Background. After the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in Alaska, the incidence of invasive pneumococcal disease (IPD) due to non-vaccine serotypes, particularly serotype 19A, increased. The aim of this study was to describe the molecular epidemiology of IPD due to serotype 19A in Alaska. Methods. IPD data were collected from 1986 to 2010 through population-based laboratory surveillance. Isolates were serotyped by the Quellung reaction and MICs determined by broth microdilution. Genotypes were assessed by multilocus sequence typing. Results. Among 3,294 cases of laboratory-confirmed IPD, 2,926 (89%) isolates were available for serotyping, of which 233 (8%) were serotype 19A. Across all ages, the proportion of IPD caused by serotype 19A increased from 3.5% (63/1823) pre-PCV7 (1986–2000) to 15.4% (170/1103) post-PCV7 (2001–2010) (p<0.001); among children <5 years of age, the proportion increased from 5.0% (39/776) to 33.0% (76/230) (p<0.001). The annual incidence rate of IPD due to serotype 19A (all ages) increased from 0.73 cases pre-PCV7 to 2.56 cases/100,000 persons post-PCV7 (p<0.001); rates among children <5 years of age increased from 4.84 cases to 14.1 cases/100,000 persons (p<0.001). Among all IPD isolates with reduced susceptibility to penicillin, 17.8% (32/180) were serotype 19A pre-PCV7 and 64% (121/189) were serotype 19A post-PCV7 (p<0.001). Eighteen different sequence types (STs) were identified; ST199 or single locus variants of ST199 (n=150) and ST172 (n=59) accounted for the majority of isolates. Multidrug-resistant isolates were clustered in ST199 and ST320. Conclusion. While PCV13 should significantly reduce the burden of disease due to 19A, these data highlight the need to continue surveillance for IPD to monitor the effects of vaccination on the expansion and emergence of non-PCV strains.

ABSTRACT The International Circumpolar Surveillance (ICS) Program was initiated in 1999 to conduct population-based surveillance for invasive pneumococcal disease in select regions of the Arctic. An interlaboratory quality control (QC) program for pneumococcal serotyping and antibiotic susceptibility testing was incorporated into ICS by reference laboratories in northern Canada (Laboratoire de Santé Publique du Québec [LSPQ] in Sainte-Anne de Bellevue, Québec; National Centre for Streptococcus [NCS] in Edmonton, Alberta) and Alaska (Arctic Investigations Program [AIP]). The World Health Organization's Collaborating Centre for Reference and Research on Pneumococci at the Statens Serum Institute (SSI) in Copenhagen, Denmark, joined the QC program in 2004. The Iceland Reference Laboratory (IRL) in Reykjavik, Iceland, joined the QC program in 2006, but due to small sample sizes, data from IRL are not included in this report. From 1999 through 2008, 190 isolates were distributed among four laboratories (AIP, NCS, LSPQ, and SSI). The overall serotype concordance was 95.8%, and the overall serogroup concordance was 97.4%. The overall modal MIC concordance for testing by broth microdilution (BMD) and agar dilution was >96% for all the antibiotics except erythromycin (92.1%) and clindamycin (89.5%). MIC comparisons between the Etest and BMD resulted in lower concordance for erythromycin (73.9%), clindamycin (65.5%), and trimethoprim-sulfamethoxazole (80%); however, categorical concordance (susceptible, resistant) remained high at 98.6%, 89.1%, and 90.9%, respectively. Our data demonstrate a high degree of correlation of serotyping and antimicrobial susceptibility testing results between four participating laboratories.

Members of the Dobrava-Belgrade virus (DOBV) species are hantaviruses carried by different Apodemus mice as reservoir hosts and causing haemorrhagic fever with renal syndrome (HFRS) in humans. In Central Europe, the Kurkino genotype of DOBV, associated with the striped field mouse, Apodemus agrarius, is prevalent. This paper presents the first extensive study of the serological and molecular diagnostics, epidemiology and clinics of DOBV-Kurkino infections in Central Europe. Serum samples from 570 German patients living in the habitat of A. agrarius (north and northeast Germany) and exhibiting febrile disease, were analysed. All samples were tested by ELISA, subsets of samples were also analysed by immunoblot, neutralization assay, and RT-PCR. A group of 86 individuals was confirmed as DOBV-infected. The virus neutralization assay allowed a reliable identification of DOBV antibodies during both acute and convalescent phases of infection. However, differentiation of relevant DOBV genotypes was not possible by neutralization test but required molecular analysis. Whereas DOBV IgM antibodies tend to persist in the infected organism, RNAaemia seems to be short. Nucleotide sequences were amplified from four patients, and their analysis demonstrated infection by DOBV-Kurkino. With respect to the initial results, the high degree of identity of local patient-derived and A. agrarius-derived virus sequences may allow a closer allocation of the geographical place where the human infection occurred. In contrast to moderate/severe HFRS caused by the DOBV genotypes Dobrava or Sochi, all available data showed a mild clinical course of HFRS caused by DOBV-Kurkino infection without lethal outcomes.

Background. Use of heptavalent protein-polysaccharide pneumococcal conjugate vaccine (PCV7) has been associated with decreases in PCV7-type invasive pneumococcal disease and nasopharyngeal (NP) carriage in children. Vaccine use has also indirectly decreased the rate of invasive disease in adults, presumably through decreased transmission of pneumococci from vaccinated children to adults.Methods. We conducted NP carriage surveys in 8 villages in Alaska in 1998 - 2004. Streptococcus pneumoniae isolates were characterized by serotype and antimicrobial susceptibility. We analyzed trends in serotype distribution, antibiotic resistance, and factors associated with adult carriage of PCV7-serotype pneumococci before and after the introduction of PCV7 in 2001.Results. We collected 15,598 NP swabs; overall, 52% of adults living in the villages surveyed participated in the colonization study. The proportion of adult carriers with PCV7-type pneumococcal carriage decreased from 28% of carriers in 1998 - 2000 to 4.5% of carriers in 2004 (P < .0001). Among adults, the proportion of colonizing isolates that were resistant to penicillin decreased from 13% in 1998 - 2000 to 6% in 2004 (P < .01), whereas the percentage of isolates with intermediate susceptibility to penicillin increased from 12% in 1998 - 2000 to 19% in 2004 (P < .01). Adults were more likely to carry PCV7-type pneumococci if they lived with a child <= 5 years old or if they lived with a child who had not been age- appropriately vaccinated with PCV7.Conclusions. Pediatric vaccination with PCV7 has resulted in decreased PCV7-type pneumococcal carriage among adults and helps to explain recent decreases in the rate of PCV7-type invasive pneumococcal disease among adults.

BACKGROUND:Community-onset methicillin-resistant Staphylococcus aureus (CO-MRSA) reports are increasing, and infections often involve soft tissue. During a CO-MRSA skin infection outbreak in Alaska, we assessed risk factors for disease and whether a virulence factor, Panton-Valentine leukocidin (PVL), could account for the high rates of MRSA skin infection in this region.METHODS:We conducted S. aureus surveillance in the outbreak region and a case-control study in 1 community, comparing 34 case patients with MRSA skin infection with 94 control subjects. An assessment of traditional saunas was performed. S. aureus isolates from regional surveillance were screened for PVL genes by use of polymerase chain reaction, and isolate relatedness was determined by use of pulsed-field gel electrophoresis (PFGE).RESULTS:Case patients received more antibiotic courses during the 12 months before the outbreak than did control subjects (median, 4 vs. 2 courses; P=.01) and were more likely to use MRSA-colonized saunas than were control subjects (44% vs. 13%; age-adjusted odds ratio, 4.6; 95% confidence interval, 1.7-12). The PVL genes were present in 110 (97%) of 113 MRSA isolates, compared with 0 of 81 methicillin-susceptible S. aureus isolates (P<.001). The majority of MRSA isolates were closely related by PFGE.CONCLUSION:Selective antibiotic pressure for drug-resistant strains carrying PVL may have led to the emergence and spread of CO-MRSA in rural Alaska.

Background and aim Gastric inflammation, atrophy and intestinal metaplasia are motv severe in H. pylo~i + subjects, particularly in those cawing CagA + strains, than in controls.Since immunity can be involved in the development and persistence of chronic gastritis, our aim was to assess, in a group of H. pylor~ + patients, whether the antibody levels to H. pylori and CagA antigens are related with the histological scorns of antral gastritis.Material and Methods Serum samples and gastric antral biopsies were taken from 70 H.pylonS+ patients.H pyIo*J and CagA lgG antibodies were tested by standardized ELISAs.CagA status was also assessed by Westeru blot.Gastritis was classified according to the Sydney System.A score from 0 to 3 was assigtmd to each of the fullowing variables: atrophy, intestinal metaplasia, inflammation, and activity.The associations between IgG titres and histological katures were assessed by' means of chi-square test.Results FiftDone of the 70 patients were carrying CagA+ stratus.Associations between the levels of H D, lori antibodies and atrophy (p=0.03) and intestinal n~etaplasia scm~.'s(p=O.02)were found in the H. pylori+ and in the C~gA + groups but not m the CagA-group.When the analysis was stratified according to age groups, these associations did not change.No associations were fuund between the leveg of H. pylori antibodies and the scores of inflammation and activity.In the H. pylon + and H. pylo~ +/CagA + groups, where associations between H. priori antibodies and atrophy and intestinal metaplasia were present, no asscx:tations were, however, found between these histological variables and the kvels of Cage4 antibodies.Conclusions.In subjects with H.

OBJECTIVE:We investigated a large outbreak of community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections in southwestern Alaska to determine the extent of these infections and whether MRSA isolates were likely community acquired.DESIGN:Retrospective cohort study.SETTING:Rural southwestern Alaska.PATIENTS:All patients with a history of culture-confirmed S. aureus infection from March 1, 1999, through August 10, 2000.RESULTS:More than 80% of culture-confirmed S. aureus infections were methicillin resistant, and 84% of MRSA infections involved skin or soft tissue; invasive disease was rare. Most (77%) of the patients with MRSA skin infections had community-acquired MRSA (no hospitalization, surgery, dialysis, indwelling line or catheter, or admission to a long-term-care facility in the 12 months before infection). Patients with MRSA skin infections were more likely to have received a prescription for an antimicrobial agent in the 180 days before infection than were patients with methicillin-susceptible S. aureus skin infections.CONCLUSIONS:Our findings indicate that the epidemiology of MRSA in rural southwestern Alaska has changed and suggest that the emergence of community-onset MRSA in this region was not related to spread of a hospital organism. Treatment guidelines were developed recommending that beta-lactam antimicrobial agents not be used as a first-line therapy for suspected S. aureus infections.