions of high animal density and a relatively cool climate, as encountered in Lombardy, requires further investigation.

Animals↗