Clostridium difficile PCR ribotype 027: assessing the risks of further worldwide spread

Abstract

Highly virulent strains of Clostridium difficile have emerged since 2003, causing large outbreaks of severe, often fatal, colitis in North America and Europe. In 2008-10, virulent strains spread between continents, with the first reported cases of fluoroquinolone-resistant C difficile PCR ribotype 027 in three Asia-Pacific countries and Central America. We present a risk assessment framework for assessing risks of further worldwide spread of this pathogen. This framework first requires identification of potential vehicles of introduction, including international transfers of hospital patients, international tourism and migration, and trade in livestock, associated commodities, and foodstuffs. It then calls for assessment of the risks of pathogen release, of exposure of individuals if release happens, and of resulting outbreaks. Health departments in countries unaffected by outbreaks should assess the risk of introduction or reintroduction of C difficile PCR ribotype 027 using a structured risk-assessment approach.

Figure 1

Countries* where Clostridium difficile PCR ribotype 027 has been reported Sources of information include reports from the USA, and Canada, reporting hospital outbreaks since 2001; the UK,, the Netherlands,, , Belgium, and Ireland, reporting hospital outbreaks since 2005; France,, Switzerland, and Luxembourg, reporting hospital outbreaks since 2006; Germany,, , reporting hospital outbreaks since 2007; and Austria, and Denmark,, , reporting hospital outbreaks since 2008. Sporadic or imported cases of infection caused by C difficile PCR ribotype 027 have also been reported from Costa Rica, Finland,, Hungary,, Italy, Norway, Poland,, Spain, Sweden, Western Australia, South Korea, and Hong Kong. The earliest known isolate from the Netherlands was collected in 2002, but—like earlier strains of PCR ribotype 027 in North America, isolates from Japan,, and the majority of recent isolates from Sweden, —it was susceptible to fluoroquinolones and is thought a historic strain not associated with the recent international epidemic. *And states or provinces of the USA, Canada, and Australia.

Figure 2

Annual passenger-carrying capacity of international air-transport links between countries affected by fluoroquinolone-resistant Clostridium difficile PCR ribotype 027 and Australia Frequency of indirect travel between affected countries and Australia via international hubs can also be estimated. Data from the International Air Transport Association.