Outbreak of Clostridium difficile 027 infection in Vienna, Austria 2008-2009

From November 2008 to 15 April 2009, 36 isolates of CD027 identified in Austria, all originating from four hospitals in Vienna. All isolates were positive for toxin A, toxin B and the binary toxin, and showed a characteristic 18 bp deletion in the tcdC gene. Clostridium difficile is an anaerobic spore-forming bacterium. Some strains may cause diarrhoea due to formation of toxins. Symptomatic C. difficile infection (CDI) is primarily linked with hospital admission and antibiotic treatment, although antibiotic exposure is neither necessary nor sufficient for CDI [1,2]. In Belgium, for instance, one third of CDI cases reported in the hospital surveillance system are not hospital-associated [3]. Symptoms range from mild diarrhoea to serious manifestations such as pseudomembranous colitis, toxic megacolon or perforation of the colon. C. difficile challenges hygiene standards as it is forms spores. The risk of infection rises with increasing age, underlying disease and immunodeficiency [4]. In recent years, a particularly virulent strain, ribotype 027 (CD027), has emerged in a number of countries, particularly in connection with hospital outbreaks, but also in community-acquired diarrhoea cases [5]. The risk of serious disease and death associated with CD027 exceeds that of other C. difficile strains. The classical CD027 is characterised - among other things - by an increased production of toxins A and B, production of a binary toxin and resistance to newer fluoroquinolones such as moxifloxacin. The first three Austrian cases of CD027 occurred in 2006 and in March 2008 [6,7]. Since August 2006, the Austrian National Reference Centre for C. difficile has ribotyped approximately 2,700 human C. difficile isolates received from all nine Austrian provinces. In recent months, a drastic increase in CD027 cases has been noted, all originating from four hospitals in Vienna. From November 2008 to 15 April 2009, 36 isolates of CD027 were received at the National Reference Centre. The Figure summarises these C. difficile 027 cases by month of reception of the sample at the reference centre.

Outbreak of Clostridium difficile 027 infection in Vienna, Austria 2008-2009

From November 2008 to 15 April 2009, 36 isolates of CD027 were identified in Austria, all originating from four hospitals in Vienna. All isolates were positive for toxin A, toxin B and the binary toxin, and showed a characteristic 18 bp deletion in the tcdC gene.

Ongoing rubella outbreak in Austria, 2008-2009

Since October 2008, a total of 143 cases of rubella have affected the two Austrian provinces Styria and Burgenland. The index case occurred in mid-October 2008, but was not notified to the public health authorities until February 2009, when the Austrian Agency for Health and Food Safety was asked to investigate a cluster of 32 rubella cases (24 laboratory-confirmed and eight clinically suspected cases). No case of rubella had been reported in the two affected provinces between February 2007 - when statutory notification for rubella was implemented - and mid-October 2008. 113 of the 143 cases (79%) were confirmed: 101 (89.3% of the 113 cases) clinical-laboratory confirmed and 12 clinical-epidemiological confirmed. Thirty cases fulfilled the criteria of a probable outbreak case only (laboratory results or data on epidemiological link are pending). For 140 outbreak cases data on age was known; the median age was 19 years (range: 2-60 years). 20 cases occurred in soldiers in seven military camps in the area. 55 cases (38.5 %) were female. One case of a laboratory-confirmed rubella infection, affecting an unvaccinated pregnant 18-years old native Austrian in the early first trimenon of pregnancy, led to voluntary abortion

Ongoing rubella outbreak in Austria, 2008-2009

Since October 2008, a total of 143 cases of rubella have affected the two Austrian provinces Styria and Burgenland. The index case occurred in mid-October 2008, but was not notified to the public health authorities until February 2009, when the Austrian Agency for Health and Food Safety was asked to investigate a cluster of 32 rubella cases (24 laboratory-confirmed and eight clinically suspected cases). No case of rubella had been reported in the two affected provinces between February 2007 - when statutory notification for rubella was implemented - and mid-October 2008. 113 of the 143 cases (79%) were confirmed: 101 (89.3% of the 113 cases) clinical-laboratory confirmed and 12 clinical-epidemiological confirmed. Thirty cases fulfilled the criteria of a probable outbreak case only (laboratory results or data on epidemiological link are pending). For 140 outbreak cases data on age was known; the median age was 19 years (range: 2-60 years). 20 cases occurred in soldiers in seven military camps in the area. 55 cases (38.5 %) were female. One case of a laboratory-confirmed rubella infection, affecting an unvaccinated pregnant 18-years old native Austrian in the early first trimenon of pregnancy, led to voluntary abortion.

Incidence and microbiology of salad-borne disease

Abstract

Because consumers have developed a better understanding of the health benefits associated with eating fresh produce, salads are increasingly being served in the home, in restaurants and as ready-to-eat pre-packaged foods. The associated increase in food-borne diseases must be seen in view of these benefits. Bacterial pathogens can survive on growing plants over prolonged periods of time under field conditions. In addition, the ability of human pathogens to infiltrate plant tissues has been recognized recently. Prepackaged, precut lettuce (i.e. damaged plant tissue) may pose a risk as an emerging source of food-borne illness. Surprisingly, there are no clear differences in pathogen contamination reported between organically grown produce and conventionally grown produce. The present intervention strategies are inadequate to ensure by 100% that salads are not contaminated with food-borne bacterial pathogens. The relative infrequency of outbreaks associated with preharvest contamination with Shigella, an organism with humans as its major reservoir, and the relative frequency of those associated with Salmonella or Shiga toxin-producing Escherichia coli, organisms with animals as their major reservoirs, underline the role of domestic and wild animals as dominant sources of preharvest contamination of vegetable salads. In the overwhelming majority of reported outbreaks, the contamination of salads did not occur before harvest nor did it originate at the processing plants, but rather the source could be traced to symptomatic or asymptomatic food handlers. Thorough epidemiological and microbiological investigation of all food-borne outbreaks is essential to finally assess the importance of preharvest contamination of salads.

Characterization of Clostridium difficile isolates using capillary gel electrophoresis-based PCR ribotyping

We have developed a Clostridium difficile PCR ribotyping method based on capillary gel electrophoresis and have compared it with conventional PCR ribotyping. A total of 146 C. difficile isolates were studied: five isolates were reference strains (PCR ribotypes 001, 014, 017, 027 and 053); 141 were clinical isolates comprising 39 Austrian PCR ribotypes collected in the period 2006–2007 at 25 Austrian healthcare facilities. Capillary gel electrophoresis yielded up to 11 fragments per isolate and 47 ribotype patterns. All but one of the five PCR ribotypes of reference strains were clearly reflected in the chromatograms of capillary-based typing. Capillary gel electrophoresis divided 24 isolates belonging to PCR ribotype type 014 into seven subgroups, whereas subtyping the same isolates using multiple-locus variable-number tandem-repeat analysis yielded three unrelated subgroups, without obvious correlation to sr subgroups. Using a web-based software program (http://webribo.ages.at), we were able to correctly identify these 014 isolates by simply allocating the seven subgroup patterns to one ribotype, i.e. to PCR ribotype 014. We consider capillary gel electrophoresis-based PCR ribotyping to be a way of overcoming the problems associated with inter-laboratory comparisons of typing results, while at the same time substantially diminishing the hands-on time for PCR ribotyping.

An outbreak of multidrug-resistant tuberculosis among refugees in Austria, 2005-2006

SETTING

In 2005-2006, the Austrian reference laboratory for tuberculosis (TB) identified multidrug-resistant (MDR) isolates from four cases of TB showing genotypes indistinguishable from each other.

OBJECTIVE

To clarify the chain of transmission of this MDR-TB strain.

DESIGN

An epidemiological case series investigation by reviewing TB notification reports and hospital discharge letters.

RESULTS

The 38-year-old primary case of the MDR-TB cluster had initially been identified as a case of non-MDR pulmonary TB in June 2004, 7 months after being detained for illegal immigration. In March 2005, he was lost to follow-up for 4 months. In June 2005, he presented with pulmonary and laryngeal TB due to MDR-TB. After discharge, the case was again lost to follow-up until April 2006, when he was readmitted with recurrent MDR-TB. A three-case cluster of pulmonary MDR-TB sharing the same strain as the primary case was detected in April 2006: the index case's 5-month-old daughter and a 25-year-old friend with a 6-month-old son.

CONCLUSION

As MDR-TB has originated in the human immunodeficiency virus seronegative community in Austria, there is a clear need to implement national guidelines for the management of drug-resistant TB in Austria.

Development of an oligonucleotide microarray method for Salmonella serotyping

Adequate identification of Salmonella enterica serovars is a prerequisite for any epidemiological investigation. This is traditionally obtained via a combination of biochemical and serological typing. However, primary strain isolation and traditional serotyping is time‐consuming and faster methods would be desirable. A microarray, based on two housekeeping and two virulence marker genes (atpD, gyrB, fliC and fljB), has been developed for the detection and identification of the two species of Salmonella (S. enterica and S. bongori), the five subspecies of S. enterica (II, IIIa, IIIb, IV, VI) and 43 S. enterica ssp. enterica serovars (covering the most prevalent ones in Austria and the UK). A comprehensive set of probes (n = 240), forming 119 probe units, was developed based on the corresponding sequences of 148 Salmonella strains, successfully validated with 57 Salmonella strains and subsequently evaluated with 35 blind samples including isolated serotypes and mixtures of different serotypes. Results demonstrated a strong discriminatory ability of the microarray among Salmonella serovars. Threshold for detection was 1 colony forming unit per 25 g of food sample following overnight (14 h) enrichment.

Update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008

Outbreaks of Clostridium difficile infections (CDI) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America and Europe. This emerging strain is referred to as PCR ribotype 027 (Type 027). Since 2005, individual countries have developed surveillance studies about the spread of type 027. C. difficile Type 027 has been reported in 16 European countries. It has been responsible for outbreaks in Belgium, Germany, Finland, France, Ireland, Luxembourg, The Netherlands, Switzerland and the United Kingdom (England, Wales, Northern Ireland and Scotland). It has also been detected in Austria, Denmark, Sweden, Norway, Hungary, Poland and Spain. Three countries experienced imported patients with CDI due to Type 027 who acquired the infection abroad. The antimicrobial resistance pattern is changing, and outbreaks due to clindamycin-resistant ermB positive Type 027 strains have occurred in three European countries. Ongoing epidemiological surveillance of cases of CDI, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of new, highly virulent clones.

Extensively drug-resistant tuberculosis – first report of a case in Austria, May 2008

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Update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008

Outbreaks of Clostridium difficile infections (CDI) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America and Europe. This emerging strain is referred to as PCR ribotype 027 (Type 027). Since 2005, individual countries have developed surveillance studies about the spread of type 027.C. difficile Type 027 has been reported in 16 European countries. It has been responsible for outbreaks in Belgium, Germany, Finland, France, Ireland, Luxembourg, The Netherlands, Switzerland and the United Kingdom (England, Wales, Northern Ireland and Scotland). It has also been detected in Austria, Denmark, Sweden, Norway, Hungary, Poland and Spain. Three countries experienced imported patients with CDI due to Type 027 who acquired the infection abroad.The antimicrobial resistance pattern is changing, and outbreaks due to clindamycin-resistant ermB positive Type 027 strains have occurred in three European countries. Ongoing epidemiological surveillance of cases of CDI, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of new, highly virulent clones.

Characterization of clinical Clostridium difficile isolates by PCR ribotyping and detection of toxin genes in Austria, 2006-2007

In order to assess the lethality of Clostridium difficile-associated disease (CDAD) and the PCR ribotypes prevalent in Austria, the Austrian Agency for Health and Food Safety requested isolates of C. difficile from patients in a structured but arbitrary sampling scheme. In the allocated period from February 2006 to January 2007, local hospital laboratories within each of the nine provinces were asked to submit C. difficile isolates from at least ten cases of CDAD. Confirmation of species identification, toxin detection, susceptibility testing against four antimicrobial agents and typing using a PCR ribotyping method were performed at the reference laboratory. In total, 149 isolates of putative C. difficile were submitted, from which 142 were included for study. Antimicrobial susceptibility patterns revealed resistance to clindamycin in 57% and high-level resistance to moxifloxacin in 38% of isolates tested. CDAD manifested as diarrhoea (including eight cases of bloody diarrhoea) in 126 cases (88.7%), as pseudomembranous colitis in 15 cases (10.6%) and as toxic megacolon in one case. Twelve of the 142 patients died within 30 days of specimen collection (8.45% lethality). A lethal outcome occurred in 2/15 cases (13.3%) when pseudomembranous colitis was present and in 10/126 cases (7.9%) in the absence of pseudomembranous colitis or toxic megacolon. Among the 142 isolates from 25 health-care facilities, 41 PCR ribotype patterns were found. The most frequent ribotypes were AI-5 (including six lethal cases out of 26 patients), 014 (two out of 24) and 053 (one out of 24). The typing patterns demonstrated the occurrence of clusters in hospitals.

Isolating Asian enterovirus 71 subgenogroup C4 in two Austrian clinical samples from 2004

Hamaguchi et al. recently reported on the on the occurrence of enterovirus type 71 (EV71) subgenogroup C4 in Japan [1]. According to the authors, this strain may have emerged in mainland China and in Taiwan. EV71 subgenogroup C4 has recently gained public health interest following reports of an ongoing outbreak in China and Vietnam in 2008: In June 2008, more than 176,000 cases of hand, foot and mouth disease (HFMD) were reported in China alone, and at least 24 deaths have been attributed to EV71 [2,3]. In the largest and most severe EV71-associated HFMD outbreak in Taiwan in 1998, 405 children had severe neurological complications and/or pulmonary oedema; 78 children died [4].

First cases of Clostridium difficile PCR ribotype 027 acquired in Austria

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An ongoing multi-state outbreak of measles linked to non-immune anthroposophic communities in Austria, Germany, and Norway, March-April 2008

From the second week of March 2008, public health authorities in the province of Salzburg observed an increased number of measles cases compared to previous years. Twenty cases of measles had been were notified Austria-wide in 2007, 24 in 2006, 10 in 2005, and 14 in 2004. The current outbreak has affected, as of 14 April, 202 people in Austria, 53 in Germany, and four in Norway, bringing the total number of cases related to this outbreak to 259. The initial case series investigation revealed that the common link was attendance of an anthroposophic school and day care centre in Salzburg city. The majority of the pupils were not vaccinated against measles.

Mumps outbreak in young adults following a festival in Austria, 2006

Mumps is not a mandatorily notifiable disease in Austria. However, in the first week of May 2006, a sudden increase in serologically confirmed cases of mumps, confined to three public health districts of the southern Austrian province of Carinthia, was identified by the Austrian Reference laboratory for MMR. An epidemiological investigation of this cluster of mumps cases was performed. A total of 214 cases fulfilled the outbreak case definition; 143 cases were laboratory confirmed and 71 cases were epidemiologically linked and fulfilled the clinical picture of the case definition. The vaccination status was known for 169 patients. Nearly half of the cases for whom the vaccination status was known occurred in non-vaccinated persons, another 40% were vaccinated with one dose of the vaccine and 11% had received two doses. Only four mumps cases occurred in children aged 14 years or younger, indicating that the vaccination coverage and the acceptance of the recommended childhood vaccinations have strongly improved within the past 15 years. Vaccination scheme failure but not vaccine failure is primarily to blame for this mumps outbreak.