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Turn Off Interior Lights Ford Explorer 2019
Turn Off Interior Lights Ford Explorer 2019 - The Ford Explorer ($31,990) comes common with the 3.5-liter V6 engine, front-wheel push, cloth upholstery, air conditioning. All-wheel push can be acquired for several models. Front-wheel push is standard. Traveler XLT ($34,020) and XLT AWD ($36,170) update with 18-inch wheels, keyless ignition, satellite radio, navigation, and 10-way power driver's seat. Explorer Limited ($42,090) functions leather sitting, 20-inch wheels, heated steering wheel, inside ambient light, heated and cooled front chairs, heated second line, power flip third line, 12-speaker Sony sound system. Limited AWD designs have the 2.3-liter turbo engine. Traveler Game ($45,950) and Platinum ($53,940) get the 3.5-liter EcoBoost V6 and all-wheel drive. Front-wheel push is common and all-wheel push is recommended on most cuts, but do not turn to discover too far. The Traveler is more of a large minivan when compared to a real off-roader. That concept should really be distinct initially you see one. This low-riding crossover SUV is without the fender-flared, two-toned search it after wore. Traveler Activities function black grilles which make them search rather too much like the Explorer-based Ford Interceptor authorities vehicle. Hey, if that is your thing—just stay out of our rearview mirror. Traveler Platinums include LED lights and distinct wheels that help them look like the $55,000 that Ford charges.
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The beds base Traveler cut includes a power driver's chair, alloy wheels, cloth upholstery, and a little 4.2-inch infotainment screen. We say omit it and jump to the Traveler XLT, which does not include a great deal more to start with but could be fixed having an excellent 8.0-inch touchscreen for infotainment with Apple CarPlay and Android Automobile Potential, along with a integral Waze app. While you're at it, a supplementary $1,300 for collision warnings and adaptive sail get a handle on may be worth the money. Now, the Traveler XLT expenses about $39,000 (or $41,000 with all-wheel drive). The 2.3-liter turbo-4 expenses $900 and leather chairs include yet another $1,800. Resources close to the Blue Oval have informed The Truth About Cars that some major changes have been in tow for the sixth-generation Traveler, that will allegedly switch to a rear-wheel-drive platform, especially the newest modular CD6 architecture. Assembly is defined to take place at the Dallas Assembly Seed and the design is estimated to use material for many their human body panels. In line with the same record, their Lincoln-badged version may reveal the platform and will also be built-in the Windy City with a mainly material body.

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With Valentine's day just around the corner (hint: it's tomorrow), Twitter would like to remind us that like everything that's "happening," #LoveHappens on Twitter.
Valentine's Day is always a special day. It's a celebration of love. Whether you've just met the love of your life or you've been together for months or years, or even if you are single – there's always love around us. And Twitter wants to remind us of this.
Over the last 12 months, "love" was mentioned in 2.5 billion Tweets. For your information, that's almost 80 mentions of the word, per second!
That has got to make us feel good about something, right?
Yes, the most popular hashtag to talk about love is none other than #Love itself.
But #ValentinesDay, despite being just one day per year, still manages to be the fourth most popular love hashtag on Twitter. Quite a success.
Finally, because we're in 2017, we should not forget about Emojis. I always thought that the heart emoji would be the one most associated with love. But I was wrong. The most popular Emoji to express love on Twitter is the Heart Eye Emoji. Did you know?
And because everyone loves a good love story, discover how Victoria and Jonathan went from perfect strangers, to chatting on Twitter, to getting married a few years later. #LoveHappens
Get the hanky ready. Watch the heart warming story of a proper Twitter romance that brought @VictoriaOB_ and @JonathanOB_ together. pic.twitter.com/ddVNxW2ybt
— Twitter UK (@TwitterUK) September 29, 2016
Happy Valentine's day!
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More from Twitter
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Facebook is investigating, and Twitter has blocked, Predictim, an app that helps parents vet prospective babysitters by analysing their social …
Here Are 8 Holiday Shopping Season Trends From Twitter
Twitter analyzed last year's activity on its platform to understand what is driving conversations during the Holiday shopping season.
Twitter Has A Health Problem, Because It Always Was About Popularity
Twitter co-founder Ev Williams says that showing how many followers you have isn't 'healthy' - He also admits that "suggested …


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Amtrak Coast Starlight Under a Full Moon
The southbound Amtrak Coast Starlight departs the Santa Barbara station under a full moon Saturday. The white building in the background is the old Bekins building. There are no enhancements at all in this photo. I mounted the camera on a tripod and turned off the flash, using only existing light. The sky and clouds are being illuminated solely by the moon.
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When learning a new language it can be hard to know where to begin. Most of us were taught in school and spent years learning word lists and grammar rules but can't even hold basic conversations.
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Speak from day 1?
One on the most debated topics in language learning is if we should speak from day 1, or if it's better to wait and build up our vocabulary first. In this post, I am going to break down the pros and cons of each, as well as my personal take on things. Speak from day 1 The idea behind speaking from day 1, is that in order to get good at speaking a language, we...
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Goal setting can be an incredibly powerful tool, not just for language learning but for anyone trying to improve a certain skill. If done right, it can increase motivation and efficiency, and have you progress must faster than if you just did random bits of study. So why is it that goal setting, remains one of the most underused tools in our arsenal? why...
Learn 1500 Chinese Characters in 3 months?
Is it possible to learn 1500 Chinese characters in 3 months? The simple answer is yes. However, the sheer thought alone of having to learn thousands of characters is enough to scare most learners away from even attempting Chinese in the first place. Images come up of writing out a bunch of unconnected drawings and squiggles hundreds of times to no avail, constantly...
Two weeks without English?!?! Chinese immersion project in Hong Kong
This summer I will be going to Hong Kong for two weeks and giving up my own Native language (English). Hey, my name is Luke Truman and for the past 9 months I have been learning Cantonese. I have been avoiding characters completely to focus all of my attention towards speaking. However, I am reaching a point where it is becoming increasingly obvious that to progress...
Hello everyone, today I wanted to share with you my recent experience completing the add1challenge. So first of all, what is the add1challenge? The add1challenge, founded by Brian Kwong, brings language learners together from around the world with the common goal of holding a 15 minute conversation with a native speaker at the end of 90 days. Before the challenge...
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Product description
The shoes have no paking box because of transportation, but you don`t have to worry about it, we`ll pack it carefully.
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Greetings! I have been an educator since 1987. A friend asked me to help a young girl who was struggling with feeling intimidated by her male tutor in ESL. I discovered then a passion for teaching and have been doing so in a variety of positions both formal and informal since then. I push my students to learn the specific information they ask of me. Perhaps more importantly though, it is my hope that they will find a passion for learning and gain skill sets that they can use in all their end... [more]
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$60 per hour.
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Hi My name is Lynne and I am a very experienced and dedicated tutor. I have taught many students of all ages and of all levels in Canada, Mexico and in the United States. I have excellent credentials. I have a BA in psychology and history from the University of Toronto and an MA in Urban Studies and US and African American History from Florida State University. I also have a Level 6 TOESL--Teaching English as a Second Language--Certificate from Language Link, an international organization... [more]
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I have been enjoying working as a tutor for some several years now. I have taught as a substitute high school and junior high school teacher for nearly every subject throughout most of San Diego, as well as taught my own college level English classes at several San Diego colleges. I am a native English speaker. I have a BA and MA in English, the BA with an emphasis in creative writing. I am patient and happy to help everyone to speak better and feel better about learning the language. I h... [more]
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I have extensive experience in teaching English at all levels, but more importantly I have a passion for teaching. I have a lifetime California secondary credential in English and Psychology. I have a Masters in TESOL (Teaching English to Speakers of Other Languages). I have several strengths in teaching, but I will concentrate on three. First of all, I am a results oriented instructor. I do not like just going through the motions. It is important to me that each and every student make prog... [more]


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South Korean national held for illegally entering Nepal
BHADRAPUR: A foreigner was held at the Bhadrapur Airport on Sunday as he was found travelling without a visa to Nepal. He had entered Nepal from the eastern border transit point at Kakarbhitta.
The man has been identified as South Korean national Li Yang-sung, according to the District Police Office, Jhapa.
It was found that Yang-sung had not registered with the immigration office at Kakrbhitta while entering Nepal and the Nepali visa was missing in his passport (No. M 50041422). He has been forwarded to the Department of Immigration, Kathmandu for further action. RSS
Published Date: Monday, March 19th, 2012 | 01:38 PM
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…..featuring jazz from as far afield as Japan and Australia….and as close to home as Bexley and Willesden. Strutting their stuff will be the ICP Orchestra, the Alex Simu Quintet, the Ben Sluijs Quartet and the trio Partikel. We'll also be hearing from pianist Wayne Horvitz, Blacksheep and Andrea Keller's Five Below. Plus much more, including a run thru the jazz gigs coming your way in Cambridge. Listen HERE at 3pm GMT.
There's so much good jazz being recorded around the world....a lot of it on small labels....and yet it rarely gets airplay. JAZZ TODAY....in it's own small way....tries to put that right!JAZZ TODAY is a fortnightly radio show on Cambridge105 Radio. It is broadcast live in Cambridge UK on 105FM, on digital and online at cambridge105.co.uk.
JAZZ TODAY ONLINE is a quarterly cloudcast of some of the best tracks to appear on JAZZ TODAY.
Tuesday, 18 December 2018
Sunday, 9 December 2018
Playlist - Dec 9th 2018
Lisbeth Quartett: Daily Task from There Is Only Make (Traumton)Don Byron & Aruan Ortiz: Black& Tan Fantasy from Random Dances & (A)tonalities (Intakt)
Marcin Masecki & Jerzy Rogiewicz: Dinah from Ragtime (BMC)
Tito Mangialajo Rantzer Quartet: Embrace-Lee from Dedications (Solista)
Miguel Zenon feat. Spektral Quartet: Rosario from Yo Soy La Tradicion (Miel)
Samuel Blaser: Tom Sherman's Barroom from Early in the Mornin' (OutNote)
Tilo Weber Quartet: Zykle from Four Fauns (Malletmuse)
Tilo Weber Quartet: Tadd's Delight from Four Fauns (Malletmuse)
Ant Law: Pure Imagination from Life I Know (Edition)
Walter Smith III, Matthew Stevens, Joel Ross, Harish Raghavan & Marcus Gilmore: ACE from In Common (Whirlwind)
Hans Koller: Home from London Ear (33Jazz)
Kenny Werner: Fall From Grace from The Space (Pirouet)
Fredrik Nordstrom: Brand New Dollars from Needs (CleanFeed)
Pipeline: Carabus from Us (We Insist)
Lionel Loueke: Molika from The Journey (AparteMusic)
David Chevallier & Valentin Ceccaldi: OIRN from Zebres (Ayler)
Robert Mitchell: Le Theatre Des Bouffes Du Nord (Depth of Field)
Follow Dices: Tajga from Eternal Colors (SJRecords)
Tito Mangialajo Rantzer Quartet: Romero from Dedications (Solista)
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JC Team of the Week: September 30
Meet this week's star men from the MGBSFL.
1. DANIEL PIKE (SPEC FC) - "stand-in goalie celebrated his birthday with a point-blank save which left 21 players having to pick their jaws off the floor"
2. AKIVA FINK (Bayern Mincha) - rock solid against Raiders
3. JAMIE MURRAY (NL Galaxy) - best performance in a Galaxy shirt
4. JOSH MARKS (Los Camden A) - "had to drop into centre-half and won every header and brought the ball out from the back, he epitomised the modern ball playing centre back and was deservedly man-of-the-match" against Lions
5. DANIEL LANDE (Mill Hill Dons) - "played the role of a modern day full-back to perfection. He offered loads going forward whilst defensively being superb throughout. He won many 50:50 battles and made some crucial interceptions. Another very solid performance from the full-back"
6. DAVID LEIWY (Faithfold A) - "When he's on it he's unplayable & today he was really on it. The HMH right-back will be having nightmares about David for weeks. Turned inside ... and out, can go either way, at the heart of everything for Faithfold. Got the goal his performance deserved, although not many would expect it to have been a header from the shortest man on the pitch MOTM.
7. NATE KASHKET (Redbridge A) - younger brother of Wycombe ace, Scott, Kashket will be a big player for RJC this season. Was at the heart of everything good about the win over Scrabble
8. JOSH COHEN (NL Galaxy) - man of the match against Los Camden, winning 52% of the vote. A tidy finish for his first followed by a header from a corner. Hat-trick goal was the icing on the cake - showed his turn of pace to run through from the halfway line. Composed finish on his right
9. ADAM HERSH (Faithfold B) - moved on to five goals for the season after a treble against Temple Fortune
10. REISS MOGILNER (ML Lions) - first competitive goals since joining from Brady. Scored all three in the draw against Los Camden
11. ZACH COHEN (Mill Hill Dons) "a hat-trick and a 50th goal for the Dons. He was superb throughout, extremely clinical in front of goal and this performance summed up why he has been able to reach 50 goals in such a quick fashion. He also played a big part in Jordan Stein's goal. Great performance"
STAR MAN: David Leiwy (Faithfold A)
MANAGER: Avi Markiewicz (Faithfold A)
REFEREE: Martin de la Fuente (Faithfold A vs HMH)
- Lions Garston Vets report
Lions Garston Vets report
- Faith, history and family among key themes in Wingate long list
Faith, history and family among key themes in Wingate long list
- US-Israeli bid to condemn Hamas at the United Nations fails
US-Israeli bid to condemn Hamas at the United Nations fails
- Corbyn supporter sentenced for abuse against Jewish MPs
Corbyn supporter sentenced for abuse against Jewish MPs
- Martin Lewis opens up about losing his mother as a child
Martin Lewis opens up about losing his mother as a child
- Jofa UK announces new additions, including America rabba
Jofa UK announces new additions, including America rabba
- Reform is also the future
Reform is also the future


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Cafe Paul Bert Paris
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In June 2015, an outbreak of cryptosporidiosis with 35 cases (23 probable and 12 laboratory-confirmed) occurred among 191 attendees of a residential rehabilitation holiday for paediatric organ transplant patients (n = 49) and their families at a hotel in Somogy county, Hungary. The overall attack rate was 18%. Most of the cases were transplanted children who experienced severe acute disease and required adjustment to their tacrolimus immunosuppression. A retrospective case-control study suggested an association between recreational water exposures and illness: cases were seven times more likely than controls to have swum in the children's pool (odds ratio 7.17; 95% confidence interval 2.9–17.2; P < 0.0001) and five times more likely to have used the jetted whirlpool (odds ratio 5.25; 95% confidence interval 2.1–13.1; P < 0.0001). This was the first outbreak of cryptosporidiosis in Hungary and it is especially unfortunate that it affected vulnerable children who experienced severe symptoms. Cryptosporidium presents specific infection control difficulties in treated recreational water venues; the link to a whirlpool is unusual and highlights the importance of the age-appropriate use of these facilities and reminding users not to immerse their heads or swallow the water. Cryptosporidiosis is more commonly linked to children' pools where improved bather hygiene and promoting exclusion of diarrhoea cases could help to avoid similar outbreaks.
We report an ongoing measles outbreak in Greece. The first cases were notified through the mandatory notification system on May 2017 in Northern Greece and concerned a cluster of three imported cases in unvaccinated Roma siblings. So far, 3150 cases have been reported in all 13 Regions. Initially, the outbreak mainly affected Greek Roma but as it progressed it spread to non-minority Greek nationals. The outbreak reached its ultimate peak on week 10/2018 but from week 15/2018 has been gradually declining. Most cases (60.6%) were Roma (especially children <10 year-old) followed by non-minority Greek nationals (29.3%; mostly young adults). The majority (80.4%) were unvaccinated. Interestingly, 129 (4.1%) cases were healthcare workers (HCWs). Genotype B3 was identified by molecular methods in all 87 cases tested. Overall, 61.3% of the cases were hospitalised. Complications were reported in 17.1% of the cases among which four deaths. The outbreak occurred after 3 years without local endemic measles transmission. Extensive vaccination implemented as the major public health measure managed to prevent the emergence of a large number of cases in refugee/migrant hosting sites. Mitigation efforts currently focus on raising awareness among HCWs and closing the immunisation gap in populations with suboptimal vaccination coverage.
An emerging recombinant norovirus GII.P16/GII.4 Sydney 2012 strain caused a gastroenteritis outbreak amongst attendees at a large health function in regional New South Wales, Australia. This was the third outbreak caused by the recombinant GII.P16/GII.4 Sydney 2012 strain in this region in 2017, which appears to be emerging as a common strain in the Hunter New England region.
In this study, we identified a multidrug-resistant tuberculosis (MDR-TB) outbreak in a high school in northern China. The aim of this work was to describe TB transmission, drug resistance and treatment outcomes for this patient cluster. In January 2017, pulmonary TB was identified in a 17-year-old boy in northern China. Subsequently, a total of 11 TB cases were identified during 6-month follow-up of attendees of the same school. Of five students with latent TB infection (LTBI) receiving isoniazid preventive therapy (IPT), two pulmonary TB cases (40.0%) emerged in March and April, for an active case rate not significantly different from that of the non-IPT group (4/16, 25.0%, P = 0.598). All TB patients were first treated with a standardised first-line treatment regimen administered by the local TB hospital, with 11 of 12 active TB patients exhibiting poor treatment outcomes. Further data demonstrated that all nine patient isolates collected during this outbreak were MDR-TB and shared a common genotypic profile. In conclusion, our data demonstrate that diagnostic delay for the index MDR-TB case of this outbreak played a primary role in transmission of MDR-TB infection within a school setting. Importantly, IPT failed to prevent progression of MDR-TB from LTBI to active TB.
The main objective of our study was to describe the epidemiological and microbiological features of an oligoclonal hospital-wide outbreak caused by OXA-48-producing Enterobacteriaceae (OXA-48-PE). OXA-48 is a carbapenemase belonging to Ambler class D beta-lactamases, identified frequently in the Mediterranean and Southern European countries, and associated with several Enterobacteriaceae species. An outbreak of OXA-48-PE with a complex epidemic pattern was detected in January 2011. Initial control measures included contact precautions and the reinforcement of infection control practices, but despite all efforts made, the epidemiological situation hardly changed and new measures were implemented during 2013. An observational retrospective study was performed to describe the main features of the outbreak and to analyse the cumulative incidence (CI) trends. Eight hundred and 16 patients colonised or infected by OXA-48-PE were identified during the 2-year period (January 2013–December 2014), female 46%, mean age (s.d.), 71.6 (15.2). The samples isolated in the incident cases were rectal swabs (80%), urine samples (10.7%), blood samples (2.8%) and other clinical samples (6.6%). The most frequent OXA-48-PE was Klebsiella pneumoniae. Eleven different clones were identified, but K. pneumoniae sequence types 11 and 405 were predominant: ST11 (64.2%) and ST405 (29.3%). OXA-48-PE CI trend suffered a statistically significant change in August 2013, which continued the following months. Though we could not eradicate the outbreak, we observed a statistically significant drop in CI after an intervention for OXA-48-PE control, based on patient cohort, active surveillance, electronic alerts and reinforcement of infection control measures in a tertiary hospital.
In June 2016, a Salmonella enterica serovar Enteritidis outbreak (n = 56) occurred after a christening reception in Central Greece, mainly affecting previously healthy adults; one related death caused media attention. Patients suffered from profuse diarrhoea, fever and frequent vomiting episodes requiring prolonged hospitalisation and sick leave from work, with a 54% hospital admission rate. The majority of cases experienced serious illness within <12 h of attending the party. We investigated the outbreak to identify the source(s) of infection and contributing factors to the disease severity. From the retrospective cohort study, the cheesy penne pasta was the most likely vehicle of infection (relative risk 7·8; 95% confidence interval 3·6–16·8), explaining 79% of the cases. S. enterica ser. Enteritidis isolates were typed as phage-type PT8, pulsed-field gel electrophoresis type XbaI.0024, multiple locus variable-number tandem repeat analysis-type 2-9-7-3-2. The strain did not share the single-nucleotide polymorphism address of the concurrent European S. enterica ser. Enteritidis PT8 outbreak clusters. Following five consecutive years with no documented S. enterica ser. Enteritidis outbreaks in Greece, this outbreak, likely associated with a virulent strain, prompted actions towards the enhancement of the national Salmonella molecular surveillance and control programmes including the intensification of training of food handlers for preventing similar outbreaks in the future. Advanced molecular techniques were useful in distinguishing unrelated outbreak strains.
An unprecedented outbreak of Ebola virus diseases (EVD) occurred in West Africa from March 2014 to January 2016. The French Institute for Public Health implemented strengthened surveillance to early identify any imported case and avoid secondary cases.
Febrile travellers returning from an affected country had to report to the national emergency healthcare hotline. Patients reporting at-risk exposures and fever during the 21st following day from the last at-risk exposure were defined as possible cases, hospitalised in isolation and tested by real-time polymerase chain reaction. Asymptomatic travellers reporting at-risk exposures were considered as contact and included in a follow-up protocol until the 21st day after the last at-risk exposure.
From March 2014 to January 2016, 1087 patients were notified: 1053 were immediately excluded because they did not match the notification criteria or did not have at-risk exposures; 34 possible cases were tested and excluded following a reliable negative result. Two confirmed cases diagnosed in West Africa were evacuated to France under stringent isolation conditions. Patients returning from Guinea (n = 531; 49%) and Mali (n = 113; 10%) accounted for the highest number of notifications.
No imported case of EVD was detected in France. We are confident that our surveillance system was able to classify patients properly during the outbreak period.
Shiga toxin-producing Escherichia coli (STEC) is a significant cause of gastrointestinal infection and the haemolytic-uremic syndrome (HUS). STEC outbreaks are commonly associated with food but animal contact is increasingly being implicated in its transmission. We report an outbreak of STEC affecting young infants at a nursery in a rural community (three HUS cases, one definite case, one probable case, three possible cases and five carriers, based on the combination of clinical, epidemiological and laboratory data) identified using culture-based and molecular techniques. The investigation identified repeated animal contact (animal farming and petting) as a likely source of STEC introduction followed by horizontal transmission. Whole genome sequencing (WGS) was used for real-time investigation of the incident and revealed a unique strain of STEC O26:H11 carrying stx2a and intimin. Following a public health intervention, no additional cases have occurred. This is the first STEC outbreak reported from Israel. WGS proved as a useful tool for rapid laboratory characterization and typing of the outbreak strain and informed the public health response at an early stage of this unusual outbreak.
Motivated by disease outbreaks and trade shocks, a dynamic equilibrium displacement model is calibrated for the U.S. pear industry to simulate welfare from various shocks compared to a baseline. Our contribution is assessing the impact to intermediary packers for fresh fruit and processors for processed fruit in addition to growers and consumers. The processed market is more sensitive than the fresh market generally, and supply shocks induce larger impacts on both markets than trade sanctions. Impacts to intermediaries are on par with growers, indicating that not considering them misstates the distribution of damages to the industry from a shock.
On 12 July 2015, a triathlon competition with 900 participants took place in Utrecht, the Netherlands. An outbreak investigation was initiated after 56 participants reported health complaints. An online questionnaire was sent to 700 participants. Stool specimens from six participants and four water specimens were collected from the swimming location. A total of 239 participants completed the questionnaire (response rate: 34%), 73 (31%) of them met the case definition for acute gastrointestinal illness (AGI). A total of 67% of the respondents were male and the median age was 38 years. Almost half (42%) of swimmers reported health complaints. Consumption of energy drinks and ingesting ⩾3 mouthfuls of canal water were identified as risk factors for AGI among swimmers only (adjusted relative risks (aRR) 1·6; 95% confidence intervals (CI) 1·0–2·5 and aRR 2·6; 95% CI 1·5–4·8). The collected water specimens tested positive for norovirus genogroup I and rotavirus and stool specimens tested positive for norovirus genogroup II. Our findings indicate that the outbreak could have been caused by exposure to norovirus during swimming. Swimmers should get information about the health risks for making an informed choice about participating. For future events, the organisers decided to change the swimming location from a canal to a recreational lake.
During May 2015, an increase in Salmonella Agona cases was reported from western Sydney, Australia. We examine the public health actions used to investigate and control this increase. A descriptive case-series investigation was conducted. Six outbreak cases were identified; all had consumed cooked tuna sushi rolls purchased within a western Sydney shopping complex. Onset of illness for outbreak cases occurred between 7 April and 24 May 2015. Salmonella was isolated from food samples collected from the implicated premise and a prohibition order issued. No further cases were identified following this action. Whole genome sequence (WGS) analysis was performed on isolates recovered during this investigation, with additional S. Agona isolates from sporadic-clinical cases and routine food sampling in New South Wales, January to July 2015. Clinical isolates of outbreak cases were indistinguishable from food isolates collected from the implicated sushi outlet. Five additional clinical isolates not originally considered to be linked to the outbreak were genomically similar to outbreak isolates, indicating the point-source contamination may have started before routine surveillance identified an increase. This investigation demonstrated the value of genomics-guided public health action, where near real-time WGS enhanced the resolution of the epidemiological investigation.
The outbreaks of varicella occurring in kindergartens and schools are increasingly notified in Shanghai despite the implementation of one-dose varicella vaccination. We analyzed surveillance data on the notified outbreaks of varicella in Minhang District of Shanghai during 2008–2014. A total of 13 511 varicella cases and 154 outbreaks involving 1558 (11·5%) cases were reported. Annual attack rates of outbreak-associated varicella in outbreak classes were 5·5%–12%. The mean age of the outbreak-associated cases was 8·6 ± 3·1 years. Among 1558 outbreak cases, 660 (42·4%) received one-dose varicella vaccine previously. The proportions of breakthrough varicella infection during outbreaks ranged from 21·5% in 2008 to 86·1% in 2014. Annual breakthrough infection rates in outbreak classes ranged from 5·4% to 7·4%. Breakthrough cases as index cases results in 9·7% of outbreaks, and the average duration of outbreaks was significantly longer in vaccinated cases as index cases than in unvaccinated cases as index cases (11·3 ± 5·8 days vs. 8·6 ± 6·1 days, P < 0·05). The mean time of breakthrough infection since vaccination was 6·2 ± 2·3 years (range 0·6–13·4 years). One-dose varicella vaccination cannot prevent the varicella outbreaks in kindergartens and schools. A second dose of varicella vaccine should be recommended for children.
A Q fever outbreak was declared in February 2016 in a company that manufactures hoists and chains and therefore with no apparent occupational-associated risk. Coxiella burnetii infection was diagnosed by serology in eight of the 29 workers of the company; seven of them had fever or flu-like signs and five had pneumonia, one requiring hospitalisation. A further case of C. burnetii pneumonia was diagnosed in a local resident. Real-time PCR (RTi–PCR) showed a widespread distribution of C. burnetii DNA in dust samples collected from the plant facilities, thus confirming the exposure of workers to the infection inside the factory. Epidemiological investigations identified a goat flock with high C. burnetii seroprevalence and active shedding which was owned and managed by one of the workers of the company as possible source of infection. Genotyping by multispacer sequence typing (MST) and a 10-loci single-nucleotide polymorphism (SNP) discrimination using RTi–PCR identified the same genotype (MST18 and SNP type 8, respectively) in the farm and the factory. These results confirmed the link between the goat farm and the outbreak and allowed the identification of the source of infection. The circumstances and possible vehicles for the bacteria entering the factory are discussed.
The characteristics of norovirus outbreaks in children (0–5 years) in childcare centres in Victoria, Australia (2012–2015) were examined. The three most common open reading frame (ORF) 2 genotypes in childcare centre outbreaks were GII.4 (42%), GII.6 (21%) and GII.3 (14%); the remaining genotypes (GI.2, GI.3, GI.4, GI.8, GI.13, GII.1, GII.2, GII.7 and GII.13) each made up <10%. The GII.4 genotype was the only norovirus genotype seen in all 4 years of the study and was the most common genotype in 2012–2014 but in 2015 the most common genotype was GII.2. The GII.4 genotype was more common in children 0–2 years, whereas GII.2 and GII.7 were more common in children 4–5 years. ORF 1/ORF 2 recombinant forms identified were GII.P4_NewOrleans_2009/GII.4_Sydney_2012, GII.P12/GII.3, GII.Pb (GII.21)/GII.3, GII.Pe/GII.2, GII.Pe/GII.4_Sydney_2012 and GII.Pg/GII.1. The findings indicate that norovirus genotype prevalence patterns in children were influenced by the age of the children and the year in which the analysis was carried out. The majority of norovirus infections (84%) occurred after the first year of life so that vaccination before the age of one would appear to be the most efficacious.
An upsurge of fever cases of unknown origin, but resembling dengue and leptospirosis was reported in Havelock, Andaman & Nicobar Islands, an important tourism spot, during May 2014. Investigations were carried out to determine the aetiology, and to describe the epidemiology of the outbreak. The data on fever cases attending Primary Health Centre (PHC), Havelock showed that the average number of cases reporting per week over the last 2 years was 46·1 (95% confidence interval 19·4–72·9). A total of 27 (43·5%) patients out of the 62 suspected cases were diagnosed as having DENV infection based on a positive enzyme immunoassay or reverse transcriptase–polymerase chain reaction. The overall attack rate was 9·4 cases/1000 population and it ranged between 2·8 and 18·8/1000 in different villages. The nucleotide sequencing showed that the virus responsible was DENV-3. DENV-3 was first detected in the Andaman & Nicobar Islands in 2013 among wharf workers in Port Blair and within a year it has spread to Havelock Island which is separated from South Andaman by 36 nautical miles.
Following an unusually heavy rainfall in June 2009, a community-wide outbreak of Campylobacter gastroenteritis occurred in a small Danish town. The outbreak investigation consisted of (1) a cohort study using an e-questionnaire of disease determinants, (2) microbiological study of stool samples, (3) serological study of blood samples from cases and asymptomatic members of case households, and (4) environmental analyses of the water distribution system. The questionnaire study identified 163 cases (respondent attack rate 16%). Results showed a significant dose-response relationship between consumption of tap water and risk of gastroenteritis. Campylobacter jejuni belonging to two related flaA types were isolated from stool samples. Serum antibody levels against Campylobacter were significantly higher in cases than in asymptomatic persons. Water samples were positive for coliform bacteria, and the likely mode of contamination was found to be surface water leaking into the drinking-water system. This geographically constrained outbreak presented an ideal opportunity to study the serological response in persons involved in a Campylobacter outbreak. The serology indicated that asymptomatic persons from the same household may have been exposed, during the outbreak period, to Campylobacter at doses that did not elicit symptoms or alternatively had been exposed to Campylobacter at a time prior to the outbreak, resulting in residual immunity and thus absence of clinical signs.
To date, only a few sporadic cases of infections due to Klebsiella pneumoniae carbapenemase (KPC) producers have been reported in Portugal. Here, we report for the first time an outbreak of K. pneumoniae KPC-3 producers in a tertiary-care hospital during 2013. Twenty-seven ertapenem-resistant K. pneumoniae were identified in patients at a tertiary-care hospital during 2013 isolated predominantly from urine (48·1%) and blood (25·9%) cultures. All isolates were highly resistant to β-lactam antibiotics and most showed intermediate resistance to imipenem. The more frequent β-lactamases were TEM- (77·7%), CTX-M- (70·3%) and KPC-type (66·6%). KPC-3 was identified by sequencing. The bla
KPC−3 gene was associated with an IncF plasmid, and efficiently transferred to E. coli J53. Pulsed-field gel electrophoresis typing revealed three clusters of isolates which were further characterized by multi-locus sequence typing as ST11, ST15 and ST348. Ertapenem-resistant ST15 was already in circulation in the hospital, related to expression of OmpK36 modified porin, but the other two sequence types had not been previously found in the hospital. We conclude that the IncF plasmid mediated transfer of KPC-3 in the outbreak and that implementation of carbapenemase gene screening in isolates from patients on admission to hospital is advisable in order to control dissemination of these antimicrobial resistance elements.
Faecal specimens collected from outbreak (n = 253) and sporadic (n = 147) cases of acute gastroenteritis that occurred in western India between 2006 and 2014 were tested for group C rotavirus (GCR) using partial VP6 gene-based RT–PCR. All specimens were tested previously for the presence of other viral and bacterial aetiological agents by conventional methods. The rate of GCR detection was 8·6% and 0·7% in outbreak and sporadic cases, respectively. GCR infections prevailed in outbreaks reported from rural areas (10·9%) compared to urban areas (1·6%). Clinical severity score of the patients with GCR infection (n = 23) indicated severe disease in the majority (70%) of cases. The age distribution analysis indicated 52·1% of GCR infections in children aged <10 years. The male:female ratio in GCR-positive patients was 2·3:1. Of the 23 GCR-positive cases, 17 (73·9%) had a sole GCR infection and six had mixed infections with other viral and/or bacterial agents. Phylogenetic analysis of nucleotide sequences classified GCR strains of the study in to I2 genotype of the VP6 gene. This is the first study to show the occurrence of GCR in gastroenteritis outbreaks in India.
Since April 2015, whole genome sequencing (WGS) has been the routine test for Salmonella identification, surveillance and outbreak investigation at the national reference laboratory in England and Wales. In May 2015, an outbreak of Salmonella Enteritidis cases was detected using WGS data and investigated. UK cases were interviewed to obtain a food history and links between suppliers were mapped to produce a food chain network for chicken eggs. The association between the food chain network and the phylogeny was explored using a network comparison approach. Food and environmental samples were taken from premises linked to cases and tested for Salmonella. Within the outbreak single nucleotide polymorphism defined cluster, 136 cases were identified in the UK and 18 in Spain. One isolate from a food containing chicken eggs was within the outbreak cluster. There was a significant association between the chicken egg food chain of UK cases and phylogeny of outbreak isolates. This is the first published Salmonella outbreak to be prospectively detected using WGS. This outbreak in the UK was linked with contemporaneous cases in Spain by WGS. We conclude that UK and Spanish cases were exposed to a common source of Salmonella-contaminated chicken eggs.
An outbreak of Legionnaires' disease occurred in an inner city district in Calgary, Canada. This outbreak spanned a 3-week period in November–December 2012, and a total of eight cases were identified. Four of these cases were critically ill requiring intensive care admission but there was no associated mortality. All cases tested positive for Legionella pneumophila serogroup 1 (LP1) by urinary antigen testing. Five of the eight patients were culture positive for LP1 from respiratory specimens. These isolates were further identified as Knoxville monoclonal subtype and sequence subtype ST222. Whole-genome sequencing revealed that the isolates differed by no more than a single vertically acquired single nucleotide variant, supporting a single point-source outbreak. Hypothesis-based environmental investigation and sampling was conducted; however, a definitive source was not identified. Geomapping of case movements within the affected urban sector revealed a 1·0 km common area of potential exposure, which coincided with multiple active construction sites that used water spray to minimize transient dust. This community point-source Legionnaires' disease outbreak is unique due to its ST222 subtype and occurrence in a relatively dry and cold weather setting in Western Canada. This report suggests community outbreaks of Legionella should not be overlooked as a possibility during late autumn and winter months in the Northern Hemisphere.
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