Significant increase of hantavirus infections in Germany since the beginning of 2007

Hantaviruses (family Bunyaviridae) are rodent-borne pathogens and occur worldwide. Hantavirus infections in Europe and Asia can result in a hemorrhagic fever with renal syndrome (HFRS) of different severity.

Outbreak of domestically acquired typhoid fever in Leipzig, Germany, June 2004

In June 2004, three confirmed cases of typhoid fever were reported to the health authorities in Leipzig, Germany. The patients had been admitted to hospital with unexplained fever and otherwise mild symptoms. All were members of the same pony club, none had been abroad. A retrospective cohort study among pony club members was performed to identify the source of infection. A suspected case was defined as unexplained fever >=38.5°C over three or more days since 1 May 2004. Additional positive serology defined a probable case and Salmonella Typhi isolation from blood or stool cultures a confirmed case. All hospitals, paediatricians and general practitioners in Leipzig and surroundings were contacted to identify additional cases. In total, six cases were identified, all among pony club members: four confirmed, including the three originally reported cases, one probable and one suspected. The only exposure common to all cases during the probable time of infection was consumption of sandwiches with herb dressing from a snack bar on 25 or 26 May (May 25: RR=5.7; 95% CI 0.9-37.9; both days: RR=, P=0.007). Foods and workers from the snack bar tested negative. However, one worker, not previously registered with the health authorities, was identified during a site visit. It cannot be excluded that further unregistered individuals worked at the snack bar between May and June 2004. Despite intense case-finding activities, no further cases were identified among the population. The most likely vehicle in this outbreak was sandwiches with herb dressing, though the source of contamination remains unknown. Even without history of travel to endemic countries, physicians should consider typhoid fever when managing patients with unexplained fever.

Significant increase of listeriosis in Germany - Epidemiological patterns 2001-2005

Listeriosis has been a mandatorily notifiable disease in Germany since January 2001. Clinical cases with isolation of Listeria monocytogenes from sterile specimens or neonates are reported to the Robert Koch-Institut. Listeriosis incidence significantly increased from 0.26 per 100 000 inhabitants (217 cases) in 2001 to 0.62 per 100 000 (519 cases) in 2005.

[Norovirus infections in Germany]

Noroviruses are responsible for the majority of acute viral gastroenteritis infections worldwide. Transmission may be faecal-oral or through contaminated food and water or airborne by virus-containing aerosols. Characteristics of noroviruses that facilitate their spread are their high concentration in stool and vomitus, their extreme environmental stability, their low infectious dose as well as the lack of long-lasting immunity. The majority of norovirus infections occur in large outbreaks among persons living in institutional settings, such as hospitals and nursing homes, although sporadic cases also occur. Children and elderly persons are most often affected. Illness is characterized by acute onset of projectile vomiting. For prevention and control of norovirus outbreaks strict control management is necessary. Based on the high genomic variability new variant noroviruses with different pathogenic factors can arise. Depending on the circulating variant the extent of the usual winter peak can vary enormously. Available diagnostic methods include RT-PCR assays for detection of viral RNA, electron microscopy and enzyme immunoassays (EIA) for detection of viral antigens. The implicated virus can be subtyped through nucleotide sequencing and linked to a specific outbreak. With the enactment of the Protection against Infection Act in January 2001 a mandatory reporting system of norovirus infections was established. Analysis of surveillance data from this system permits a detailed overview of the nationwide epidemiology of this disease in Germany.

Phosphorus release from ash, dried sludge and sludge residue from supercritical water oxidation by acid or base

Leaching of ash and dried sewage sludge were investigated and compared with the leaching results of sludge residue from supercritical water oxidation (SCWO). This article focuses on how the composition of ash and sludge residues influences the extraction of phosphate and heavy metals and if different treatment temperatures of the sludge effect the leachability. Results showed that acid leaching gave a higher release of phosphate than alkaline leaching for all ash and sludge residue samples. Also, alkaline leaching dissolved phosphate with a lower metal contamination than acid leaching. Furthermore, it was found that iron had a low release at both alkaline and acid leaching from ash and from SCWO residue. The difference in composition of ash and sludge residue samples had no significant influence on release of phosphate at high concentrations of acid. Phosphate release from ash, dried sludge at 300 degrees C and SCWO residue showed similar results at 1M acid leaching. However, it seems to be easier to release phosphate from the SCWO residue than from the ash at low acid concentrations. SCWO residue showed higher release than the other ashes at 0.5M HCl. Results for alkaline leaching showed higher release from ash at 1M NaOH than from SCWO residue or from dried sludge at 300 degrees C. The leaching of phosphate from dried sludge seems to be temperature dependent, as the dried sludge treated at higher temperature showed less release of phosphate. It was found that the pre-treatment of the ash may be important for better release of phosphate.

Post-depositional redistribution and gradual accumulation of 137Cs in a riparian wetland ecosystem in Sweden

After the Chernobyl accident, high activity concentrations of (137)Cs (>1 MBq m(-2)) were detected in a riparian swamp in the central-eastern part of Sweden. The objective of this study was to clarify the redistribution processes behind the accumulation of (137)Cs in the wetland. A mass balance budget of (137)Cs was calculated based on soil and sediment samples and reports in the literature. Results showed that accumulation occurred over several years. Of all the (137)Cs activity discharged between 1986 and 2002 from the upstream lake, 29% was estimated to be retained in the wetland. In 2003, measurements showed that 17 kBq m(-2) sedimented on the stream banks of the wetland. Continuing overbank sedimentation by spring flooding prolongs the time that the wetland will contain high activity concentrations of (137)Cs. Consequently, organisms living in wetlands serving as sinks for (137)Cs may become exposed over long time periods to high activity concentrations.

Significant increase of listeriosis in Germany--epidemiological patterns 2001-2005

Listeriosis has been a mandatorily notifiable disease in Germany since January 2001. Clinical cases with isolation of Listeria monocytogenes from sterile specimens or neonates are reported to the Robert Koch-Institut. Listeriosis incidence significantly increased from 0.26 per 100 000 inhabitants (217 cases) in 2001 to 0.62 per 100 000 (519 cases) in 2005. The increase only occurred among non pregnancy-associated cases and was mainly due to a rise in cases in the age group > or =60 years. The highest incidences were observed in neonates and adults > or =70 years. Male cases predominated, except for cases occurring in adults of child-bearing age. The overall case fatality rate was 9%. No temporal or spatial clusters of cases were observed and no outbreaks with a common source vehicle were identified. In 46% of the cases malignancies were reported as predisposing factor. Reasons for the increase of listeriosis in Germany remain unclear. The newly implemented surveillance system, and raised diagnostic awareness, cannot explain the particularly high increase in incidence from 2004 to 2005. Increased contamination of common foodstuffs or changes in underlying medical conditions or treatment options may have contributed to the increase. A project for enhanced listeriosis surveillance was begun in 2005 to obtain more detailed information about the clinical course, underlying conditions, medical treatment, knowledge about listeriosis and possible food risk factors from all newly diagnosed cases. For better outbreak detection, a nationwide system for molecular subtyping of listeria strains from humans and food is necessary. Recommendations for prevention should be extended to all risk groups with predisposing conditions

A syringe exchange programme in prison as prevention strategy against HIV infection and hepatitis B and C in Berlin, Germany

In two prisons in Berlin, Germany, provision of sterile injection equipment for injecting drug users (IDUs) started in 1998. To assess the programme's impact, the frequency of injecting drug use and syringe sharing, and the incidence of HIV, HBV, and HCV infection were determined in a follow-up study. Of all IDUs (n=174), 75% continued to inject. After the project start the level of syringe sharing declined from 71% during a 4-month period of previous imprisonment to 11% during the first 4 months of follow-up, and to virtually zero thereafter. Baseline seroprevalences for HIV, HBV, and HCV were 18, 53, and 82%. HIV and HCV seroprevalence at baseline was significantly associated with drug injection in prison prior to the project start. No HIV and HBV seroconversions, but four HCV seroconversions occurred. The provision of syringes for IDUs in appropriate prison settings may contribute to a substantial reduction of syringe sharing. However, the prevention of HCV infection requires additional strategies.

Nosocomial transmission of hepatitis C virus from an anesthesiologist to three patients – epidemiologic and molecular evidence

Acute hepatitis C occurred in three patients who had undergone gynecologic surgery in an outpatient clinic on a single day. Epidemiologic and virologic investigations revealed virus transmission from an anesthesiologist with chronic hepatitis C. HCV sequencing demonstrated that all four persons were infected by the same strain. The precise mode of transmission could not be elucidated but hygienic standards had been severely neglected.

Molecular epidemiology of Salmonella enterica serovar Agona: characterization of a diffuse outbreak caused by aniseed-fennel-caraway infusion

During 2002-2003 increased numbers of notified salmonellosis due to S. enterica serovar Agona were observed in Germany. In order to understand the recent spread of this serovar and to trace the route of infection to its source, a new phage-typing scheme and pulsed field gel electrophoresis (PFGE) were used to analyse these isolates. By using 14 bacteriophages, 52 phage types were distinguished among the S. Agona strains. PFGE also differentiated 52 different patterns. A combination of both methods generated 94 clonal types among 165 S. Agona strains originating from Germany and other countries including the United States, United Arab Emirates, Turkey, India, Austria and Finland, indicating a great biological diversity within this serovar. However, 36 recent S. Agona isolates from infantile gastroenteritis in Germany, from an untreated batch of aniseed imported from Turkey and from fennel-aniseed-caraway infusion (packed in tea bags) revealed clonal identity indicating their epidemiological relatedness as a new source of infection. It is suggested that strains of S. Agona will continue to be of public health concern, and that phage typing together with PFGE typing should be applied as reliable and rapid tools for epidemiological subtyping and future monitoring.

[Hepatitis B and C risk factors in Germany--results of the national surveillance]

Collection of risk factor data is part of the national surveillance of hepatitis B and C in Germany. After modifications of risk factor surveillance had been implemented in September 2003, the response rate for data on risk factors increased markedly. For the period between September 2003 and August 2004, information on risk factors (at least one "yes" or "no" answer) was available for 66% (1853) of all notified hepatitis B cases and for 67% (5813) of all notified hepatitis C cases. More than 30% of those hepatitis B cases occurred among risk groups for whom hepatitis B immunisation is recommended by the German Advisory Committee on Immunisation (STIKO). Of the hepatitis C cases with risk factor data, 40% reported previous or continuing injecting drug use (IDU). IDU was predominant among young men (78% among men, aged 15 to 29 years) and can explain the comparatively high incidence observed in young adults, especially among men. The impact of other risk factors (e. g. medical interventions) cannot be quantified without a proper control group. The results of this study demonstrate that--in addition to the hepatitis B immunisation of children and adolescents--vaccination coverage of specific risk groups, as defined by the STIKO, should be increased. Measures to prevent hepatitis C have to focus on intravenous drug users and clearly have to be intensified.

Bundesweiter Ausbruch durch Salmonella Give in Deutschland im Jahr 2004

PURPOSE

In spring and summer 2004, a multistate outbreak of infections caused by Salmonella enterica serovar Give (S. Give), a relatively rare serovar in Germany, was detected. In order to identify a common exposure and to describe the characteristics of infections caused by S. Give, an outbreak investigation was performed.

MATERIALS AND METHODS

In addition to passive surveillance through mandatory case-reporting, active case-finding was conducted. A case-control study was undertaken in order to identify the probable vehicle of infection. S. Give strains were isolated and molecular subtyping was performed by pulsed-field gel electrophoresis (PFGE). Rates of hospitalization were assessed in patients with S. Give infection, and compared to the rates found in patients infected by the most common serovar in Germany, S. enteritidis.

RESULTS

From March to July 2004, 115 cases of gastroenteritis caused by S. Give were identified, with highest incidences being observed in the states of Lower Saxony and Saxony-Anhalt. Consumption of raw minced pork was strongly associated with S. Give infections (OR: 8.0; 95% CI 2.3-27.7; P = 0.001). This result was confirmed by the detection of common outbreak strains in isolates from both patients and pork, using PFGE. Infections caused by S. Give lead to hospitalization in 55% of patients > or = 60 years, but only in 17 % of younger patients (OR: 6.0; 95% CI 2.1-16.3; P < 0.001) and 33% in patients > or = 60 years with infections caused by S. enteritidis (OR: 2.5; 95% CI 1.1-5.4; P = 0.02).

CONCLUSION

This is, to our knowledge, the first documented multistate outbreak of salmonellosis associated with the consumption of raw minced pork in Germany. Since contamination of pork meat with Salmonella cannot be avoided, people with risk factors for severe infection should generally avoid the consumption of raw minced pork. The high hospitalization rates in patients > or = 60 years infected with S. Give possibly indicate a higher virulence of this specific serovar. Even in non-typhoidal salmonellosis, early antibiotic therapy should be considered depending on infecting serovar, age and medical history of the patient.

[Malaria in Germany 1993 to 2003. Data from the Robert Koch Institute on affected groups of people, countries traveled to and treatment]

BACKGROUND AND OBJECTIVE

In Germany, malaria is a major imported disease. The national surveillance data from 1993 to 2003 were analysed to assess epidemiologic trends in imported malaria.

METHODS

Malaria is a notifiable disease in Germany. Laboratory and epidemiologic data are obtained for each malaria case in a standardised way and reported to the Robert Koch-Institut where the central database exists for statistical analysis.

RESULTS

From 1993 to 2003, a total of 9148 malaria cases were reported to the Robert Koch-Institut. The annual cases ranged from 598 (1993) to 1045 (2001). No clear trend over the years was observed. The proportion of malaria cases of German origin declined significantly over the years to 50 % in 2003. The proportion of cases aged 40 to 49 years increased over time. However, in each year the highest malaria incidence was found in the age group 20 to 39 years. Case fatality decreased substantially in recent years. In about 25 % of patients malaria diagnosis and treatment start were delayed. This is of great concern since 70 to 80 % of all cases were caused by Plasmodium falciparum. In recent years atovaquone + proguanil as well as arthemether + lumefantrin were increasingly used for treatment (both combination therapies made up for 35 % of treatments in 2003).

CONCLUSIONS

Further improvements in counselling and adequate use of malaria prophylaxis in travelers and in timely malaria diagnosis and treatment are necessary.

[Zoonotic infections in humans. Review of the epidemiological situation in Germany]

Zoonosen sind Infektionskrankheiten, die auf natürlichem Weg vom Tier (Vertebraten) auf den Menschen übertragen werden können. Die Bedeutung der Zoonosen liegt in der Häufigkeit der Erkrankungsfälle, der hohen Letalität einzelner Zoonosen und der Möglichkeit von bisher auf das Tierreservoir beschränkten Erregern, die Artengrenze zum Menschen zu überwinden. Veränderte Bedingungen der Lebensmittelproduktion (inklusive Massentierhaltung) und der Ernährung sowie demographische, klimatische und ökologische Faktoren fördern die Verbreitung von Zoonoseerregern. Im Rahmen des seit 1. Januar 2001 geltenden Infektionsschutzgesetzes unterliegt eine Reihe von Zoonosen der Meldepflicht. Auf Ebene der Europäischen Union regelt u. a. die Zoonosen-Überwachungsrichtlinie, die am 17. November 2003 verabschiedet wurde, die Überwachung menschlicher Erkrankungen. Maßnahmen zur Prävention und Bekämpfung von Zoonosen müssen auf nationaler wie internationaler Ebene kontinuierlich weiterentwickelt werden.

["Emerging infectious diseases". Dengue-fever, West-Nile-fever, SARS, avian influenza, HIV]

Some emerging infectious diseases have recently become endemic in Germany. Others remain confined to specific regions in the world. Physicians notice them only when travelers after infection in endemic areas present themselves with symptoms. Several of these emerging infections will be explained. HIV is an example for an imported pathogen which has become endemic in Germany. SARS and avian influenza are zoonoses with the potential to spread from person to person. Avian influenza in humans provides a possibility for the reassortment of a potential new pandemic strain. Outbreaks of dengue fever in endemic areas are reflected in increased infections in travelers returning from these areas. Currently, West-Nile-virus infections are only imported into Germany. The timely implementation of diagnostic, therapeutic and infection control measures requires physicians to include these diseases in their differential diagnosis. To achieve this goal, good cooperation between physicians, laboratories and the public health service is essential.

Estimation of radiation doses from (137)Cs to frogs in a wetland ecosystem

Currently, there is no established methodology to estimate radiation doses to non-human biota. Therefore, in this study, various dose models were used to estimate radiation doses to moor frogs (Rana arvalis) in a wetland ecosystem contaminated with (137)Cs. External dose estimations were based on activity concentrations of (137)Cs in soil and water, considering changes in habitat over a life-cycle. Internal doses were calculated from the activity concentrations of (137)Cs measured in moor frogs. Depending on the dose model used, the results varied substantially. External dose rates ranged from 21 to 160 mGy/y, and internal dose rates varied between 1 and 14 mGy/y. Maximum total dose rates to frogs were below the expected safe level for terrestrial populations, but close to the suggested critical dose rate for amphibians. The results show that realistic assumptions in dose models are particularly important at high levels of contamination.

SARS: retrospective cohort study among German guests of the Hotel 'M', Hong Kong

Hong Kong played a pivotal role in the international spread of the Severe Acute Respiratory Syndrome (SARS): a doctor who spent the night of 21-22 February 2003 at Hotel 'M' was identified as the index case for four national and international clusters of SARS. In parallel to the international collaborative study led by WHO and United States, a retrospective study on the cohort of German persons staying at Hotel 'M' was conducted. The inclusion criteria covered a period from 21 February to 3 March 2003 to allow the detection of cases possibly due to environmental contamination. In the twenty-one German guests traced as having stayed at Hotel "M" during this period, one case of laboratory confirmed SARS was found. The case history suggests that close vicinity to the index patient may have played a role in transmission. In line with findings of environmental investigations in the hotel, environmental contamination should be considered as a possible source of infection.