Humoral immune response to SARS-CoV-2 mRNA vaccines is associated with choice of vaccine and systemic adverse reactions

Purpose

Although the fast development of safe and effective messenger RNA (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 has been a success, waning humoral immunity has led to the recommendation of booster immunization. However, knowledge of the humoral immune response to different booster strategies and the association with adverse reactions is limited.

Materials and Methods

We investigated adverse reactions and anti-spike protein immunoglobulin G (IgG) concentrations among health care workers who received primary immunization with mRNA-1273 and booster immunization with mRNA-1273 or BNT162b2.

Results

Adverse reactions were reported by 85.1% after the first dose, 94.7% after the second dose, 87.5% after a third dose of BNT162b2, and 86.0% after a third dose of mRNA-1273. They lasted for a median of 1.8, 2.0, 2.5, and 1.8 days, respectively; 6.4%, 43.6%, and 21.0% of the participants were unable to work after the first, second, and third vaccination, respectively, which should be considered when scheduling vaccinations among essential workers. Booster immunization induced a 13.75-fold (interquartile range, 9.30-24.47) increase of anti-spike protein IgG concentrations with significantly higher concentrations after homologous compared to heterologous vaccination. We found an association between fever, chills, and arthralgia after the second vaccination and anti-spike protein IgG concentrations indicating a linkage between adverse reactions, inflammation, and humoral immune response.

Conclusion

Further investigations should focus on the possible advantages of homologous and heterologous booster vaccinations and their capability of stimulating memory B-cells. Additionally, understanding inflammatory processes induced by mRNA vaccines might help to improve reactogenicity while maintaining immunogenicity and efficacy.

Large inter-individual variability of cellular and humoral immunological responses to mRNA-1273 (Moderna) vaccination against SARS-CoV-2 in health care workers

PURPOSE

Studies on the immune responses to severe acute respiratory syndrome coronavirus 2 vaccines are necessary to evaluate the ongoing vaccination programs by correlating serological response data and clinical effectiveness data. We performed a longitudinal immunological profiling of health care workers vaccinated with mRNA-1273 (Moderna, Cambridge, MA, USA). Half of these vaccinees had experienced a mild coronavirus disease 2019 (COVID-19) infection in the spring of 2020 ("COVID-recovered" cohort), whereas the other half of the vaccinees had no previous COVID-19 infection ("COVID-naive" cohort).

MATERIALS AND METHODS

Serum was drawn at multiple time points and subjected to assays measuring anti-Spike immunoglobulin G (IgG), avidity of anti-Spike IgG, avidity of anti-receptor binding domain (RBD) IgG, virus neutralizing activity, and interferon-γ release from stimulated lymphocytes.

RESULTS

Between both cohorts and within each cohort, we found remarkable inter-individual differences regarding cellular and humoral immune responses to the Moderna mRNA-1273 vaccine.

CONCLUSION

First, our study indicates that the success of mRNA-1273 vaccinations should be verified by serological assays in order to identify "low-responders" to vaccination. Second, the kinetics of anti-S IgG and neutralizing activity correlate well with clinical effectiveness data, thus explaining incipient protection against infection 2 weeks after the first dose of mRNA-1273 in COVID-naive vaccinees. Third, our IgG-avidity data indicate that this incipient protection is mediated by low-avidity anti-RBD IgG and low-avidity anti-S IgG.

Two novel SARS-CoV-2 surrogate virus neutralization assays are suitable for assessing successful immunization with mRNA-1273

BACKGROUND

Due to large vaccination efforts with novel vaccines there is an increasing need for laboratory tests assessing successful immunizations with SARS-CoV-2 vaccines. Unfortunately classical neutralization assays are laborious, time-consuming and require an adequate biosafety level laboratory. Recently, convenient ELISA-based surrogate neutralization assays (sVNTs) for determination of neutralizing SARS-CoV-2 antibodies have been developed.

STUDY DESIGN

Our study compares the two novel ELISA-based SARS-CoV-2 surrogate neutralization assays "cPass SARS-CoV-2 Surrogate Virus Neutralization Test Kit" (GenScript Biotech, USA) and the "TECO SARS-CoV-2 Neutralization Antibody Assay" (TECOmedical, Switzerland) using 93 sera drawn from health care workers (HCVs) 2-3 weeks following the second vaccination with mRNA-1273 and 40 control sera from the pre-SARS-CoV-2 era before 2019.

RESULTS

We found a sensitivity of 100% and 91,4% and a specificity of 100% and 100% for the GenScript assay and the TECO assay, respectively. Both sVNTs show a high correlation with anti-S IgG. Moreover, both sVNTs correlate well with each other.

CONCLUSIONS

Surrogate neutralization assays based on the RBD as bait feature a high specificity and sensitivity for identifying humoral neutralizing activity in individuals vaccinated with the spike-based vaccine mRNA-1273. Although these assays appear well-suited for confirming successful vaccinations with spike-based vaccines, additional studies should compare both assays regarding other purposes such as screening COVID-recovered patients or individuals vaccinated with inactivated whole virus vaccines.

Severity of adverse reactions is associated with T-cell response in mRNA-1273 vaccinated health care workers

Knowledge about mRNA-1273 elicited T-cell response is limited. We investigated adverse reactions and interferon gamma release by specific T-cells among mRNA-1273 vaccinated health care workers. Seven to 13 weeks after complete vaccination low levels of specific T-cells were detected not correlating with antibody response. Severity of symptoms after first and number of symptoms after second immunization were associated with T-cell response. Assessment of T-cell response in addition to antibody response is crucial because even few specific T-cells could add to protection against infection. Investigation of mRNA-1273 induced inflammatory processes might help improve reactogenicity and immunogenicity.

Evaluation of the QuantiFERON SARS-CoV-2 interferon-ɣ release assay in mRNA-1273 vaccinated health care workers

Current studies focus on cellular and humoral immunity induced by novel SARS-CoV-2 vaccines. Non-responders to vaccinations are not uncommonly encountered in clinical medicine (e.g. in the field of hepatitis B). Whereas vaccine-induced humoral immunity against SARS-CoV-2 is compromised by emerging Variants of Concern (VOCs), cellular immunity against SARS-CoV-2 is emerging as resilient against VOCs. Thus commercially available test kits for diagnostic laboratories designed to evaluate cellular immune responses to SARS-CoV-2 are urgently needed. Here we evaluated the novel QuantiFERON SARS-CoV-2 assay (Qiagen) measuring INF-ɣ release induced by two spike-derived peptide pools (Ag1 and Ag2) in a cohort of health care workers vaccinated with the mRNA-1273 vaccine and confirmed humoral response. Our study indicates the usefulness of this novel assay for routine laboratories to evaluate cellular immunity against SARS-CoV-2 in response to mRNA-1273 vaccination.

Nasopharyngeal Carriage in Children After the Introduction of Generalized Infant Pneumococcal Conjugate Vaccine Immunization in Germany

Epidemiological data on nasopharyngeal (NP) bacterial carriage in children in Germany are scarce. We prospectively characterized NP colonization to evaluate the impact of pneumococcal immunization. We longitudinally collected NP swabs from 2-month-old infants (visit 1; V1) at eight representative pediatric offices 10/2008-06/2009. The second swabs were taken at age 9–12 months (V2); the third swab was taken 3–6 months after the booster vaccination at age 17–19 months (V3), and the fourth swab (V4) at age 59–61 months. Samples were broth enriched, cultured for bacteria, and isolates were serotyped. Demographic risk factors for colonization were evaluated. Among 242 vaccinees, bacterial NP carriage increased with age [from 27.2% (V1) to 70.1% (V4)]; leading isolates were S. pneumoniae, H. influenzae, M. catarrhalis, and S. pyogenes. Overall pneumococcal carriage increased [14.7% (V1), 31.5% (V2), 34.8% (V3), 42.2% (V4)], being even greater among day-care attendees. Serotype distribution changed during the study period, with vaccine serotypes declining. At visit 4, 10-valent pneumococcal conjugate vaccine (PCV10) serotypes were no longer among the NP flora, while some serotypes unique to 13-valent pneumococcal conjugate vaccine (PCV13; 3 and 19A) were found. In Germany, universal infant PCV immunization was associated with an almost complete eradication of PCV-serotypes and concomitant increase of non-PCV-serotypes, mainly 11A, 22F, and 23A.

Bacterial Spectrum of Spontaneously Ruptured Otitis Media in a 7-Year, Longitudinal, Multicenter, Epidemiological Cross-Sectional Study in Germany

We analyzed middle ear fluid (MEF) and nasopharyngeal swabs (NPS) from spontaneously ruptured acute otitis media (AOM) cases occurring in children under 5 years in Germany. The aim of the study was the assessment of disease burden and bacterial etiology in the era of routine pneumococcal vaccination. Furthermore, we aimed to compare isolates from MEF with isolates from NPS and to analyze the Streptococcus pneumoniae serotype distribution. We analyzed MEF and NPS samples in children 2 months to 5 years for vaccination status, frequency of bacterial strains, serotype/emm-type distribution of S. pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes; and intraindividual correlation between MEF and NPS. From 2008 to 2014, MEF samples were collected from 2,138 subjects of which 2,001 (93.6%) also provided an NPS sample. In 851 of 2,138 MEF samples (39.8%), we identified organisms with confirmed pathogenic potential—S. pyogenes: 315 (14.7%), S. pneumoniae: 170 (8.0%), Staphylococcus aureus: 168 (7.9%), H. influenzae: 133 (6.2%), and Moraxella catarrhalis. Among NPS samples, 1,018 (50.9%) contained S. pneumoniae, 775 (38.7%) H. influenzae, 648 (32.4%) M. catarrhalis, and 344 (17.2%) S. pyogenes. Over the seven study years, the number of AOM patients steadily decreased, while the recruiting base remained constant. S. pneumoniae MEF isolates decreased by 86%, with serotype 3 being the most prevalent (25.7–42.9%). PCV13-non-PCV7-non-3 serotypes reduced to 0%. Among NPS, PCV7 serotypes decreased from 14.1 to 3.7%, PCV10: 17.6 to 3.7%, and PCV13: 55.3 to 25.7%. PCV13-non-PCV7-non-3 serotypes increased in the first 3 years of the study (17.1–22.9%), then decreased to 4.6% in year 7. Non-typeable H. influenzae reduced from 87.1 to 41.7% in MEF and from 91.4 to 54.2% in NPS. MEF and NPS isolates from the same subject were identical for 91.9% of S. pneumoniae, 99.0% of S. pyogenes, and 83.3% of H. influenzae. Among PCV7-vaccinated children, 5.6% had a PCV7 vaccine type in the MEF sample, and among PCV13-vaccinated children, 51.7% had a PCV13 serotype. Among non-vaccinated children, the percentages were 14.8 and 70.4. Pneumococcal conjugate vaccination has impacted the prevalence and etiology of spontaneously ruptured otitis media among children in Germany. Overall case numbers and pneumococcal vaccine type cases have strongly decreased.

Comparison of the SARS-CoV-2 Rapid antigen test to the real star Sars-CoV-2 RT PCR kit

There is an ongoing need for reliable antigen assays for timely and easy detection of individuals with acute SARS-CoV-2 infection. Using 75 swabs from patients previously tested positive by SARS-CoV-2 PCR and 75 swabs from patients previously tested negative by SARS-CoV-2 PCR, we investigated the sensitivity and specificity of the SARS-CoV-2 Rapid Antigen Test (Roche). We determined a specificity of 96 %. The assay's sensitivity with samples with a cycle threshold of < 25, 25 - <30, 30 - <35, and> = 35 was 100 %, 95 %, 44.8 % and 22.2 %, respectively. We conclude that sensitivity and specificity of the antigen assay is inferior to the PCR assay. However, the antigen assay may be a quick and easy to perform alternative for differentiation of individuals contagious for SARS-CoV-2 from non-contagious individuals.

Determination of SARS-CoV-2 antibodies with assays from Diasorin, Roche and IDvet

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The sensitivity and specificity of seven serological assays for SARS-CoV-2 were compared.

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No single assay offered a combination of very high sensitivity and very high specificity.

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To maximize sensitivity and specificity two assays should be combined.

There is an ongoing need for highly reliable serological assays to detect individuals with past SARS-CoV-2 infection. Using 75 sera from patients tested positive or negative by SARS-CoV-2 PCR, we investigated the sensitivity and specificity of the Liaison SARS-CoV-2 S1/S2 IgG assay (DiaSorin), the Elecsys Anti-SARS-CoV-2 assay (Roche), and the ID Screen SARS-CoV-2-N IgG indirect kit (IDVet). We determined a sensitivity of 95.5 %, 95.5 %, and 100 % and a specificity of 90.5 %, 96.2 %, and 92.5 % for the DiaSorin assay, the Roche assay, and the IDVet assay, respectively. We conclude that serologic assays combining very high sensitivity and specificity are still not commercially available for SARS-CoV-2. For maximizing sensitivity and specificity of SARS-CoV-2 serological diagnostics, the combination of two assays may be helpful.

Comparison of four new commercial serologic assays for determination of SARS-CoV-2 IgG

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4 new SARS-CoV-2 IgG assays can identify individuals with past SARS-CoV-2 infection.

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Combination of two different assays may increase sensitivity and specificity.

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Two assays were identified allowing quantification over a broad linear range.

Background

Facing the ongoing pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there is an urgent need for serological assays identifying individuals with past coronavirus disease 2019 (COVID-19).

Study design

Our study is the first to compare four new commercially available assays using 75 sera from patients tested positive or negative by SARS-CoV-2 PCR: the anti SARS-CoV-2 ELISA (IgG) (Euroimmun, Germany), the EDI New Coronavirus COVID-19 IgG ELISA, (Epitope diagnostics (EDI), USA), the recomWell SARS-CoV-2 IgG ELISA (Mikrogen, Germany), and the SARS-CoV-2 Virachip IgG (Viramed, Germany).

Results

We found a sensitivity of 86.4 %, 100 %, 86.4 %, and 77.3 % and a specificity of 96,2 %, 88,7 %, 100 %, and 100 % for the Euroimmun assay, the EDI assay, the Mikrogen assay, and the Viramed assay, respectively.

Conclusions

Commercially available SARS-CoV-2 IgG assays have a sufficient specificity and sensitivity for identifying individuals with past SARS-CoV-2 infection.

Correction: Limited indirect effects of an infant pneumococcal vaccination program in an aging population

[This corrects the article DOI: 10.1371/journal.pone.0220453.].

Limited indirect effects of an infant pneumococcal vaccination program in an aging population

BACKGROUND

A general recommendation for adult pneumococcal vaccination with 23-valent polysaccharide vaccine (PPV23) for adults 60 and older has been in place in Germany since 1998, but uptake has been low. Just over a decade after the implementation of an infant pneumococcal conjugate vaccine recommendation, we examined indirect protection effects on adult invasive pneumococcal disease (IPD) in Germany.

METHODS AND FINDINGS

Reported IPD cases decreased in children under two years of age from 11.09 per 100,000 in 2003-2006 to 5.94 per 100,000 in 2017/18, while in adult age groups, reported IPD cases rose across the board, most dramatically in adults 60 years of age and over, from 1.64 to 10.08 cases per 100,000. PCV13-type IPD represents 31% of all cases in this age group, the lion's share of which is due to the rapid increase of serotype 3 IPD, which, by itself, has reached 2.11 reported cases per 100,000 and makes up 21% of all IPD cases in this age group. The two vaccine formulations currently in development (PCV15 and PCV20) would increase current (PCV13) coverage by 8.5% points and 28.0% points in children, while in adults coverage would increase by 10.4% points and 21.9% points, respectively.

CONCLUSIONS

While original models predicted that indirect effects of childhood vaccination would suffice for adults, it seems that the herd protection effect has reached its limit, with vaccine serotypes 4, 19F, and 19A IPD persisting in adults after initial reductions, and serotype 3 IPD not showing any herd protection effect at all.

Invasive Pneumococcal Disease in Refugee Children, Germany

Refugee children in Germany are not routinely given a pneumococcal conjugate vaccine. Cases of invasive pneumococcal disease (IPD) in 21 refugee children were compared with those in 405 Germany-born children for 3 pneumococcal seasons. Refugee children had significantly higher odds of vaccine-type IPD and multidrug-resistant IPD than did Germany-born children.

Mining the Age-Dependent Reference Intervals of B Vitamins from Routine Laboratory Test Results

Objective

To describe the reference intervals of folate, vitamin B12, vitamin B6, and vitamin B1 by sex and age.

Methods

The study was performed by gathering data on 55,811 subjects from 57 medical centers. Groups were categorized based on age and grouped according to statistical significance values. The reference values for the different groups were determined using the Bhattacharya and Hoffmann methods.

Results

Vitamin B1 and B6 values and folate (vitamin B9) levels between the sexes were statistically significantly increased in the group aged 0 to 10 years. Likewise, we witnessed a similar increase in vitamin B12 levels in the group aged 0 to 5 years. However, low vitamin B6 levels (P <.001) were detected in nongeriatric patients (aged 0-60 years), and the reference intervals (3.4-41.9 µg/L) also were significantly different from those in the geriatric group (aged 61-100 years; 2.0-29.4 µg/L).

Conclusion

A lower vitamin B6 reference limit allows detection of subclinical vitamin deficiency more precisely in the geriatric group; respective reference intervals should be revised accordingly.

Regional variations in serotype distribution and vaccination status in children under six years of age with invasive pneumococcal disease in Germany

Overview

The protective effect of infant pneumococcal conjugate vaccine (PCV) recommendation can be seen in Germany as a whole and in smaller regional groups. Comparisons between population-normalized geographic regions of Germany show different serotype distributions after program implementation, particularly in non-vaccine serotypes. The prior distinct differences in serotype distribution in children between the former East and former West German federal states have vanished. Children under six remain a vulnerable group, but the occurrence of vaccine-type (VT) invasive pneumococcal disease (IPD) in children correctly vaccinated (using a three-dose primary series plus one booster dose) with PCV13 was low (9 out of 374 cases, 2.4%). However, only 18.4% of children in Germany with IPD were correctly vaccinated with PCV13 according to the recommended schedule. Continued surveillance and better schedule adherence are essential to definitively establish the most effective PCV administration schedule.

Vaccination effects

For all PCV products used in Germany (PCV7, PCV10, and PCV13), vaccination status was the most common statistically significant predictor of infection with a particular serotype: Unvaccinated children old enough to have received at least one dose of vaccine in the PCV7 group had significantly higher odds (OR: 6.84, 95%CI: 2.66–22.06, adjusted for per capita income and residence in the northeastern federal states) of contracting VT IPD. In the PCV10 group, VT IPD had an OR of 4.52 (95% CI: 1.60–15.62, adjusted for year of infection, median household size, and residence in the southern federal states) in unvaccinated children, and in the PCV13 group, unvaccinated children continued to have higher odds (OR: 6.21, 95%CI: 3.45–11.36, adjusted for year of infection, age of child, per capita income, residence in the southern federal states, and percentage of children using public daycare) of getting vaccine-type IPD. Being unvaccinated was the most frequent significant indicator for infection with vaccine-type serotypes for each analysis group, while geographic groupings showed more limited potential to predict serotype of infection in early childhood IPD in Germany.

Epidemiology and distribution of 10 superantigens among invasive Streptococcus pyogenes disease in Germany from 2009 to 2014

A nationwide laboratory-based surveillance study of invasive S. pyogenes infections was conducted in Germany. Invasive isolates (n = 719) were obtained between 2009 and 2014. Most isolates were obtained from blood (92.1%). The proportions of isolates from cerebrospinal fluid, pleural fluid, synovial fluid and peritoneal fluid were 3.9%, 1.8%, 1.7% and 0.6%, respectively. The most common emm types were emm 1 (31.8%), emm 28 (15.4%) and emm 89 (14.5%). The most common superantigen genes (speA, speC, speG, speH, speI, speJ, speK, speL, speM, ssa) identified from S. pyogenes were speG (92.1%), speJ (50.9%), and speC (42.0%). Significant associations of superantigen genes with underlying conditions or risks were observed in speG, speH, speJ, and speK. Significant associations between emm types or superantigen genes with clinical complications were observed in emm type 3 and in superantigen gene speA 1-3. Most frequent clinical manifestations included sepsis 59.4%, STSS 6.3%, meningitis 5.4%, and necrotizing fasciitis 5.0% (significantly associated with emm1).

Fluoroquinolone resistance in Streptococcus pneumoniae isolates in Germany from 2004-2005 to 2014-2015

Streptococcus pneumoniae is a major cause of bacterial pneumonia, sepsis and meningitis worldwide. Prevalence of levofloxacin-resistant S. pneumoniae isolates in Germany and associated mutations in the quinolone resistance determining regions (QRDRs), as well as serotype distribution and multi locus sequence types (MLST) are shown. 21,764 invasive S. pneumoniae isolates from Germany, isolated in the epidemiological seasons from 2004/05 to 2014/15 were analyzed at the German National Reference Centre for Streptococci (GNRCS) for their levofloxacin resistance by micro broth dilution method. All resistant (minimal inhibitory concentration (MIC) ≥8μg/ml) and intermediate (MIC >2μg/ml and <8μg/ml) isolates were selected for the present study. Additionally, 29 susceptible isolates were randomly selected. A total of ninety isolates were tested for their levofloxacin-MIC by Etest, their serotype and sequence type, as well as for point-mutations at the QRDRs in the genes parC, parE, gyrA and gyrB. Twenty-five isolates exhibited levofloxacin MICs <2μg/ml (Etest) and no mutations in the QRDRs. Four isolates with MICs=2μg/ml had one mutation in parC; isolates with MICs >2μg/ml all had one or more mutations in the QRDRs. Four of nine intermediate isolates had a mutation in either parC or gyrA, and four isolates had mutations in both parC and gyrB. One isolate had mutations in both parC and gyrA. All isolates with MICs ≥8μg/ml (52) had mutations in both topoisomerase IV and gyrase. Serotypes associated with levofloxacin resistance shifted from a majority of PCV13 serotypes before the introduction of the PCV13 vaccine towards non-PCV serotypes. Resistant isolates were almost exclusively found among adults (98.1%).

Effectiveness of Pneumococcal Conjugate Vaccines (PCV7 and PCV13) against Invasive Pneumococcal Disease among Children under Two Years of Age in Germany

Background

In this study we calculate the effectiveness of pneumococcal conjugate vaccines (PCV) against invasive pneumococcal disease (IPD) among children under the age of two years using the indirect cohort method. We also discuss the timeliness of vaccination and the residual cases of vaccine type IPD.

Methods and Findings

From July 2006 until June 2015, 921 IPD cases were reported and for 618 children (67.1%), the vaccination status at the time of infection could be accurately determined. Of these, 379 (61.3%) were vaccinated and 239 (38.7%) were not vaccinated. The adjusted vaccine effectiveness (VE) of PCV7 for all included serotypes + 6A was 80% (95% CI: 63–89) for at least one dose, 97% (89–100) after three primary doses (post primary) and 95% (57–100) post booster. The adjusted overall VE of PCV13 was 86% (74–93) for at least one dose, 85% (62–94) post primary and 91% (61–99) post booster. For the additional serotypes included in PCV13, the adjusted VE was 82% (66–91), 80% (46–93) and 90% (54–98) respectively. The serotype specific VE for at least one dose was high for serotypes 1 (83%; 15–97), 3 (74%; 2–93), 7F (84%; 18–98) and 19A (77%; 47–90). Only 39.5% of children with IPD obtained their first dose of PCV7 according to schedule (2^nd dose: 32.9%, 3^rd dose: 22.0%, booster dose: 63.6%). For children vaccinated with PCV13 values were slightly better: 43.8%, 33.5%, 26.3% and 74.3% respectively. Among 90 residual cases with PCV7 serotypes, 73 (81.1%) were in unvaccinated children, and 15 (16.7%) in children who had not obtained the number of doses recommended for their age, and only two (2.2%) in children vaccinated according to age. Of 82 cases with PCV13 serotypes occurring after the switch from PCV7 to PCV13, 56 (68.3%) were not vaccinated, 22 (26.8%) were incompletely vaccinated, and four (4.9%) were vaccinated according to age.

Conclusions

Our data show a high effectiveness of pneumococcal conjugate vaccination in Germany. However, the administration of vaccine doses among children with IPD is often delayed, resulting in many vaccine type cases in non- or incompletely-vaccinated children. Whether the recently-implemented change to a 2+1 schedule will improve the timeliness of vaccination should be subject to careful monitoring.

Incidence of invasive pneumococcal disease in 5-15 year old children with and without comorbidities in Germany after the introduction of PCV13: Implications for vaccinating children with comorbidities

OBJECTIVE

To describe the burden of suffering from IPD in children aged 5-15 years with and without comorbidities up to 5 years after the introduction of PCV13 in Germany and to identify the potential benefit for PCV13 and PPV23 vaccination.

METHODS

The surveillance of IPD for children <16 years was based on two independently reporting sources: active surveillance in pediatric hospitals and a laboratory-based sentinel surveillance system.

CASE DEFINITION

IPD with cultural detection of pneumococci at a physiologically sterile site in children from 2010 to 2014 in Germany. Incidence was estimated by capture-recapture analysis with stratification by absence/presence of comorbidities. Coverage of the observed serotypes by different vaccines was assessed.

RESULTS

142 (Capture recapture-corrected: 437) cases were reported: 72.5% were healthy children and 27.5% had a comorbidity. The incidence of IPD related to children with comorbidities was 0.2 per 100,000. One third of these cases had serotypes not included in either vaccine. The remaining cases might benefit from pneumococcal vaccination but one third of all cases was not vaccinated. The additional potential benefit of PPV23 compared to PCV13 with respect to coverage was 10%.

CONCLUSION

The incidence of IPD in children with comorbidities in Germany is low. Pneumococcal vaccination uptake in children with comorbidities should be increased, although only about two-thirds of the cases might be preventable by presently available vaccines.

Antimicrobial Susceptibility of Invasive Streptococcus pyogenes Isolates in Germany during 2003-2013

A nationwide laboratory-based surveillance study of invasive S. pyogenes infections was conducted in Germany. Invasive isolates (n = 1,281) were obtained between 2003 and 2013. All isolates were susceptible to penicillin, cefotaxime and vancomycin. Tetracycline showed the highest rate of resistant or intermediate resistant isolates with 9.8%, followed by macrolides (4.0%), trimethoprim/sulfamethoxazole (SXT) (1.9%), levofloxacin (1.3%), chloramphenicol (0.9%) and clindamycin (0.7%). The most prominent trends were the appearance of levofloxacin non-susceptible isolates since 2011, and an increase of SXT non-susceptibility since 2012.

Effects of Infant Pneumococcal Conjugate Vaccination on Serotype Distribution in Invasive Pneumococcal Disease among Children and Adults in Germany

This study describes the effects of the introduction of universal infant pneumococcal conjugate vaccination in 2006 on invasive pneumococcal disease (IPD) among children and adults in Germany with a focus on the dynamics of serotype distribution in vaccinated and non-vaccinated age groups. Over a period of 22 years (1992-2014), microbiological diagnostic laboratories from all over Germany have been sending isolates of IPD cases to the German National Reference Center for Streptococci on a voluntary basis. Streptococcus pneumoniae isolates were serotyped using Neufeld's Quellung method. Among children <16 years, the proportion of PCV7 serotypes among isolates from IPD cases decreased from 61.8% before vaccination (1997-2006) to 23.5% in the early vaccination period (2007-2010; p = 1.30E-72) and sank further to 5.2% in the late vaccination period (2010-2014; p = 4.59E-25). Similar reductions were seen for the separate age groups <2 years, 2-4 years and 5-15 years. Among adults, the proportion of PCV7 serotypes decreased from 43.4% in the pre-vaccination period (1992-2006) to 24.7% (p = 3.78E-88) in the early vaccination period and 8.2% (p = 5.97E-161) in the late vaccination period. Both among children and among adults, the non-PCV7 serotypes 1, 3, 7F and 19A significantly increased in the early vaccination period. After the switch from PCV7 to PVC10/PCV13 for infant vaccination in 2010, serotypes 1, 6A and 7F significantly decreased. A decrease in serotype 19A was only observed in 2013-2014, as compared to 2010-2011 (children p = 4.16E-04, adults p = 6.98E-06). Among adults, serotype 3, which strongly increased in the early vaccination period (p = 4.44E-15), remained at a constant proportion in the late vaccination period. The proportion of non-PCV13 vaccine serotypes increased over the whole vaccination period, with serotypes 10A, 12F, 23B, 24F and 38 most significantly increasing among children and serotypes 6C, 12F, 15A, 22F and 23B increasing among adults. Eight years of childhood pneumococcal conjugate vaccination have had a strong effect on the pneumococcal population in Germany, both among the target group for vaccination as well as among older children and adults.

Increase of serotypes 15A and 23B in IPD in Germany in the PCV13 vaccination era

Background

This study presents an analysis of 1,491 serogroup 23 and 762 serogroup 15 isolates from invasive pneumococcal disease (IPD) in children and adults before and after the general recommendation for childhood pneumococcal conjugate vaccination in Germany in July 2006. Vaccination formulations used were PCV7 (from July 2006), PCV10 (from April 2009) and PCV13 (from December 2009, replacing PCV7).

Methods

The German National Reference Center for Streptococci (GNRCS) has conducted surveillance of IPD since 1992. Isolates were serotyped and tested for antibiotic susceptibility. Selected isolates were characterized using MLST.

Results

In an analysis of 23,957 isolates from IPD in children and adults sent to the GNRCS between July 1992 and June 2014, we found a strongly significant increase of non-PCV13 serotypes in the late vaccination (PCV13) period (2010-2014). Among these, the proportions of serotypes 15A and 23B were the most strongly significantly increasing. After the recommendation for pneumococcal conjugate childhood vaccination in 2006 and the introduction of higher-valent vaccines in 2009, the proportion of 15A increased significantly from 0.5% in the early vaccination period (2007-2010) to 2.4% in the late vaccination period (2010-2014, p=3.14x10^-22). The proportion of serotype 23B increased from 0.5% to 2.8% in the same period (p=1.55x10^-29). Penicillin non-susceptibility levels of the serotype 15A (47.4%) and serotype 23B (46.5%) isolates were high, with MIC values ranging from 0.12-2 μg/ml (15A) and 0.12-0.5 μg/ml (23B). MLSTs of serotype 23B isolates grouped in two clonal complexes (CC): CC439, with sequence type (ST) 439 as the main representative and CC338 (linked to CC156), with ST1349 as most prevalent clone. Both CCs have been present over almost the whole surveillance period. All penicillin non-susceptible isolates occurred in CC338. Serotype 15A isolates appeared to be more diverse. Six CCs, one group of three STs and two singletons were found among 20 isolates. Most prevalent was CC63, with ST63 as most prominent representative (n=5). Most penicillin non-susceptible isolates were found among CC63 isolates.

Conclusions

The prevalence of non-PCV13 serotypes in Germany has increased significantly between July 2007 and June 2014, with 15A and 23B being the most strongly increasing serotypes of all. Both serotypes show a high proportion of penicillin non-susceptibility.

Bacterial spectrum of spontaneously ruptured otitis media in the era of pneumococcal conjugate vaccination in Germany

Otitis media is a common pediatric disease and the main reason for antibiotic prescription in children. Before implementation of routine childhood pneumococcal vaccination in Germany, serotypes contained in the seven-valent pneumococcal conjugate vaccine (PCV) were among the most frequent pneumococcal serotypes responsible for acute otitis media (AOM). This report describes the first 3 years of a prospective, multicenter, epidemiological cross-sectional study examining the bacteriology of middle ear fluids (MEF) and nasopharyngeal swabs (NPS) of children 2 months to 5 years of age with spontaneously perforated AOM in the era of routine pneumococcal vaccination. MEF was obtained from 963 subjects; NPS from 877. Reported case numbers steeply decreased over the three study years even though the recruiting base remained the same. Among subjects with relevant bacterial growth in their MEF swabs, 113 (11.7%) had Streptococcus pyogenes, 97 (10.1%) Staphylococcus aureus, 88 (9.1%) Streptococcus pneumoniae, 63 (6.5%) Haemophilus influenzae, and 8 (0.8%) Moraxella catarrhalis. S. pneumoniae isolates decreased from 41 (9.3%) in year 1 to 12 (5.7%) in year 3 (p = 0.128). PCV7 serotypes accounted for only 7.9% (n = 7) of isolated pneumococci. Of the 877 subjects with NPS cultures, 465 (53.0%) carried S. pneumoniae, 314 (35.8%) H. influenzae, 292 (33.3%) M. catarrhalis, and 110 (12.5%) S. pyogenes; 79.4% (n = 765) of the children were vaccinated with at least one dose of PCV. Carriage of pneumococci was slightly lower in vaccinated (47.8%) than in unvaccinated (52.7%) children (p = 0.254). PCV7 serotypes were carried by 9.6% of unvaccinated children but by only 4.2% of vaccinated children, resulting in a 56.3% vaccine effectiveness.

CONCLUSIONS

Following universal PCV7 immunization, a clear epidemiological impact of pneumococcal conjugate vaccination was observed as PCV7 serotypes have almost disappeared among AOM.

Pneumococcal meningitis and vaccine effects in the era of conjugate vaccination: results of 20 years of nationwide surveillance in Germany

Background

Long-term complications and a case mortality rate of 7.5% make meningitis caused by Streptococcus pneumoniae a serious clinical threat. In 2006, a general pneumococcal conjugate vaccination (PCV) recommendation was issued for all children under 2 years in Germany. Here, we investigate serotype changes in meningitis cases after this vaccine recommendation.

Methods

The German National Reference Center for Streptococci (NRCS) has conducted surveillance for invasive pneumococcal disease (IPD) in Germany since 1992. Pneumococcal isolates were serotyped by the Neufeld’s Quellung reaction and antibiotic susceptibility was tested using the broth microdilution method.

Results

Of 22,204 IPD isolates sent to the NRCS from July 1992 to June 2013, 3,086 were meningitis cases. Microbiological and statistical investigations were performed to characterize and quantify all meningitis cases, focusing on changes reflecting implementation of the national PCV recommendation. 1,766 isolates (57.2% of meningitis cases) were from adults (≥16 years) and 1,320 isolates (42.8%) originated from children (<16 years). Overall, the leading serotypes were 14 (9.7%), 7F (7.8%), 3 (6.9%), 19F (5.7%) and 23F (5.0%). Among children, serotypes 14 (16.2%), 7F (8.9%) and 19F (7.1%) were most common, whereas among adults, serotypes 3 (9.6%), 7F (6.9%), 22F (5.0%), 23F (4.9%) and 14 (4.8%) were most prevalent. After the introduction of general PCV7/10/13 vaccination a significant decrease for most vaccine serotypes was observed. Generally, the differences in antibiotic nonsusceptibility between children <16 years and adults ≥16 were low. For macrolides in the pre-PCV7 period, a significantly higher proportion of resistant isolates was found in children (25.1%), compared to the post-vaccination period (9.7%; p<0.0001).

Conclusions

Implementation of the pneumococcal conjugate vaccines broadly reduced vaccine-type meningitis cases. Changes in serotype prevalence must be continuously monitored to observe future trends concerning pneumococcal meningitis.

[Invasive pneumococcal disease in Germany in the era of pneumococcal conjugate vaccination]

BACKGROUND

Pneumococci remain a major cause of bacterial pneumonia, sepsis and meningitis globally.

METHODS

The German National Reference Center for Streptococci at the Institute for Medical Microbiology of the University Hospital RWTH Aachen, Germany, has carried out surveillance studies on invasive pneumococcal disease (IPD) since 1992. This report is based on IPD-cases from adults and children, received between July 1992 and June 2013 and July 1997 and June 2013 respectively.

RESULTS

From 1997-2006 the proportion of infections among children ≤ 23 months of age with serotypes included in the 7-valent vaccine was about 65%. Since the start of childhood vaccination in 2006 the percentage has continuously decreased, reaching < 5% in 2012 /2013. Also among adults, for whom conjugate vaccination was not indicated, this percentage decreased from 40-45% in 1992-2006 to about 8% in 2012 /2013. This phenomenon is denoted as herd protection. The resistance rate against Penicillin G remained under 4% among children and under 2.5% among adults over the whole study period. Since 2005 /2006 macrolide resistance levels have decreased to about 5% among children and 8% among adults.

CONCLUSION

The continuous decrease of vaccine serotypes as well as the decreasing IPD incidence since the beginning of childhood vaccination document the success of pneumococcal conjugate vaccination.

Epidemiology of Streptococcus pneumoniae serogroup 6 isolates from IPD in children and adults in Germany

This study presents serogroup 6 isolates from invasive pneumococcal disease (IPD) before and after the recommendation for childhood pneumococcal conjugate vaccination in Germany (July 2006). A total of 19,299 (children: 3508, adults: 15,791) isolates were serotyped. Serogroup 6 isolates accounted for 9.5% (children) and 6.7% (adults), respectively. 548 isolates had serotype 6A, 558 had serotype 6B, 285 had serotype 6C, and 4 had serotype 6D. Among children, serotype 6B was most prevalent (7.5% of isolates) before vaccination, followed by 6A and 6C. After the 7-valent pneumococcal conjugate vaccine (PCV7), the prevalence of serotype 6B significantly decreased (p = 0.040), a pattern which continued in the higher-valent PCV period (PCV10, PCV13). Serotype 6A prevalence showed a slight increase directly after the start of PCV7 vaccination, followed by a decrease which continued throughout the PCV10/13 period. Serotype 6C prevalence remained low. Serotype 6D was not found among IPD isolates from children. Among adults, prevalence of both 6A and 6B decreased, with 6B reaching statistical significance (p = 0.045) and 6A showing a small increase in 2011–2012. Serotype 6C prevalence was 1.5% or lower before vaccination, but increased post-vaccination to 3.6% in 2011/12 (p = 0.031). Four serotype 6D isolates were found post-PCV7 childhood vaccination, and two post-PCV10/13. Antibiotic resistance was found mainly in serotype 6B; serotype 6A showed lower resistance rates. Serotype 6C isolates only showed resistance among adults; serotype 6D isolates showed no resistance. Multilocus sequence typing showed that sequence type (ST) 1692 was the most prevalent serotype 6C clone. Thirty-two other STs were found among serotype 6C isolates, of which 12 have not been previously reported. The four serotype 6D isolates had ST 948, ST 2185 and two new STs: 8422 and 8442. Two serogroup 6 isolates could not be assigned to a serotype, but had STs common to serogroup 6.

Epidemiology of serotype 19A isolates from invasive pneumococcal disease in German children

BACKGROUND

This study presents an analysis of 159 serotype 19A isolates from IPD in children before and after the general recommendation for childhood pneumococcal conjugate vaccination in Germany in July 2006. Vaccination formulations used were PCV7, PCV10 (from April 2009) and PCV13 (from Dec. 2009, replacing PCV7).

METHODS

Isolates from invasive pneumococcal disease in children were serotyped using the Quellung reaction, tested for antibiotic susceptibility and analysed for their multi locus sequence type.

RESULTS

In an analysis of 3328 isolates from invasive pneumococcal disease (IPD) in children that were sent to the German National Reference Center for Streptococci between July 1997 and June 2011, we show that the proportion of 19A isolates ranged between 1.7 and 4.2% in the period 1997 to 2006. After the recommendation for pneumococcal conjugate childhood vaccination, which was issued in July 2006, the proportion of 19A isolates increased significantly to 15.0% in 2010/11. Eight clonal complexes (CC) and groups accounted for 77.2% and 65.3% of all serotype 19A isolates before and after vaccination, respectively. While three CCs and several STs were not detected after vaccine introduction, four CCs and several STs first appeared after vaccination, including three ST320 isolates that could be traced to recent imports from the US, UK and India. The proportion of penicillin-nonsusceptible and of multidrug-resistant 19A isolates moderately increased after vaccine introduction. A significant increase in the use of cephalosporins and azithromycin was noted post-vaccination (p=0.00001 and p=0.0013 respectively).

CONCLUSIONS

The prevalence of serotype 19A in Germany has increased significantly between July 2007 and June 2011. Possible reasons for this are the introduction of pneumococcal conjugate vaccination, increased use of cephalosporins and azithromycin, import of multidrug-resistant isolates and increased reporting.

Four years of universal pneumococcal conjugate infant vaccination in Germany: impact on incidence of invasive pneumococcal disease and serotype distribution in children

INTRODUCTION

Vaccination with pneumococcal conjugate vaccine (PCV) for all children <2 years was recommended in Germany in July 2006. Initially PCV7 was exclusively used; PCV10 became available from April 2009 and PCV7 was replaced by PCV13 in December 2009.

OBJECTIVE

To compare the incidence and serotype distribution of invasive pneumococcal disease (IPD) for pneumococcal meningitis and non-meningitis IPD in children from 2007 to 2010 with reference to the pre-vaccination period from 1997 to 2001.

METHODS

Nationwide surveillance of IPD for children <16 years in Germany was based on two independent reporting sources: active surveillance in paediatric hospitals and passive web-based surveillance through microbiological laboratories. Serotyping was performed using the Neufeld Quellung reaction.

CASE DEFINITION

isolation of Streptococcus pneumoniae from a normally sterile body site. IPD incidence was estimated by capture-recapture analysis. Rate ratios comparing post- to pre-vaccination incidence were calculated as well as PCV7 and non-PCV7 serotype specific incidences.

RESULTS

While PCV7 incidence decreased by 88% (95%CI: 83 to 91) in children <16 years both in pneumococcal meningitis and non-meningitis IPD, an increase in Non-PCV7 serotypes was observed which was more pronounced in non-meningitis cases (168%; 95%CI: 140-257) than in pneumoccocal meningitis (65%; 95%CI: 23-123). The changes in incidence after four years were: <16 years: -35% (95%CI: -49 to -19), <2 years: -46% (95%CI: -61 to -27) for pneumococcal meningitis and+11% (95%CI: -4 to +29) and -26% (95%CI: -41 to -7) for non-meningitis IPD respectively.

CONCLUSION

Infant PCV7 vaccination in Germany prompted a decrease in the incidence of pneumococcal meningitis similar to that observed in England/Wales. In non-meningitis IPD the decrease was smaller and confined to the age group <2 years with no change or an increase in incidence in other age groups pointing to potential ascertainment bias due to increased blood-culturing.

[Infections with pneumococci, menigococci, H. influenzae and diphtheria in Germany: the RKI Reference Network for Invasive Bacterial Infections (IBI) at the 5th Würzburg Workshop on Epidemiology, Prevention and Therapy for Invasive Meningococcal Diseases 2010 (meeting report)]

The surveillance and prevention of invasive bacterial infections requires flexible strategic coordination of all involved health-care professionals. For this purpose, the German National Reference Centres for Meningococci, Streptococci and the Consultant Laboratories for Haemophilus influenzae and diphtheria have formed the Reference Network for Invasive bacterial infections (IBI). The 5th Würzburg Workshop on Meningococcal Diseases 2010 provided the network with a forum for the interdisciplinary exchange between scientists, public health professionals, medical microbiologists and clinicians. The topics covered the analysis of surveillance data for meningococcal disease in the last decade, as well as methods to control for antibody response following vaccination, including a serum bactericidal antibody (SBA) assay, and the development of new vaccines that also include the most common serogroup B. The presentation on diphtheria showed that this rare disease in Germany has become a diagnostic challenge, and that apart from the classical pathogen also toxigenic C. ulcerans strains must be considered. Due to the successful vaccination against Hib, H. influenzae disease has changed from a classical childhood disease to an infection of elderly people mainly caused by unencapsulated strains. Following the introduction of vaccines, changes in the serotype distribution and antibiotic resistance profiles have become apparent for S. pneumoniae infections. The epidemiological data were complemented by clinical aspects concerning the vaccination of immunocompromised children.

Macrolide susceptibility and serotype specific macrolide resistance of invasive isolates of Streptococcus pneumoniae in Germany from 1992 to 2008

Background

Macrolide resistant Streptococcus pneumoniae has been on a gradual increase in Germany for over a decade. The current study was undertaken against the background of the recent observation of declining macrolide resistance rates especially among German children. Nationwide surveillance of invasive pneumococcal disease has been conducted in Germany since 1992. A population- and laboratory-based approach was used to collect data on invasive pneumococcal disease, and isolates sent to the National Reference Center for Streptococci by diagnostic microbiological laboratories from 1992 to 2008 were included in this study.

Results

From 1992 to 2008, data on macrolide susceptibility were available for 11,807 invasive isolates. 8,834 isolates (74.8%) were from adults (≥ 16 years), and 2,973 isolates (25.2%) from children (< 16 years). The overall nonsusceptibility rate of all isolates was 16.2% (intermediate, 0.2%; resistant, 16.0%). Higher resistance rates were observed among children (intermediate, 0.2%; resistant, 23.8%) than among adults (intermediate, 0.3%; resistant 13.4%). Maximum nonsusceptibility rates during the period under study were observed in 2005 (children: intermediate, 0.3%; resistant, 32.3%; adults: intermediate, 0.0%; resistant, 18.6%), while nonsusceptibility rates in 2008 were considerably lower, especially for children (children: intermediate, 0.0%; resistant, 15.2%; adults: intermediate, 0.1%; resistant, 12.9%). The rate of resistance was higher among the vaccine serotypes (7-valent, 36.6%; 10-valent, 28.2%; 13-valent, 24.3%) than among the non vaccine serotypes (non 7-valent, 6.5%; non 10-valent, 7.4%; non 13-valent, 6.3%). Serotype 14 (69.6% nonsusceptibility) proved to be the most resistant serotype.

Conclusions

There has been a considerable and statistically significant decrease in macrolide nonsusceptibility in Germany since 2005, especially among children.

Temporal Variations among Invasive Pneumococcal Disease Serotypes in Children and Adults in Germany (1992-2008)

Nationwide surveillance of invasive pneumococcal disease has been conducted in Germany since 1992. From 1992 to 2008, a total of 12,137 isolates from invasive pneumococcal disease were collected. Data on serotypes were available for 9,394 invasive isolates. The leading serotypes were serotypes 14 (16.5%), 3 (8.0%), 7F (7.6%), 1 (7.3%), and 23F (6.0%). Variations in serotype distribution over the years are particularly extensive, especially concerning serotype 14 (min 7.4%, max 33.5%) with the highest percentages among the isolates serotyped from around 1997 to 2006. Serotypes 1 and 7F increased over the last decade. No increase was observed concerning serotype 19A. Higher pneumococcal conjugate vaccine coverages were observed among children (7v, 57.3%; 10v, 72.8%; 13v, 83.5%) than among adults (7v, 39.9%; 10v, 55.5%; 13v, 73.5%). The temporal variations in serotype distribution have to be kept in mind when interpreting vaccine coverages reported in epidemiological studies.

Multi-organ failure in a previously healthy 10-year-old boy: streptococcal toxic shock syndrome (STSS) - a rare differential diagnosis

Streptococcal Toxic Shock Syndrome (STSS) is a severe toxin-mediated disease with acute onset. A previously healthy 10-year-old boy presented with abdominal pain, vomiting, diarrhoea and fever for 3 days. He was admitted with signs of an acute abdomen. A treatment with ibuprofen had been started before admission. The child developed a multi-organ failure with persistent hematuria, persistent fever, ascites, pericardial and pleural effusions. Intensive microbial and viral analysis did not result in any relevant finding. Detection by PCR of DNA of the streptococcal super-antigens speM and speL supported the diagnosis of STSS. After an intensive-care treatment of 4 weeks according to international critical-care guidelines the child could be discharged without residuals.

Epidemiology of invasive Streptococcus pyogenes disease in Germany during 2003-2007

A nationwide laboratory-based surveillance study of invasive Streptococcus pyogenes infections was conducted in Germany. Invasive isolates (n=586) were obtained between 2003 and 2007. Most isolates were obtained from blood (53.9%) or skin lesions (17.6%). The most common emm types were emm 1 (30.5%), emm 28 (18.3%) and emm 3 (9.6%). Overall, speA was positive in 45.9%, speC in 44.7% and ssa in 14.8% of isolates. SpeA was common in emm type 1 (100%) and emm type 3 (96.4%), whereas speC was often observed in emm type 28 (93.5%). The most frequent clinical manifestations included sepsis (40.1%), necrotizing fasciitis (20.8%) and streptococcal toxic shock syndrome (16.6%). All isolates were susceptible to penicillin G, cefotaxime and levofloxacin. Tetracycline shows the highest rate of resistant or intermediate isolates with 11.6%, followed by clarithromycin (5.5%) and clindamycin (1.2%). The most prominent trend is the reduction of tetracycline-nonsusceptible isolates from 18.6% in 2003 to 8.9% in 2007.

Environmental exposure to dioxins and polychlorinated biphenyls reduce levels of gonadal hormones in newborns: Results from the Duisburg cohort study

BACKGROUND

Endocrine dysfunction related to the hypothalamic-pituitary-thyroid (HPT) and/or the hypothalamic-pituitary-gonadal axis (HPG) is being discussed as underlying developmental adversity of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) and polychlorinated biphenyls (PCBs). This study was done to evaluate effects related to the HPG axis.

METHODS

A birth-cohort study was initiated in the year 2000. Healthy mother-infant pairs were recruited in the industrialized city of Duisburg, Germany. Dioxins, dioxin-like PCBs and six indicator PCBs were measured in maternal blood during pregnancy and in maternal milk. Testosterone and estradiol levels were measured in maternal and cord serum of 104 mother-infant pairs representing a subsample with a complete data set of the total basic sample of 232 participants. Linear regression analysis was used to describe the association of PCDD/Fs or PCB in maternal blood or milk with sex steroid concentrations after adjustment for confounding.

RESULTS

Median concentrations for PCDD/Fs in maternal blood fat and milk fat in terms of WHO-TEq were 15.3 and 13.1pg WHO-TEq/g, respectively, and for the sum of the indicator PCBs (#28, #52, #101, #138, #153, #180) 149 and 177ng/g. The adjusted ratio of geometric means when doubling the concentration of PCDD/Fs in maternal blood fat was 0.86, 95% confidence interval (95% CI): 0.72-1.03 for testosterone and 0.73 (0.61-0.87) for estradiol in cord serum. Typically, testosterone reduction was more pronounced in cord serum of female and estradiol reduction in that of male babies. Reduction of hormone levels was generally more pronounced for dioxins than for indicator PCBs.

CONCLUSIONS

The hypothalamic-pituitary-gonadal axis of newborn babies is influenced by prenatal exposure to PCDD/Fs and PCBs in a manner suggestive of AhR-mediation. The clinical relevance of this finding remains to be established, however.

Hormonal status modulates circulating endothelial progenitor cells

OBJECTIVE

Endothelial progenitor cells (EPCs) may have an important role in vascular homeostasis and repair.

METHODS

We examined the level of circulating EPCs in pre- (n = 22; mean age 28.7 years), and postmenopausal healthy females without (n = 30; mean age 61.6 years) or under current hormone replacement therapy (HRT) (n = 19; mean age 59.8 years).

RESULTS

Premenopausal females had the highest level of circulating EPCs (0.147 +/- 0.076 per thousand of polymorphnuclear cells). The level of EPCs was lowest in postmenopausal females (0.094 +/- 0.058 per thousand), and increased significantly with HRT on average by 25.5%. In addition, the proliferative capacity of circulating EPCs was assessed under cell culture conditions. This capacity was significantly increased in EPCs isolated from postmenopausal subjects under current HRT as compared to corresponding samples obtained from postmenopausal females without HRT.

CONCLUSIONS

This observation is in line with the hypothesis that the hormonal status in females modulates the cardiovascular risk and that circulating EPCs could be involved in this phenomenon.

[Catecholamine-dependent hereditary Cushing's syndrome - follow-up after unilateral adrenalectomy]

CASE REPORT

We report on the laboratory, clinical, radiologic and histological findings of a 44-year-old male patient who was hospitalized with the clinical signs of Cushing's syndrome. The laboratory findings were suggestive of an adrenal genesis. Abdominal computed tomography revealed macronodular hyperplasia of both adrenal glands. Specific endocrinological tests demonstrated an increased secretion of cortisol during adrenergic stimulation which, however, was absent following beta-blocker medication. This would seem to point to an aberrant, beta-receptor-mediated regulation of cortisol secretion as being the cause of increased cortisol production. ACTH-independent bilateral macronodular adrenocortical hyperplasia was also noted in the patient's mother. Neither the father nor the brother were affected by the disease. Apart from one case of familial appearance involving mother and daughter previously reported in the literature, this is the second description of a familial appearance and the first case involving mother and son. The patient underwent a left-sided adrenalectomy. Quick postoperative normalization of S-cortisol day profile and excretion of free dU-cortisol were noted under supportive temporary blockade of beta-receptors. In the further course, meanwhile spanning 2 1/4 years, a low basal cortisol secretion of the right adrenal gland has been observed, together with a lack of suppressibility in the dexamethasone suppression test.

CONCLUSION

In the presence of mild clinical signs of adrenocortical insufficiency, matutinal administration of 5 mg hydrocortisone has proven sufficient for the past 6 months to reestablish a physiologic S-cortisol day profile with morning peak.