Risks Related to Chikungunya Infections among European Union Travelers, 2012-2018

Autochthonous outbreaks of chikungunya have occurred in the European Union (EU) after virus introduction by infected travelers. We reviewed the surveillance data of travel-related cases reported in the EU during 2012–2018 to document factors associated with increased infection rates among travelers and to assess how surveillance data could support preparedness against secondary transmission and timely control of outbreaks. Thirteen EU countries reported 2,616 travel-related chikungunya cases. We observed 3 successive epidemiologic periods; the highest number of cases (75%) occurred during 2014–2015, when most cases were associated with the Caribbean and South America. The highest infection rates among travelers were observed during the same phase. Although surveillance of travel-related cases is relevant for estimating the infection risk for travelers, we could not identify a relationship between the number of infected travelers and a higher likelihood of secondary transmission in the EU.

One Health approach for West Nile virus surveillance in the European Union: relevance of equine data for blood safety

West Nile virus (WNV) infection is notifiable in humans and equids in the European Union (EU). An area where a human case is detected is considered affected until the end of the mosquito transmission season (week 48) and blood safety measures have to be implemented. We used human and equine case notifications between 2013 and 2017 to define the WNV distribution in the EU and to investigate the relevance of using equine cases as a complementary trigger for blood safety measures. Adding areas with equine cases to the definition of an affected area would have a major impact on blood safety measures. Adding areas with equine cases where human cases have been reported in the past would increase the timeliness of blood safety measures with only a limited impact. Although the occurrence of human and/or equine cases confirms virus circulation in the EU, no evidence was found that occurrence of equine cases leads to human cases and vice versa. We conclude that information about equine data should contribute to raising awareness among public health experts and trigger enhanced surveillance. Further studies are required before extending the definition of affected areas to areas with human and/or equine cases.

The European Medical Corps: first Public Health Team mission and future perspectives

The 2013-2016 Ebola epidemic in West Africa challenged traditional international mechanisms for public health team mobilisation to control outbreaks. Consequently, in February 2016, the European Union (EU) launched the European Medical Corps (EMC), a mechanism developed in collaboration with the World Health Organization (WHO) to rapidly deploy teams and equipment in response to public health emergencies inside and outside the EU. Public Health Teams (PHTs), a component of the EMC, consist of experts in communicable disease prevention and control from participating countries and the European Centre for Disease Prevention and Control (ECDC), to support affected countries and WHO in risk assessment and outbreak response. The European Commission's Directorate-General European Civil Protection and Humanitarian Aid Operations and Directorate-General Health and Food Safety, and ECDC, plan and support deployments. The first EMC-PHT deployment took place in May 2016, with a team sent to Angola for a yellow fever outbreak. The aims were to evaluate transmission risks to local populations and EU citizens in Angola, the risk of regional spread and importation into the EU, and to advise Angolan and EU authorities on control measures. International actors should gain awareness of the EMC, its response capacities and the means for requesting assistance.

Event-based surveillance of food- and waterborne diseases in Europe: urgent inquiries (outbreak alerts) during 2008 to 2013

During 2008 to 2013, 215 outbreak alerts, also known as 'urgent inquiries' (UI), for food- and waterborne diseases were launched in Europe, the majority of them (135; 63%) being related to salmonellosis. For 110 (51%) UI, a potential food vehicle of infection was identified, with vegetables being the most reported category (34;31%). A total of 28% (n = 60) of the outbreaks reported had an international dimension, involving at least two countries (mean: 4; standard deviation: 2; range:2–14). Participating countries posted 2,343 messages(initial posts and replies, excluding updates), with a median of 11 messages per urgent inquiry (range:1–28). Of 60 multicountry UI, 50 involved between two and four countries. The UI allowed early detection of multicountry outbreaks, facilitated the identification of the suspected vehicles and consequently contributed to the timely implementation of control measures. The introduction of an epidemic intelligence information system platform in 2010 has strengthened the role of the Food- and Waterborne Diseases and Zoonoses network in facilitating timely exchange of information between public health authorities of the participating countries.

Changing hepatitis A epidemiology in the European Union: new challenges and opportunities

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Human-Dromedary Camel Interactions and the Risk of Acquiring Zoonotic Middle East Respiratory Syndrome Coronavirus Infection

Middle East respiratory syndrome coronavirus (MERS‐CoV) cases without documented contact with another human MERS‐CoV case make up 61% (517/853) of all reported cases. These primary cases are of particular interest for understanding the source(s) and route(s) of transmission and for designing long‐term disease control measures. Dromedary camels are the only animal species for which there is convincing evidence that it is a host species for MERS‐CoV and hence a potential source of human infections. However, only a small proportion of the primary cases have reported contact with camels. Other possible sources and vehicles of infection include food‐borne transmission through consumption of unpasteurized camel milk and raw meat, medicinal use of camel urine and zoonotic transmission from other species. There are critical knowledge gaps around this new disease which can only be closed through traditional field epidemiological investigations and studies designed to test hypothesis regarding sources of infection and risk factors for disease. Since the 1960s, there has been a radical change in dromedary camel farming practices in the Arabian Peninsula with an intensification of the production and a concentration of the production around cities. It is possible that the recent intensification of camel herding in the Arabian Peninsula has increased the virus' reproductive number and attack rate in camel herds while the ‘urbanization’ of camel herding increased the frequency of zoonotic ‘spillover’ infections from camels to humans. It is reasonable to assume, although difficult to measure, that the sensitivity of public health surveillance to detect previously unknown diseases is lower in East Africa than in Saudi Arabia and that sporadic human cases may have gone undetected there.

Multidisciplinary investigation of a multicountry outbreak of Salmonella Stanley infections associated with turkey meat in the European Union, August 2011 to January 2013

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Enhanced epidemic intelligence using a web-based screening system during the 2010 FIFA World Cup in South Africa

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Infectious diseases prioritisation for event-based surveillance at the European Union level for the 2012 Olympic and Paralympic Games

In 2012, London hosted the Olympic and Paralympic Games (the Games), with events occurring throughout the United Kingdom (UK) between 27 July and 9 September 2012. Public health surveillance was performed by the Health Protection Agency (HPA). Collaboration between the HPA and the European Centre for Disease Prevention and Control (ECDC) was established for the detection and assessment of significant infectious disease events (SIDEs) occurring outside the UK during the time of the Games. Additionally, ECDC undertook an internal prioritisation exercise to facilitate ECDC’s decisions on which SIDEs should have preferentially enhanced monitoring through epidemic intelligence activities for detection and reporting in daily surveillance in the European Union (EU). A team of ECDC experts evaluated potential public health risks to the Games, selecting and prioritising SIDEs for event-based surveillance with regard to their potential for importation to the Games, occurrence during the Games or export to the EU/European Economic Area from the Games. The team opted for a multilevel approach including comprehensive disease selection, development and use of a qualitative matrix scoring system and a Delphi method for disease prioritisation. The experts selected 71 infectious diseases to enter the prioritisation exercise of which 27 were considered as priority for epidemic intelligence activities by ECDC for the EU for the Games.

Taking stock of the first 133 MERS coronavirus cases globally--Is the epidemic changing?

Since June 2012, 133 Middle East respiratory syndrome coronavirus (MERS-CoV) cases have been identified in nine countries. Two time periods in 2013 were compared to identify changes in the epidemiology. The case-fatality risk (CFR) is 45% and is decreasing. Men have a higher CFR (52%) and are over-represented among cases. Thirteen out of 14 known primary cases died. The sex-ratio is more balanced in the latter period. Nosocomial transmission was implied in 26% of the cases.

Outbreak with a novel avian influenza A(H7N9) virus in China - scenarios and triggers for assessing risks and planning responses in the European Union, May 2013

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Outbreak with a novel avian influenza A(H7N9) virus in China--scenarios and triggers for assessing risks and planning responses in the European Union, May 2013

As part of the risk assessment and strategic planning related to the emergence of avian influenza A(H7N9) in China the European Centre for Disease Prevention and Control (ECDC) has considered two major scenarios. The current situation is the one of a zoonotic epidemic (Scenario A) in which the virus might be transmitted sporadically to humans in close contact with an animal reservoir. The second scenario is the movement towards efficient human to human transmission (a pandemic Scenario B). We identified epidemiological events within the different scenarios that would trigger a new risk assessment and a review of the response activities to implement in the European Union (EU). Further, we identified the surveillance activities needed to detect these events. The EU should prepare for importation of isolated human cases infected in the affected area, though this event would not change the level of public health risk. Awareness among clinicians and local public health authorities, combined with nationally available testing, will be crucial. A ’one health’ surveillance strategy is needed to detect extension of the infection towards Europe. The emergence of a novel reassortant influenza A(H7N9) underlines that pandemic preparedness remains important for Europe.

Challenges and Opportunities in Routine Time Series Analysis of Surveillance Data

Objective

To discuss challenges and opportunities in the introduction of an automated approach for time series analysis (TSA) regarding epidemiological methodology for generation of hypotheses, steps to be performed and interpretation of outputs.

Introduction

ECDC long term strategies for surveillance include analysis of trends of communicable disease of public health importance for European Union countries to guide public health actions. The European Surveillance System (TESSy) holds data on 49 communicable diseases reported by 30 countries for at least the past five years. To simplify time related analysis using surveillance data, ECDC launched a project to enable descriptive and routine TSA without the need for complex programming.

Methods

Protocols for TESSy data were developed specifying hypotheses to be tested, types and format of variables needed for TSA for several diseases, including VTEC, and legionellosis. Stata scripts were developed to comply with the basic steps of TSA, including data aggregation, data checking, data description, analysis of trends and seasonality, residual analysis, simple modelling and long-term forecasting. TSA steps were presented as successive tabs in a TSA dialogue box in Stata. Before using the Stata TSA dialogue box, experts were offered a two-day training, and provided with an in-depth manual supporting use and interpretation of TSA outputs using the Stata TSA dialogue box.

Results

For VTEC, it was possible to identify a small increase in the trend and a seasonal pattern in surveillance data with an estimate of the start of the increased risk for infection in the beginning of the summer season [1]. For legionellosis, an increasing trend in the number of reported cases was observed in 2010 [2]. Feedback from the training showed that using the Stata TSA dialogue box enables a quick exploratory analysis even by non-Stata users who could focus on interpretation of results, rather than the programme writing. However, we emphasise that statistical knowledge of TSA as well as rigorous preparation of the datasets (including data quality checks) and generation of hypotheses, are essential to ensure appropriate analysis and meaningful interpretation of the results.

Conclusions

Using the Stata TSA dialogue box saves time when performing rapid exploratory TSA of epidemiological data, avoiding the need for complex programming which is still needed for sophisticated TSA. Results of exploratory TSA analysis can trigger new hypothesis, for more advanced and sophisticated TSA. The introduction of a new technology (Stata TSA dialogue box) does not replace multi-disciplinary approach, knowledge and application of a methodological approach to TSA to produce meaningful results that can inform public health decision making. Further testing and training will be performed to enhance simplicity before appropriate dissemination of the Stata TSA dialogue box for a wider use.

Surveillance status and recent data for Mycoplasma pneumoniae infections in the European Union and European Economic Area, January 2012

In January 2012, the European Centre for Disease Prevention and Control (ECDC) conducted an email based survey of European Union and European Economic Area countries to describe the existing surveillance activities for Mycoplasma pneumoniae infections, recent findings and existence of clinical guidelines for the treatment of M. pneumoniae infection. Of the 20 countries that participated in the survey, seven reported increases in M. pneumoniae infections observed during the autumn and winter of 2011.

Applicability of evidence-based practice in public health: risk assessment on Q fever under an ongoing outbreak

With reference to the Q fever outbreak in the Netherlands in 2009-10, we tested if an evidence-based approach, comparable to the methodology used in clinical medicine, was appropriate for giving public health advice under time constrains. According to the principles of evidence-based methodologies, articles were retrieved from bibliographic databases and categorised by type and size, outcome, strengths and limitations. The risk assessment was conducted in two months and involved six staff members. We retrieved and read 559 abstracts and selected approximately 150 full text articles. The most striking finding was the lack of sound scientific evidence behind standard treatment regimes for Q fever in pregnancy. Difficulties in applying existing evidence rating systems and in expressing uncertainties were identified as problems during the process. By systematically assessing the evidence on several questions about Q fever, we were able to draw new conclusions and specify earlier statements. We found it difficult to grade the mostly observational studies with the known evidence-based grading systems. There is need to develop new methods for grading evidence from different sources in the field of public health. We conclude that an evidence-based approach is feasible for providing a risk assessment within two to three months.

Applicability of evidence-based practice in public health: risk assessment on Q fever under an ongoing outbreak

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Assessing the risk of a community outbreak of hepatitis A on blood safety in Latvia, 2008

Post-transfusion hepatitis A virus (HAV) infection worldwide is considered a sporadic event. An outbreak of HAV infection occurred in Latvia between the end of 2007 and throughout 2008 with more than 2,800 confirmed cases reported over a 13-month period (incidence of 123 per 100,000 population). The majority of reported HAV infection cases were in people over 18 years of age and in people living in the capital city, Riga. We estimated that the crude risk for HAV contamination of whole blood supplies in Riga between February and October 2008 ranged from 1.4 to 10.6per 10,000 donated units. In people under 40 years of age, the risk of receiving an infectious blood transfusion was more than 3.0 per 10,000 recipients between August and October 2008 during the peak of the outbreak. We conclude that there is a previously under-recognised impact of HAV on blood safety during widespread outbreaks of this disease. Estimating the risk of contamination of blood supplies during an infectious disease outbreak scenario is important for fine tuning risk assessments and potentially improving public health practices.

Assessing the impact of the 2009 H1N1 influenza pandemic on reporting of other threats through the Early Warning and Response System

Since the start of 2009 H1N1 influenza pandemic, a notable surge in messages communicated through the Early Warning and Response System (EWRS) for the prevention and control of communicable diseases in the European Union has been recorded. In order to measure the impact of this increase on the reporting of other events, we compared the messages posted in the EWRS since April 2009 with those posted in the previous years (2004-2008). The analysis revealed that a ten-fold increase in messages was recorded during the pandemic period, from April to September 2009, and that the reporting of other threats dropped to a significantly low rate. These results suggest an important impact on the notification process of events in case of a situation requiring extensive mobilisation of public health resources. It emphasises the importance keeping an appropriate balancing of resources during sustained emergencies, in particular in view of a possible second wave of pandemic influenza cases, to ensure prompt detection and reporting of potential concomitant emerging threats.

New perspectives after the transition of EPIET to ECDC – the future of the programme

Strengthening capacity in intervention epidemiology is key to the overall goal of responding to the challenge to detect and counter threats posed by outbreaks of infectious diseases in the European Union (EU). Since its founding in 1995, the European Programme for Intervention Epidemiology Training (EPIET) has become a core resource in training in intervention epidemiology in the EU. EPIET was integrated into the European Centre for Disease Prevention and Control (ECDC) on 1 November 2007 and this has resulted in an increased sustainability of the programme, allowing for long-term planning. Also, a new training programme, the European public health microbiology training (EUPHEM), was set up in 2008 to increase the response capacity for microbiology. Collaboration with EU Member States and other training programmes has been further intensified. Merging EPIET and other training activities in the ECDC training section has created the opportunity to develop an integrated multilevel approach to training in applied field epidemiology. An integrated approach to training activities on EU level, and increasing the number of EPIET and EPIET-associated fellows are essential to respond to the training needs of EU Member States, particularly new Member States. An external evaluation of EPIET in 2009 will provide guidance for a future strategy for the programme. This article examines the achievements of the EPIET programme after its transition to ECDC and provides an outlook on its future.

New perspectives after the transition of EPIET to ECDC - the future of the programme

Strengthening capacity in intervention epidemiology is key to the overall goal of responding to the challenge to detect and counter threats posed by outbreaks of infectious diseases in the European Union (EU). Since its founding in 1995, the European Programme for Intervention Epidemiology Training (EPIET) has become a core resource in training in intervention epidemiology in the EU. EPIET was integrated into the European Centre for Disease Prevention and Control (ECDC) on 1 November 2007 and this has resulted in an increased sustainability of the programme, allowing for long-term planning. Also, a new training programme, the European public health microbiology training (EUPHEM), was set up in 2008 to increase the response capacity for microbiology. Collaboration with EU Member States and other training programmes has been further intensified. Merging EPIET and other training activities in the ECDC training section has created the opportunity to develop an integrated multilevel approach to training in applied field epidemiology. An integrated approach to training activities on EU level, and increasing the number of EPIET and EPIET-associated fellows are essential to respond to the training needs of EU Member States, particularly new Member States. An external evaluation of EPIET in 2009 will provide guidance for a future strategy for the programme. This article examines the achievements of the EPIET programme after its transition to ECDC and provides an outlook on its future.

Contribution of EPIET to public health workforce in the EU, 1995-2008

We analyse activities and outputs of fellows of the European Programme for Intervention Epidemiology Training (EPIET) between 1995 and 2008 and describe the employment history of graduates after the training to demonstrate the contribution of this programme and of national EPIET-associated programmes to the public health workforce in the European Union and Norway. Up to 2008, some 161 fellows entered the training: 121 in EPIET and 40 in EPIET-associated programmes. Of these 149 were awarded a diploma. Fellows engaged in projects in all areas of surveillance, in outbreaks and field investigations and produced 340 publications in peer-reviewed journals. Seventy fellows were sent to 98 individual assignments on 65 international missions. The vast majority of graduates (90%) take up a position and remain employed in applied public health, either on regional, national or international level. Several (27) are working outside the EU, all in public health, including 13 working in Switzerland for international organisations. Only three of the 12 EU Member States that joined the EU since 2004, employ EPIET graduates. A major challenge for training the public health workforce is the retention of professionals in countries with limited job opportunities or wages significantly below the EU average.

Contribution of EPIET to public health workforce in the EU, 1995-2008

We analyse activities and outputs of fellows of the European Programme for Intervention Epidemiology Training (EPIET) between 1995 and 2008 and describe the employment history of graduates after the training to demonstrate the contribution of this programme and of national EPIET-associated programmes to the public health workforce in the European Union and Norway. Up to 2008, some 161 fellows entered the training: 121 in EPIET and 40 in EPIET-associated programmes. Of these 149 were awarded a diploma. Fellows engaged in projects in all areas of surveillance, in outbreaks and field investigations and produced 340 publications in peer-reviewed journals. Seventy fellows were sent to 98 individual assignments on 65 international missions. The vast majority of graduates (90%) take up a position and remain employed in applied public health, either on regional, national or international level. Several (27) are working outside the EU, all in public health, including 13 working in Switzerland for international organisations. Only three of the 12 EU Member States that joined the EU since 2004, employ EPIET graduates. A major challenge for training the public health workforce is the retention of professionals in countries with limited job opportunities or wages significantly below the EU average.

Public health preparedness for two mass gathering events in the context of pandemic influenza (H1N1) 2009--Serbia, July 2009

Preparedness planning for two large mass gatherings events were considered in Serbia in the context of pandemic influenza (H1N1) 2009. Planning included approaches to prevention, detection and response in order to mitigate the situation at this early stage of the epidemic in Serbia. Cases of influenza A(H1N1)v were identified nationally immediately prior to the mass gatherings but also identified in association with both events, as expected in the context of the pandemic situation. This article describes the experiences of planning and the epidemiological situation during the period of the mass gathering events.

Europe's initial experience with pandemic (H1N1) 2009 - mitigation and delaying policies and practices

Europe has experienced more than two months of the first transmissions and outbreak of the 2009 pandemic of A(H1N1)v. This article summarises some of the experience to date and looks towards the expected autumn increases of influenza activity that will affect every country. To date the distribution of transmission has been highly heterogenous between and within countries, with one country the United Kingdom (UK) experiencing the most cases and the highest transmission rates. Most infections are mild but there are steadily increasing numbers of people needing hospital care and more deaths are being reported. An initial difference in practice between Europe and North America was over case-finding and treatment with some authorities in Europe using active case-finding, contact tracing and treatment/prophylaxis with antivirals to try and delay transmission. This article details the history of this practice in the past two months and explains how and why countries are moving to mitigation, especially treating with antivirals those at higher risk of experiencing severe disease.

Epidemic intelligence and travel-related diseases: ECDC experience and further developments

The European Centre for Disease Prevention and Control (ECDC) started to work on information gathering for early detection of public health threats in June 2005. Since then, based on a framework including events and data-based surveillance, EDCD has been learning by doing. The internal tools and procedures for epidemic intelligence (EI) were developed while screening signals. Information including relevant epidemiological data, media news detected and actions taken are recorded in a specific event information system (Threat Tracking Tool). We describe the main elements, process and outputs of EI activities at ECDC. We also describe the main results regarding travel-related diseases. Efforts are needed to better identify and gather information about travellers coming to the EU with imported diseases with a potential for further spread inside our territory.

Why are Mexican data important?

This issue of Eurosurveillance contains an article by a French team on the transmission of the new influenza A(H1N1) in Mexico, which uses published figures from the outbreak to estimate important parameters for transmission, among them the reproduction rate, R [1]. Such studies may have important implications for public health action in Europe.

Hepatitis A in the European Union: responding to challenges related to new epidemiological patterns

In the European Union (EU), the overall incidence of hepatitis A has decreased over the last 10 years from 15.1 per 100,000 population in 1996 to 3.9 per 100,000 in 2006. However, reduction in circulation of HAV leads to decreased acquisition of immunity and, in the absence of universal vaccination, an accumulation of susceptible individuals. The impact of increasing susceptibility of the general population on the risk for outbreaks is clearly illustrated in independent outbreaks in Czech Republic, Latvia and Slovakia in 2008, described in three of the articles published in this week’s issue of Eurosurveillance.

Electronic surveillance of outbreaks in Lebanon

BACKGROUND

This paper describes and assesses the electronic surveillance of outbreaks based on the early warning for four endemic diseases - typhoid fever, amebic dysentery, viral hepatitis A and brucellosis - in Lebanon, for the first 28 weeks of 2005 and first 26 weeks of 2007.

METHODS

The electronic early warning system is based on the mandatory notification of 37 targeted diseases. The four target diseases assessed in this paper are based on monthly notification. Standards were set for case definitions and forms. Physicians and hospitals report to the Ministry of Public Health (MOPH), where data is checked and transmitted to a central location for entry into the national database, which stores historical and current data, as well as population estimates based on national surveys. The event date was selected for case dating. Indicators triggering abnormalities include number of cases, rates, and relative ratios. Four relative ratios were selected using the period of 1 week, 4 weeks or 52 weeks for the current and previous years. Screening was conducted on a weekly basis in 2005, and on a daily basis in 2007. Abnormal signals were verified, documented and grouped by alert-episodes for each disease, district, and period. MOPH teams verified and investigated case clustering.

RESULTS

During the first 28 weeks of 2005 and the first 26 weeks of 2007, screening operations were 68% and 89%, respectively, for completeness. Detected abnormal signals were 26 and 166 and identified alert-episodes were 11 and 22, respectively. Verified clusters were 7 and 11; positive predictive value for clusters identification was 64% and 50%, respectively. The time interval between first cases and first abnormal signals was on average 4 weeks and 5 weeks, respectively.

CONCLUSION

Timely reporting, transmission, data entry, analysis and communication are the elements of timely outbreak detection. The electronic surveillance of outbreaks for epidemic-prone diseases, which are mandatory notified on a monthly basis using indicator-based thresholds, is capable of detecting spatio-temporal clusters and outbreaks; however, with some delay. The national surveillance system needs to be reviewed in order to provide timely data for early warning surveillance and response.

Unknown disease in South Africa identified as arenavirus infection

On 12 September 2008, a tourist guide organising safari trips, residing in Lusaka, Zambia, was evacuated in a critical condition to Johannesburg, South Africa. She was admitted to a clinic where she died on 14 September about 10 days after the onset of symptoms. The symptoms included a prodromal phase with fever, myalgia, vomiting, diarrhoea, followed by rash, liver dysfunction and convulsions [1]. Cerebral oedema was detected on scan examination. No laboratory specimen was available for investigation. The paramedic who had cared for the index case during her evacuation to Johannesburg developed prodromal symptoms similar to the index case. He was hospitalised on 27 September. His condition deteriorated and he died on 2 October. An intensive care unit nurse who cared for the index case in Johannesburg developed similar flu-like symptoms and was hospitalised on 1 October. Her condition deteriorated on 4 October and she died on 5 October of acute respiratory distress syndrome. In both cases, the incubation period is estimated to have been about one week. On 13 October, the World Health Organization (WHO) posted a website update informing about a fourth case affecting a nurse who had been in contact with the paramedic [2]. On 12 October 2008, the National Institute for Communicable Diseases (NICD) in South Africa provided preliminary evidence that the causative agent of the disease was a virus from the Arenaviridae family [3]. Specimens were shipped to the United States Centers for Disease Control and Prevention (CDC) in Atlanta for additional investigations.

Unknown disease in South Africa identified as arenavirus infection

On 12 September 2008, a tourist guide organising safari trips, residing in Lusaka, Zambia, was evacuated in a critical condition to Johannesburg, South Africa. She was admitted to a clinic where she died on 14 September about 10 days after the onset of symptoms. The symptoms included a prodromal phase with fever, myalgia, vomiting, diarrhoea, followed by rash, liver dysfunction and convulsions [1]. Cerebral oedema was detected on scan examination. No laboratory specimen was available for investigation.

Melamine contamination of dairy products in China – public health impact on citizens of the European Union

On 10 September 2008, ProMED issued a request for information concerning 14 cases of kidney stones in infants hospitalised in Gansu province, China, in the previous two months [1]. On 21 September, Chinese authorities reported 39,965 cases of kidney stones in infants, including three deaths related to the consumption of melamine-contaminated powdered infant formula. On that day, 12,892 of them were hospitalised, 104 with severe illness. Most of these cases (82%) affected children under two years of age.

Preparedness activities ahead of the Beijing 2008 Olympic Games - enhancing EU epidemic intelligence

This Friday, 8 August 2008 will see the official opening of the Beijing 2008 Olympic Games. In the following weeks (8-24 August) an estimated 10,500 athletes from 205 participating countries will compete in the Olympics, followed by the Paralympics (6-17 September). Sporting events will be held in Olympic venues hosted mainly in Beijing city, Tianjin, Hong Kong, Shanghai, Shenyang, Qinhuangdao and Qingdao (See Figure). An estimated 2.4 million spectators are anticipated to join in the celebration of the Olympics alone, with over 20,000 accredited media present [1] and 450,000 foreigners expected [2].