Autochthonous and imported giardiasis cases: An analysis of two decades of national surveillance data, Germany, 2002 to 2021

BackgroundGiardia duodenalis is a major cause of gastroenteritis globally, and is the most common food- and waterborne parasitic infection in Europe.AimTo describe the epidemiology of reported acute giardiasis cases in Germany and compare demographic and clinical characteristics between imported and autochthonous cases.MethodsWe conducted a descriptive analysis of giardiasis cases that fulfilled the national case definition and were reported between January 2002 and December 2021. We defined an imported case as having at least one place of exposure abroad in the 3-25 days before symptom onset. We analysed case numbers and incidence by age, sex, month reported and geographic region, both overall and stratified by autochthonous and imported cases.ResultsFrom 2002 to 2021, 72,318 giardiasis cases were reported in Germany, corresponding to a mean annual incidence of 4.4 per 100,000 population. Annual incidence gradually decreased since 2013, declining sharply during the COVID-19 pandemic in 2020-21. Of 69,345 cases reported between 2002 and 2019, 35% were imported. Incidence of autochthonous cases (overall yearly mean: 3.1/100,000) was highest in males and young children (< 5 years); imported cases were predominantly adults aged 20-39 years. We identified seasonal patterns for imported and autochthonous cases.ConclusionsGiardiasis in Germany is typically assumed to be imported. Our data, however, underline the importance of autochthonous giardiasis. Travel advice might reduce imported infections, but prevention strategies for autochthonous infections are less clear. Dietary, behavioural and environmental risk factors need to be further investigated to enhance infection prevention measures for autochthonous giardiasis.

Impact of the COVID-19 pandemic on norovirus circulation in Germany

Human norovirus is a major cause of viral gastroenteritis in all age groups. The virus is constantly and rapidly changing, allowing mutations and recombination events to create great diversity of circulating viruses. With the start of the COVID-19 pandemic in 2020, a wide range of public health measures were introduced worldwide to control human-to-human transmission of SARS-CoV-2. In Germany, control measures such as distance rules, contact restrictions, personal protection equipment as well as intensive hand hygiene were introduced. To better understand the effect of the measures to control the COVID-19 pandemic on incidence and the molecular epidemiological dynamics of norovirus outbreaks in Germany, we analyzed national notification data between July 2017 and December 2022 and characterized norovirus sequences circulating between January 2018 and December 2022. Compared to a reference period before the pandemic, the incidence of notified norovirus gastroenteritis decreased by 89.7% to 9.6 per 100,000 during the 2020/2021 norovirus season, corresponding to an incidence rate ratio (IRR) of 0.10. Samples from 539 outbreaks were genotyped in two regions of the viral genome from pre-pandemic (January 2018 to February 2020) and samples from 208 outbreaks during pandemic time period (March 2020 to December 2022). As expected, norovirus outbreaks were mainly found in child care facilities and nursing homes. In total, 36 genotypes were detected in the study period. A high proportion of recombinant strains (86%) was found in patients, the proportion of detected recombinant viruses did not vary between the pre-pandemic and pandemic phase. The proportion of the predominant recombinant strain GII.4 Sydney[P16] was unchanged before pandemic and during pandemic at 37.5%. The diversity of most common genotypes in nursing homes and child care facilities showed a different proportion of genotypes causing outbreaks. In nursing homes as well as in child care facilities GII.4 Sydney[P16] was predominant during the whole study period. Compared to the nursing homes, a greater variety of genotypes at the expense of GII.4 Sydney[P16] was detected in child care facilities. Furthermore, the overall proportion of recombinant strain GII.3[P12] increased during the pandemic, due to outbreaks in child care facilities. The COVID-19 pandemic had a high impact on the occurrence of sporadic cases and norovirus outbreaks in Germany, leading to a near suppression of the typical norovirus winter season following the start of the pandemic. The number of norovirus-associated outbreak samples sent to the Consultant Laboratory dropped by 63% during the pandemic. We could not identify a clear influence on circulating norovirus genotypes. The dominance of GII.4 Sydney recombinant strains was independent from the pandemic. Further studies are needed to follow up on the diversity of less predominant genotypes to see if the pandemic could have acted as a bottleneck to the spread of previously minoritized genotypes like GII.3[P12].

Epidemiology of reported cases of leptospirosis in the EU/EEA, 2010 to 2021

BackgroundLeptospirosis is a zoonotic disease caused by bacteria of the genus Leptospira. Humans are infected by exposure to animal urine or urine-contaminated environments. Although disease incidence is lower in Europe compared with tropical regions, there have been reports of an increase in leptospirosis cases since the 2000s in some European countries.AimWe aimed to describe the epidemiology of reported cases of leptospirosis in the European Union/European Economic Area (EU/EEA) during 2010-2021 and to identify potential changes in epidemiological patterns.MethodsWe ran a descriptive analysis of leptospirosis cases reported by EU/EEA countries to the European Centre for Disease Prevention and Control with disease during 2010-2021. We also analysed trends at EU/EEA and national level.ResultsDuring 2010-2021, 23 countries reported 12,180 confirmed leptospirosis cases corresponding to a mean annual notification rate of 0.24 cases per 100,000 population. Five countries (France, Germany, the Netherlands, Portugal and Romania) accounted for 79% of all reported cases. The highest notification rate was observed in Slovenia with 0.82 cases per 100,000 population. Overall, the notification rate increased by 5.0% per year from 2010 to 2021 (95% CI: 1.2-8.8%), although trends differed across countries.ConclusionThe notification rate of leptospirosis at EU/EEA level increased during 2010-2021 despite including the first 2 years of the COVID-19 pandemic and associated changes in population behaviours. Studies at (sub)national level would help broaden the understanding of differences at country-level and specificities in terms of exposure to Leptospira, as well as biases in diagnosis and reporting.

Travel-related giardiasis: incidence and time trends for various destination countries

BACKGROUND

Giardiasis is a common gastrointestinal illness in travellers. Data on the actual giardiasis risk of travellers to different travel destinations are scarce. We aim to estimate the risk of giardiasis in travellers from Germany by destination country and region.

METHODS

We analysed travel-related giardiasis cases, their countries and regions of exposure and the age and sex distribution of cases reported in 2014-19 in Germany. We defined a travel-related giardiasis case as a laboratory-confirmed (i.e. positive microscopy, antigen test or nucleic acid test) symptomatic individual with outbound travel abroad within 3-25 days before symptom onset. Based on the number of reported cases per exposure country and UNWTO travel data for Germany, we calculated the number of travel-related giardiasis cases per 100 000 travellers and compared the incidence in 2014-16 and 2017-19 to identify potential trends.

RESULTS

In 2014-19, 21 172 giardiasis cases were reported in Germany, corresponding to an overall incidence of 4.3 per 100 000 population. Of all cases, 6879 (32%) were travel-related with a median age of 34 [interquartile range (IQR): 25-50], 51% were male. Southern Asia was the most frequently reported exposure region and had the highest incidence in travellers (64.1 per 100 000 returning travellers) in 2017-19, followed by Latin America (19.2) and Sub-Saharan Africa (12.9). We observed statistically significant decreasing trends for Southern Asia and Sub-Saharan Africa. Latin America was the only region with a statistically significant increasing trend.

CONCLUSIONS

Almost one-third of recent giardiasis cases in Germany were travel-related. Giardiasis incidence in travellers differs greatly depending on the destination region. Decreasing trends in many regions might be due to improvements in food hygiene or travel conditions. Our results may inform medical consultation pre and post patient's travel.

Risk Factors for Hepatitis E Virus Infection and Eating Habits in Kidney Transplant Recipients

There is a significant risk for ongoing and treatment-resistant courses of hepatitis E virus (HEV) infection in patients after solid organ transplantation. The aim of this study was to identify risk factors for the development of hepatitis E, including the dietary habits of patients. We conducted a retrospective single-center study with 59 adult kidney and combined kidney transplant recipients who were diagnosed with HEV infection between 2013 and 2020. The outcomes of HEV infections were analyzed during a median follow-up of 4.3 years. Patients were compared with a control cohort of 251 transplant patients with elevated liver enzymes but without evidence of an HEV infection. Patients' alimentary exposures during the time before disease onset or diagnosis were assessed. Previous intense immunosuppression, especially treatment with high-dose steroids and rituximab, was a significant risk factor to acquire hepatitis E after solid organ transplantation. Only 11 out of 59 (18.6%) patients reached remission without further ribavirin (RBV) treatment. A total of 48 patients were treated with RBV, of which 19 patients (39.6%) had either viral rebounds after the end of treatment or did not reach viral clearance at all. Higher age (>60 years) and a BMI ≤ 20 kg/m² were risk factors for RBV treatment failure. Deterioration in kidney function with a drop in eGFR (p = 0.046) and a rise in proteinuria was more common in patients with persistent hepatitis E viremia. HEV infection was associated with the consumption of undercooked pork or pork products prior to infection. Patients also reported processing raw meat with bare hands at home more frequently than the controls. Overall, we showed that the intensity of immunosuppression, higher age, a low BMI and the consumption of undercooked pork meat correlated with the development of hepatitis E.

Hepatitis A seroprevalence, vaccination status and demographic determinants in children and adolescents in Germany, 2014-2017, a population-based study

Children play an important role in hepatitis A virus (HAV) transmission but, due to frequent asymptomatic or mild courses, these infections are underrecognized in routine surveillance. Here, we analyzed hepatitis A (HA) seroprevalence, vaccination status and demographic determinants and estimated previous HAV infections in a cross-sectional population-based study of children and adolescents with residence in Germany 2014-2017, performing weighted univariable and multivariable logistic regression. Of 3567 participants aged 3-17 years, serological results were available for 3013 (84.5%), vaccination records for 3214 (90.1%) and both for 2721 (76.3%). Of 2721 with complete results, 467 (17.2%) were seropositive, thereof 412 (15.1%) with and 55 (2.0%) without previous HA vaccination, indicating previous HAV infection. Seropositivity was associated with age, residence in Eastern states, high socioeconomic status and migration background with personal migration experience. Participants with migration background and personal migration experience also had the highest odds ratios for previous HAV infection. Germany remains a country with very low HA endemicity. The current vaccination recommendations focusing on individuals with a high risk for HAV exposure (e.g. travelers to endemic countries) or severe disease appear appropriate. Migration and travel patterns as well as the endemicity in other countries influence the domestic situation, warranting further monitoring.

Impact of climate change on vector- and rodent-borne infectious diseases

Background

Endemic and imported vector- and rodent-borne infectious agents can be linked to high morbidity and mortality. Therefore, vector- and rodent-borne human diseases and the effects of climate change are important public health issues.

Methods

For this review, the relevant literature was identified and evaluated according to the thematic aspects and supplemented with an analysis of surveillance data for Germany.

Results

Factors such as increasing temperatures, changing precipitation patterns, and human behaviour may influence the epidemiology of vector- and rodent-borne infectious diseases in Germany.

Conclusions

The effects of climatic changes on the spread of vector- and rodent-borne infectious diseases need to be further studied in detail and considered in the context of climate adaptation measures.

Molecular epidemiology and genotype-specific disease severity of hepatitis E virus infections in Germany, 2010-2019

Zoonotic hepatitis E virus (HEV) is endemic in Europe. Genotype 3 (HEV-3) is predominant but information on subtype distribution, trends and clinical implications in Germany is scarce. We analysed 936 HEV RNA positive samples of human origin and corresponding national surveillance data from 2010 to 2019. Samples were referred to the National Consultant Laboratory and sequenced in at least one of four genomic regions. Sequences were analysed using bioinformatics methods and compared to the latest HEV reference set. 1,656 sequences were obtained from 300 female, 611 male and 25 of unknown sex aged 3–92 years (median 55 years). HEV-3c was predominant (67.3%) followed by HEV-3f, HEV-3e and HEV-3i(-like) with 14.3%, 9.7% and 4.0% (other subtypes ≤1.1%). The proportion of HEV-3 group 2 (3abchijklm) strains increased over time. Jaundice, upper abdominal pain, fever, hospitalization, and death due to HEV were significantly more often reported for patients infected with HEV-3 group 1 (3efg) compared to group 2. Larger spatio-temporal clusters of identical sequences were not observed. HEV-3 group 1 infections are more severe as compared to the predominant group 2. Detection of group 2 strains increased over the last years, possibly due to more frequent diagnosis of asymptomatic and mild courses. The diversity of strains and the space–time distribution is compatible with a foodborne zoonosis with supra-regional distribution of the infection vehicle (pork products).

[Hantavirus Disease: An Update]

In addition to the well-known clinical early symptoms of hantavirus disease (fever, flank and abdominal pain as well as arthralgia), unusual neurological changes in the context of infection come into focus. The spectrum of neurological symptoms ranges from transient myopia to severe pareses in the context of Guillain-Barré syndrome. In endemic areas, rapid IgM tests for initial assessment are of certain value for differential diagnosis. For therapeutic approaches, only supportive measures up to transient dialysis are available.Molecular genetic analysis and comparison of hantavirus strains of patients and mice from the same geographical area allowed molecular characterization of different outbreak regions. In the meantime, the Puumala viruses of the main outbreak regions in Germany are molecularly well characterized; therefore, the nucleotide sequence of the virus strain detected in a patient makes it possible to draw conclusions about the geographic region where the patient's infection took place.The human pathogenic hantaviruses being prevalent in Germany are the Puumala virus (reservoir: bank vole) and the Dobrava-Belgrade virus, genotype Kurkino (reservoir: striped field mouse). Recently, the molecular detection of further hantaviruses in patients with hantavirus disease was achieved. It can be concluded that also the Seoul virus (reservoir: rats) and the Tulavirus (reservoir: field mouse and related species) occasionally cause hantavirus disease in Germany.New results revealed that human infections can occur not only by the generally accepted route of inhalation of virus-containing aerosols, but also by ingestion of virus-containing materials.For patients with hantavirus infection or disease, it can be assumed that they are not infectious for their environment. A new systematic review could not confirm a human-to-human transmission previously postulated for South American hantaviruses.While all known human pathogenic hantaviruses are transmitted by rodents, other hantaviruses have been recently detected in shrews, moles, and bats. The clinical significance of these new viruses is quite unclear as yet.

[Epidemiology of viral hepatitis A to E in Germany]

Viral hepatitis A to E describes various infectious inflammations of the liver parenchyma that are caused by the hepatitis viruses A to E (HAV, HBV, HCV, HDV, and HEV). Although the clinical pictures are similar, the pathogens belong to different virus families and differ in terms of pathogenesis, transmission routes, clinical course, prevention, and therapy options. In Germany, there is mandatory reporting according to the Infection Protection Act (IfSG) for direct or indirect laboratory evidence and for suspicion, illness, and death of viral hepatitis. The data are transmitted to the Robert Koch Institute.In this article, on the basis of published studies and notification data, we describe the epidemiology of hepatitis A to E as well as current challenges and prevention approaches. In particular, the latter contains the improvement of existing vaccination recommendations (hepatitis A and B); improvement of access to prevention, testing, and care including therapy with antiviral drugs (hepatitis B, C, and D) and the detection and prevention of foodborne infections and outbreaks; and improvements in the field of food safety (hepatitis A and E).

[The different periods of COVID-19 in Germany: a descriptive analysis from January 2020 to February 2021]

The first case of coronavirus SARS-CoV‑2 infection in Germany was diagnosed on 27 January 2020. To describe the pandemic course in 2020, we regarded four epidemiologically different periods and used data on COVID-19 cases from the mandatory reporting system as well as hospitalized COVID-19 cases with severe acute respiratory infection from the syndromic hospital surveillance.Period 0 covers weeks 5 to 9 of 2020, where mainly sporadic cases of younger age were observed and few regional outbreaks emerged. In total, 167 cases with mostly mild outcomes were reported. Subsequently, the first COVID-19 wave occurred in period 1 (weeks 10 to 20 of 2020) with a total of 175,013 cases throughout Germany. Increasingly, outbreaks in hospitals and nursing homes were registered. Moreover, elderly cases and severe outcomes were observed more frequently. Period 2 (weeks 21 to 39 of 2020) was an interim period with more mild cases, where many cases were younger and often travel-associated. Additionally, larger trans-regional outbreaks in business settings were reported. Among the 111,790 cases, severe outcomes were less frequent than in period 1. In period 3 (week 40 of 2020 to week 8 of 2021), the second COVID-19 wave started and peaked at the end of 2020. With 2,158,013 reported cases and considerably more severe outcomes in all age groups, the second wave was substantially stronger than the first wave.Irrespective of the different periods, more elderly persons and more men were affected by severe outcomes.

Predicting the need of aortic valve surgery in patients with chronic aortic regurgitation: a comparison between cardiovascular magnetic resonance imaging and transthoracic echocardiography

To compare the ability of cardiac magnetic resonance tomography (CMR) and transthoracic echocardiography (TTE) to predict the need for valve surgery in patients with chronic aortic regurgitation on a mid-term basis. 66 individuals underwent assessment of aortic regurgitation (AR) both in CMR and TTE between August 2012 and April 2017. The follow-up rate was 76% with a median of 5.1 years. Cox proportional hazards method was used to assess the association of the time-to-aortic-valve-surgery, including valve replacement and reconstruction, and imaging parameters. A direct comparison of most predictive CMR and echocardiographic parameters was performed by using nested-factor-models. Sixteen patients (32%) were treated with aortic valve surgery during follow-up. Aortic valve insufficiency parameters, both of echocardiography and CMR, showed good discriminative and predictive power regarding the need of valve surgery. Within all examined parameters AR gradation derived by CMR correlated best with outcome [χ² = 27.1; HR 12.2 (95% CI: 4.56, 36.8); (p < 0.0001)]. In direct comparison of both modalities, CMR assessment provided additive prognostic power beyond echocardiographic assessment of AR but not vice versa (improvement of χ² from 21.4 to 28.4; p = 0.008). Nested model analysis demonstrated an overall better correlation with outcome by using both modalities compared with using echo alone with the best improvement in the moderate to severe AR range with an echo grade II out of III and a regurgitation fraction of 32% in CMR. This study corroborates the capability of CMR in direct quantification of AR and its role for guiding further treatment decisions particularly in patients with moderate AR in echocardiography.

Suitability of current typing procedures to identify epidemiologically linked human Giardia duodenalis isolates

Background

Giardia duodenalis is a leading cause of gastroenteritis worldwide. Humans are mainly infected by two different subtypes, i.e., assemblage A and B. Genotyping is hampered by allelic sequence heterozygosity (ASH) mainly in assemblage B, and by occurrence of mixed infections. Here we assessed the suitability of current genotyping protocols of G. duodenalis for epidemiological applications such as molecular tracing of transmission chains.

Methodology/Principal findings

Two G. duodenalis isolate collections, from an outpatient tropical medicine clinic and from several primary care laboratories, were characterized by assemblage-specific qPCR (TIF, CATH gene loci) and a common multi locus sequence typing (MLST; TPI, BG, GDH gene loci). Assemblage A isolates were further typed at additional loci (HCMP22547, CID1, RHP26, HCMP6372, DIS3, NEK15411).

Of 175/202 (86.6%) patients the G. duodenalis assemblage could be identified: Assemblages A 25/175 (14.3%), B 115/175 (65.7%) and A+B mixed 35/175 (20.0%). By incorporating allelic sequence heterozygosity in the analysis, the three marker MLST correctly identified 6/9 (66,7%) and 4/5 (80.0%) consecutive samples from chronic assemblage B infections in the two collections, respectively, and identified a cluster of five independent patients carrying assemblage B parasites of identical MLST type. Extended MLST for assemblage A altogether identified 5/6 (83,3%) consecutive samples from chronic assemblage A infections and 15 novel genotypes. Based on the observed A+B mixed infections it is estimated that only 75% and 50% of assemblage A or B only cases represent single strain infections, respectively. We demonstrate that typing results are consistent with this prediction.

Conclusions/Significance

Typing of assemblage A and B isolates with resolution for epidemiological applications is possible but requires separate genotyping protocols. The high frequency of multiple infections and their impact on typing results are findings with immediate consequences for result interpretation in this field.

Giardia duodenalis is a leading cause of gastroenteritis worldwide. Humans are mainly infected by the two different genetic subtypes, assemblage A and B. Molecular typing tools for epidemiological applications such as tracking transmission, attribution to a source and outbreak investigations have been developed and are highly desirable. However, to what degree the tetraploid genome with allelic sequence heterogeneity (ASH), and the frequent occurrence of mixed, assemblage A and B infections hamper performance is unclear. Here, we assessed the suitability of current genotyping protocols for deciphering the molecular epidemiology of G. duodenalis. Against a common reporting bias, we incorporated ASH in the analysis and we show that typing with resolution for epidemiological applications is possible for both, assemblage A and B isolates, but requires separate protocols. We also demonstrate how the high frequency of multiple infections overall impacts on typing results, which has immediate consequences for result interpretation in this field.

Resurgence of an international hepatitis A outbreak linked to imported frozen strawberries, Germany, 2018 to 2020

Following outbreaks linked to frozen strawberries in Sweden and Austria in 2018, 65 cases linked to the same hepatitis A virus strain were detected in Germany between October 2018 and January 2020, presenting in two waves. Two case–control studies and a comparison of cases’ consumption frequencies with purchase data from a large consumer panel provided strong evidence for frozen strawberry cake as the main vehicle of transmission. Of 46 cases interviewed, 27 reported consuming frozen strawberry cake and 25 of these identified cake(s) from brand A spontaneously or in product picture-assisted recall. Trace back investigations revealed that the Polish producer involved in the previous outbreaks in Sweden and Austria had received frozen strawberries from Egypt via a wholesaler that also delivered frozen strawberries to manufacturer of brand A. Phylogenetic analyses linked the outbreak strain to similar strains formerly isolated from sewage, stool and strawberries in Egypt. Complete trace back and timely recall of products with strong evidence of contamination is important to control an outbreak and prevent later resurgence, particularly for food items with a long shelf life. Continued molecular surveillance of hepatitis A is needed to identify outbreaks and monitor the success of food safety interventions.

Hepatitis A outbreak among MSM in Berlin due to low vaccination coverage: Epidemiology, management, and successful interventions

OBJECTIVES

To describe the characteristics of a large hepatitis A virus (HAV) outbreak among men who have sex with men (MSM) in Berlin and to assess the impact of measures implemented.

METHODS

Cases of laboratory-confirmed, symptomatic HAV infection notified in Berlin, Germany between August 2016 and February 2018 were analysed using routine and enhanced surveillance data including genotyping results. Several studies involving different groups of participants were conducted to further investigate the outbreak, including surveys on knowledge and practices of HAV vaccination among physicians and vaccination coverage and determinants of vaccination status among MSM. The measures implemented were categorized by target group in a Gantt chart. To assess their impact, health insurance data on HAV vaccination uptake were analysed, comparing Berlin and other federal states.

RESULTS

During the outbreak period, a total of 222 cases were reported (of which 91 were sequence-confirmed), with a peak in case numbers in January 2017. Physicians were aware of the existing vaccination recommendations, but vaccination coverage among 756 MSM was low, with 32.7% being completely vaccinated and 17.3% being incompletely vaccinated before 2017. HAV vaccination before 2017 was associated with being born in Germany (odds ratio 2.36) and HIV-positive (odds ratio 1.80). HAV monovalent vaccination uptake increased by 164% from 2016 to 2017 among males in Berlin, compared to 7% in other federal states.

CONCLUSIONS

Multiple measures targeting the MSM community, physicians, and public health to increase HAV vaccination uptake were successfully implemented. To prevent future HAV outbreaks, we recommend monitoring vaccination coverage among MSM, promoting awareness of existing recommendations among physicians, and ensuring access for foreign-born and young MSM.

Francisella tularensis Subspecies holarctica and Tularemia in Germany

Tularemia is a zoonotic disease caused by Francisella tularensis a small, pleomorphic, facultative intracellular bacterium. In Europe, infections in animals and humans are caused mainly by Francisella tularensis subspecies holarctica. Humans can be exposed to the pathogen directly and indirectly through contact with sick animals, carcasses, mosquitoes and ticks, environmental sources such as contaminated water or soil, and food. So far, F. tularensis subsp. holarctica is the only Francisella species known to cause tularemia in Germany. On the basis of surveillance data, outbreak investigations, and literature, we review herein the epidemiological situation-noteworthy clinical cases next to genetic diversity of F. tularensis subsp. holarctica strains isolated from patients. In the last 15 years, the yearly number of notified cases of tularemia has increased steadily in Germany, suggesting that the disease is re-emerging. By sequencing F. tularensis subsp. holarctica genomes, knowledge has been added to recent findings, completing the picture of genotypic diversity and geographical segregation of Francisella clades in Germany. Here, we also shortly summarize the current knowledge about a new Francisella species (Francisella sp. strain W12-1067) that has been recently identified in Germany. This species is the second Francisella species discovered in Germany.

Molecular and epidemiological characteristics of human Puumala and Dobrava-Belgrade hantavirus infections, Germany, 2001 to 2017

Introduction

Two hantavirus species, Puumala (PUUV) and Dobrava-Belgrade (DOBV) virus (genotype Kurkino), are endemic in Germany. Recent PUUV outbreaks raised questions concerning increasing frequency of outbreaks and expansion of PUUV endemic areas.

Aims

To describe the epidemiology of human PUUV and DOBV infections in Germany.

Methods

We conducted an observational retrospective study analysing national hantavirus surveillance data notified to the national public health institute and hantavirus nucleotide sequences from patients collected at the national consultation laboratory between 2001 and 2017. Matching molecular sequences with surveillance data, we conducted epidemiological, phylogenetic and phylogeographic analyses.

Results

In total, 12,148 cases of symptomatic hantavirus infection were notified 2001–17 (mean annual incidence: 0.87/100,000; range: 0.09–3.51). PUUV infections showed a highly variable space-time disease incidence pattern, causing large outbreaks every 2–3 years with peaks in early summer and up to 3,000 annually reported cases. Sex-specific differences in disease presentation were observed. Of 202 PUUV nucleotide sequences obtained from cases, 189 (93.6%) fall into well-supported phylogenetic clusters corresponding to different endemic areas in Germany. DOBV infections caused few, mostly sporadic cases in autumn and winter in the north and east of Germany.

Conclusions

The frequency of PUUV outbreaks increased between 2001 and 2017 but our data does not support the suggested expansion of endemic areas. The epidemiology of PUUV and DOBV-Kurkino infections differs in several aspects. Moreover, the latter are relatively rare and combining efforts and data of several countries to identify risk factors and develop specific recommendations for prevention could be worthwhile.

Improving preparedness to respond to cross-border hepatitis A outbreaks in the European Union/European Economic Area: towards comparable sequencing of hepatitis A virus

Introduction

Sequence-based typing of hepatitis A virus (HAV) is important for outbreak detection, investigation and surveillance. In 2013, sequencing was central to resolving a large European Union (EU)-wide outbreak related to frozen berries. However, as the sequenced HAV genome regions were only partly comparable between countries, results were not always conclusive.

Aim

The objective was to gather information on HAV surveillance and sequencing in EU/European Economic Area (EEA) countries to find ways to harmonise their procedures, for improvement of cross-border outbreak responses.

Methods

In 2014, the European Centre for Disease Prevention and Control (ECDC) conducted a survey on HAV surveillance practices in EU/EEA countries. The survey enquired whether a referral system for confirming primary diagnostics of hepatitis A existed as well as a central collection/storage of hepatitis A cases’ samples for typing. Questions on HAV sequencing procedures were also asked. Based on the results, an expert consultation proposed harmonised procedures for cross-border outbreak response, in particular regarding sequencing. In 2016, a follow-up survey assessed uptake of suggested methods.

Results

Of 31 EU/EEA countries, 23 (2014) and 27 (2016) participated. Numbers of countries with central collection and storage of HAV positive samples and of those performing sequencing increased from 12 to 15 and 12 to 14 respectively in 2016, with all countries typing an overlapping fragment of 218 nt. However, variation existed in the sequenced genomic regions and their lengths.

Conclusions

While HAV sequences in EU/EEA countries are comparable for surveillance, collaboration in sharing and comparing these can be further strengthened.

Epidemiological trends of notified human brucellosis in Germany, 2006-2018

OBJECTIVE

We describe epidemiological trends of human brucellosis in Germany over a 13 year period based on national surveillance data.

METHODS

We analyzed demographic, clinical, laboratory and exposure information of symptomatic laboratory-confirmed brucellosis cases notified 2006-18. Using official population data, we calculated incidences and risk ratios (RR).

RESULTS

From 2006 to 2018, 408 brucellosis cases were notified in Germany (mean annual incidence: 0.38/1,000,000 population), of which 75% were travel-associated. Yearly notifications peaked in 2014 (n = 47) and remained elevated compared to 2006-2013 (mean: n = 25). Asylum seekers (AS) arriving in Germany accounted for 9/44 (2015) and 15/36 (2016) cases, respectively. RR AS/non-AS 2015-2016: 28, 95% CI: 17-45. Unpasteurized milk products were most frequently notified as source of infection. Imported food and occupational exposure played a role in autochthonous cases.

CONCLUSIONS

The incidence of human brucellosis has markedly increased in recent years. Most of the observed rise in notifications can be explained by infections in AS. Exposure still predominantly occurs abroad. Risk factors for autochthonous infections need to be investigated further, though imported dairy products seem to play a role. Physicians should consider brucellosis as differential diagnosis in AS and people with travel to endemic regions with compatible symptoms.

Standardising surveillance of hepatitis E virus infection in the EU/EEA: A review of national practices and suggestions for the way forward

BACKGROUND

Hepatitis E virus (HEV) infection is not notifiable at EU/EEA level, therefore surveillance relies on national policies only. Between 2005 and 2015, more than 20,000 cases were reported in EU/EEA countries. HEV testing is established in 26 countries and 19 countries sequence HEV viruses.

OBJECTIVE AND STUDY DESIGN

WHO's European Action plan for viral hepatitis recommends harmonised surveillance objectives and case definitions. ECDC's HEV expert group developed minimal and optimal criteria for national hepatitis E surveillance to support EU/EEA countries in enhancing their capacity and to harmonise methods.

RESULTS

The experts agreed that the primary objectives of national surveillance for HEV infections should focus on the basic epidemiology of the disease: to monitor the incidence of acute cases and chronic infections. The secondary objectives should be to describe viral phylotypes or subtypes and to identify potential clusters/outbreaks and possible routes of transmission. Seventeen of 20 countries with existing surveillance systems collect the minimal data set required to describe the epidemiology of acute cases. Eleven countries test for chronic infections. Twelve countries collect data to identify potential clusters/outbreaks and information on possible routes of transmission.

DISCUSSION

Overall, the majority of EU/EEA countries collect the suggested data and meet the outlined requirements to confirm an acute case.

Travel-associated hepatitis A in Europe, 2009 to 2015

Travel to countries with high or intermediate hepatitis A virus (HAV) endemicity is a risk factor for infection in residents of countries with low HAV endemicity. Aim: The objective of this study was to estimate the risk for hepatitis A among European travellers using surveillance and travel denominator data. Methods: We retrieved hepatitis A surveillance data from 13 European Union (EU)/ European Economic Area (EEA) countries with comprehensive surveillance systems and travel denominator data from the Statistical Office of the European Union. A travel-associated case of hepatitis A was defined as any case reported as imported. Results: From 2009 to 2015, the 13 countries reported 18,839 confirmed cases of hepatitis A, of which 5,233 (27.8%) were travel-associated. Of these, 39.8% were among children younger than 15 years. The overall risk associated with travel abroad decreased over the period at an annual rate of 3.7% (95% confidence interval (CI): 0.7–2.7) from 0.70 cases per million nights in 2009 to 0.51 in 2015. The highest risk was observed in travellers to Africa (2.11 cases per million nights). Cases more likely to be reported as travel-associated were male and of younger age (< 25 years). Conclusion: Travel is still a major risk factor for HAV infection in the EU/EEA, although the risk of infection may have slightly decreased in recent years. Children younger than 15 years accounted for a large proportion of cases and should be prioritised for vaccination.

Case-control study on risk factors for acute hepatitis E in Germany, 2012 to 2014

Notified cases of hepatitis E have increased 40-fold in the past 10 years in Germany. Food safety is a major concern as hepatitis E virus (HEV) RNA has been detected in ready-to-eat retail-level food products. The objective of this case–control study was to assess risk factors for autochthonous symptomatic hepatitis E and explore reasons for delays in diagnosis. Methods: Demographic, clinical and exposure data from notified hepatitis E cases and individually matched population controls were collected in semi-standardised telephone interviews. Conditional logistic regression analysis was used to calculate matched odds ratios (mOR) and population attributable fractions (PAF). Results: In total, 270 cases and 1,159 controls were included (mean age 53 years, 61% men in both groups). Associated with disease were: consumption of undercooked pork liver, pork, wild boar meat, frankfurters, liver sausage and raw vegetables; contact with waste water (occupational) and various host factors (mORs between 1.9 and 34.1, p value < 0.03). PAF for frankfurters and liver sausage were 17.6%, and 23.6%, respectively. There were statistically significant differences in the clinical presentation and hospitalisation proportion of acute hepatitis E in men and women. Diagnosis was preceded by more invasive procedures in 29.2% of patients, suggesting that hepatitis E was not immediately considered as a common differential diagnosis. Conclusions: Our study suggests that there are indeed sex-specific differences in disease development and lends important epidemiological evidence to specific ready-to-eat pork products as a major source for autochthonous hepatitis E. A review of existing consumer recommendations and production methods may be indicated.

Hepatitis A virus infections, immunisations and demographic determinants in children and adolescents, Germany

Hepatitis A is a vaccine-preventable disease with a global distribution. It predominantly occurs in regions with inadequate living conditions, but also affects populations in industrialised countries. Children are frequently involved in the transmission of hepatitis A virus (HAV) and thus play a central role in the epidemiology of hepatitis A. Here, we investigated HAV infections, immunisations, and associated demographic determinants in a nationwide, population-based, cross-sectional survey conducted in Germany from 2003-2006. Out of 17,640 children and adolescents, complete data sets (HAV serology, demographic information and vaccination card) were available for 12,249 (69%), all aged 3-17 years. We found protective antibody levels (>=20 IU/L) in 1,755 (14%) individuals, 1,395 (11%) were vaccinated against hepatitis A, 360 (3%) individuals were HAV seropositive without prior hepatitis A vaccination, thus indicating a previous HAV infection. Antibody prevalence (attributable to vaccination or infection) increased significantly with age. Multivariate logistic regression revealed that predominantly children and adolescents with migration background-even if they were born in Germany-are affected by HAV infections. Our results provide a rationale to emphasise existing vaccination recommendations and, moreover, to consider additional groups with a higher risk of infection for targeted vaccination, especially children with a migration background.

Hepatitis A outbreak disproportionately affecting men who have sex with men (MSM) in the European Union and European Economic Area, June 2016 to May 2017

Between 1 June 2016 and 31 May 2017, 17 European Union (EU) and European Economic Area countries reported 4,096 cases associated with a multi-country hepatitis A (HA) outbreak. Molecular analysis identified three co-circulating hepatitis A virus (HAV) strains of genotype IA: VRD_521_2016, V16-25801 and RIVM-HAV16-090. We categorised cases as confirmed, probable or possible, according to the EU outbreak case definitions. Confirmed cases were infected with one of the three outbreak strains. We investigated case characteristics and strain-specific risk factors for transmission. A total of 1,400 (34%) cases were confirmed; VRD_521_2016 and RIVM-HAV16-090 accounted for 92% of these. Among confirmed cases with available epidemiological data, 92% (361/393) were unvaccinated, 43% (83/195) travelled to Spain during the incubation period and 84% (565/676) identified as men who have sex with men (MSM). Results depict an HA outbreak of multiple HAV strains, within a cross-European population, that was particularly driven by transmission between non-immune MSM engaging in high-risk sexual behaviour. The most effective preventive measure to curb this outbreak is HAV vaccination of MSM, supplemented by primary prevention campaigns that target the MSM population and promote protective sexual behaviour.

Two concurrent outbreaks of hepatitis A highlight the risk of infection for non-immune travellers to Morocco, January to June 2018

From January to June 2018, two ongoing hepatitis A outbreaks affected travellers returning from Morocco and cases in Europe without travel history, resulting in 163 patients in eight European countries. Most interviewed travel-related cases were unaware of the hepatitis A risk in Morocco. Molecular analysis revealed two distinct hepatitis A virus (HAV) strains (subgenotype IA DK2018_231; subgenotype IB V18-16428). Vaccination recommendations should be emphasised to increase awareness among non-immune travellers to Morocco and HAV-endemic countries.

Hepatitis E virus seroprevalence, seroincidence and seroreversion in the German adult population

A steep rise in Hepatitis E diagnoses is currently being observed in Germany and other European countries. The objective of this study was (i) to assess whether this trend mirrors an increase in infection pressure or is caused by increased attention and testing and (ii) estimate individual and population-based Hepatitis E Virus (HEV) seroconversion and seroreversion rates for Germany. We measured anti-HEV IgG prevalence in 10 407 adults participating in two linked, population-representative serosurveys (total n = 12 971) conducted in 1998 and 2010. In this period, we found a moderate but statistically significant decline of overall anti-HEV IgG prevalence from 18.6% to 15.3%. At both time points, seroprevalence increased with age and peaked in persons born between 1935 and 1959 suggesting a past period of increased infection pressure. Paired samples of individuals participating in 1998 and 2010 (n = 2564) revealed respective seroconversion and seroreversion rates of 6.2% and 22.6% among seronegative and seropositive individuals during 12 years, or 5.2 and 2.9 per 1000 inhabitants per year. This corresponds to a total of 417 242 [95%CI: 344 363-495 971] new seroconversions per year in the German population. While anti-HEV seroprevalence has decreased in the last decade, infection pressure and seroincidence remains high in Germany. Continuously rising numbers of Hepatitis E diagnoses in Europe are likely due to an increased awareness of clinicians and indicate that still there is a gap between incident and diagnosed cases. Studies on the true burden of the disease, specific risk factors and sources of autochthonous infections as well as targeted prevention measures are urgently needed.

Ongoing haemolytic uraemic syndrome (HUS) outbreak caused by sorbitol-fermenting (SF) Shiga toxin-producing Escherichia coli (STEC) O157, Germany, December 2016 to May 2017

We report an ongoing, protracted and geographically dispersed outbreak of haemolytic uraemic syndrome (HUS) and gastroenteritis in Germany, involving 30 cases since December 2016. The outbreak was caused by the sorbitol-fermenting immotile variant of Shiga toxin-producing (STEC) Escherichia coli O157. Molecular typing revealed close relatedness between isolates from 14 cases. One HUS patient died. Results of a case–control study suggest packaged minced meat as the most likely food vehicle. Food safety investigations are ongoing.

Tularemia in Germany-A Re-emerging Zoonosis

Tularemia, also known as “rabbit fever,” is a zoonosis caused by the facultative intracellular, gram-negative bacterium Francisella tularensis. Infection occurs through contact with infected animals (often hares), arthropod vectors (such as ticks or deer flies), inhalation of contaminated dust or through contaminated food and water. In this review, we would like to provide an overview of the current epidemiological situation in Germany using published studies and case reports, an analysis of recent surveillance data and our own experience from the laboratory diagnostics, and investigation of cases. While in Germany tularemia is a rarely reported disease, there is evidence of recent re-emergence. We also describe some peculiarities that were observed in Germany, such as a broad genetic diversity, and a recently discovered new genus of Francisella and protracted or severe clinical courses of infections with the subspecies holarctica. Because tularemia is a zoonosis, we also touch upon the situation in the animal reservoir and one-health aspects of this disease. Apparently, many pieces of the puzzle need to be found and put into place before the complex interaction between wildlife, the environment and humans are fully understood. Funding for investigations into rare diseases is scarce. Therefore, combining efforts in several countries in the framework of international projects may be necessary to advance further our understanding of this serious but also scientifically interesting disease.

Causal or not: applying the Bradford Hill aspects of evidence to the association between Zika virus and microcephaly

While experts have suspected a causal link between outbreaks of Zika virus and microcephaly, it was not demonstrated. The currently available data are here organized into the Austin Bradford Hill's aspects of evidence for the consideration of causality.

Hepatitis E virus infection in Europe: surveillance and descriptive epidemiology of confirmed cases, 2005 to 2015

Hepatitis E virus (HEV) is an under-recognised cause of acute hepatitis in high-income countries. The purpose of this study was to provide an overview of testing, diagnosis, surveillance activities, and data on confirmed cases in the European Union/European Economic Area (EU/EEA). A semi-structured survey was developed and sent to 31 EU/EEA countries in February 2016, 30 responded. Twenty of these countries reported that they have specific surveillance systems for HEV infection. Applied specific case definition for HEV infection varied widely across countries. The number of reported cases has increased from 514 cases per year in 2005 to 5,617 in 2015, with most infections being locally acquired. This increase could not be explained by additional countries implementing surveillance for HEV infections over time. Hospitalisations increased from less than 100 in 2005 to more than 1,100 in 2015 and 28 fatal cases were reported over the study period. EU/EEA countries are at different stages in their surveillance, testing schemes and policy response to the emergence of HEV infection in humans. The available data demonstrated a Europe-wide increase in cases. Standardised case definitions and testing policies would allow a better understanding of the epidemiology of HEV as an emerging cause of liver-related morbidity.

Ongoing outbreaks of hepatitis A among men who have sex with men (MSM), Berlin, November 2016 to January 2017 - linked to other German cities and European countries

Since 14 November 2016, 38 cases of hepatitis A have been notified in Berlin; of these, 37 were male and 30 reported to have sex with men (MSM). Median age of MSM cases is 31 years (range: 24–52 years). Phylogenetic analysis revealed three distinct sequences, linking cases in Berlin to those in other German cities and to clusters recognised in other European countries in 2016.

Steep rise in norovirus cases and emergence of a new recombinant strain GII.P16-GII.2, Germany, winter 2016

Since early November 2016, the number of laboratory-confirmed norovirus infections reported in Germany has been increasing steeply. Here, we report the detection and genetic characterisation of an emerging norovirus recombinant, GII.P16-GII.2. This strain was frequently identified as the cause of sporadic cases as well as outbreaks in nine federal states of Germany. Our findings suggest that the emergence of GII.P16-GII.2 contributed to rising case numbers of norovirus gastroenteritis in Germany.

Flow-assisted basophil activation tests in immediate drug hypersensitivity: two decades of Antwerp experience

The last two decades have witnessed that flow-assisted analysis of in vitro-activated basophils can constitute a valuable adjunct in the in vitro diagnostic approach of immediate drug hypersensitivity reactions (IDHR). This article summarises the current experience with the basophil activation test in the diagnosis of IDHR, with particular focus on allergy to curarising neuromuscular blocking agents, antibiotics (β-lactams and fluoroquinolones), iodinated radiocontrast media and opiates.

Hepatitis E virus antibody prevalence in hunters from a district in Central Germany, 2013: a cross-sectional study providing evidence for the benefit of protective gloves during disembowelling of wild boars

Background

In Germany, 17 % of the general human population have antibodies to hepatitis E virus (HEV) (recomLine HEV-IgG/IgM immunoassay [Mikrogen GmbH]). Wild boars represent an animal reservoir for HEV genotype 3, which is the common genotype in Germany. We estimated the seroprevalence among hunters with contact to wild boars to identify factors that may be associated with past or present HEV infection.

Methods

In 2013, the local veterinarian authority in a district in Central Germany attended meetings of hunters who provided blood specimens and completed a questionnaire collecting information on age, sex, hunting-related activities and consumption of wild boar meat. Specimens of wild boars were taken during drive hunts in this district during the season 2012/2013. All specimens were tested for HEV RNA and anti-HEV IgM and IgG antibodies. Log-binomial regression was used to estimate prevalence ratios (PR) for the hunters.

Results

Of 126 hunters (median age 55; 94 % male) 21 % tested positive for anti-HEV IgG antibodies (95 % confidence interval [CI] 13–28 %) (recomWell HEV IgG assay [Mikrogen GmbH]). Anti-HEV prevalence was highest in the age group of the 70–79-year-olds (67 %; 95 % CI 39–95 %). Wild boars showed an average anti-HEV prevalence of 41 %. HEV RNA was detected in 4/22 (18 %) liver specimens and in 1/22 (4.5 %) muscle specimens. Most wild boars were tested positive for HEV RNA (3/10; 30 %) and HEV-specific antibodies (7/15; 47 %) in the southwestern part of the district. Hunters preferring this hunting ground had a lower anti-HEV prevalence when gloves were frequently used during disembowelling of wild boars compared to hunters using gloves never or infrequently (age-adjusted PR 0.12; 95 % CI 0.02–0.86).

Conclusions

Hunters may benefit from wearing gloves when in contact with blood or body fluids of HEV animal reservoirs. Anti-HEV prevalence among the hunters of this study did not significantly differ from that of the general population suggesting that other factors play a major role in the epidemiology of HEV in Germany.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1199-y) contains supplementary material, which is available to authorized users.

Large and prolonged food-borne multistate hepatitis A outbreak in Europe associated with consumption of frozen berries, 2013 to 2014

In May 2013, Italy declared a national outbreak of hepatitis A, which also affected several foreign tourists who had recently visited the country. Molecular investigations identified some cases as infected with an identical strain of hepatitis A virus subgenotype IA. After additional European Union/European Economic Area (EU/EEA) countries reported locally acquired and travel-related cases associated with the same outbreak, an international outbreak investigation team was convened, a European outbreak case definition was issued and harmonisation of the national epidemiological and microbiological investigations was encouraged. From January 2013 to August 2014, 1,589 hepatitis A cases were reported associated with the multistate outbreak; 1,102 (70%) of the cases were hospitalised for a median time of six days; two related deaths were reported. Epidemiological and microbiological investigations implicated mixed frozen berries as the vehicle of infection of the outbreak. In order to control the spread of the outbreak, suspected or contaminated food batches were recalled, the public was recommended to heat-treat berries, and post-exposure prophylaxis of contacts was performed. The outbreak highlighted how large food-borne hepatitis A outbreaks may affect the increasingly susceptible EU/EEA general population and how, with the growing international food trade, frozen berries are a potential high-risk food.

Outbreak of trichinellosis due to wild boar meat and evaluation of the effectiveness of post exposure prophylaxis, Germany, 2013

BACKGROUND

Food safety authorities discovered that wild boar meat products contaminated with Trichinella spiralis had entered the food chain in Germany in March 2013. Public health authorities issued guidelines for health professionals including post-exposure prophylaxis (PEP) using mebendazole and advised the public to seek medical advice if exposed. Our objective was to identify factors associated with the development of trichinellosis and to evaluate post exposure prophylaxis.

METHODS

Persons who reported to local public health departments as exposed were interviewed concerning exposure, symptoms, and medication. Serum samples were tested by an in-house Trichinella-specific enzyme-linked innunosorbent assay. Cases were defined as persons presenting with myalgia and/or periorbital edema and Trichinella-specific immunoglobulin M and immunoglobulin G antibodies after exposure to implicated products.

RESULTS

Of 101 persons interviewed, 71 were exposed and serologically tested. Antibodies were detected in 21/71 (30%) and 14/71 (20%) met the case definition. Attack rates were positively correlated to the amount of implicated product consumed. Among n = 37 persons who received anthelmintics as PEP, 6 persons developed trichinellosis. These cases exclusively occurred among persons starting PEP 6 days or later post-exposure. Exposure to implicated products and delaying PEP were also significantly associated with developing trichinellosis (P < .01) in a multivariable analysis.

CONCLUSIONS

Concerted efforts by food safety and public health authorities lead to timely outbreak control and facilitated the provision of early PEP. PEP appears to be effective in preventing trichinellosis when given early, preferably within 6 days. We therefore recommend initiating PEP without delay in similar settings and encourage public health professionals to fast-track this intervention.

Molecular allergy diagnosis: status anno 2015

IgE antibodies play a key role in type I allergic reactions. Today, different in vitro immunoassays for allergen-specific IgE antibodies are available. However, some major issues should be taken into account for correct interpretation of specific IgE (sIgE) antibody results, as these assays do not demonstrate absolute positive and negative predictive values. Therefore, additional diagnostic tests are needed to make the correct diagnosis. During the last two decades significant progress in biochemistry and molecular biology enabled the detection and quantification of sIgE antibodies to allergen protein components and epitope-emulating peptides, also called molecular allergy diagnosis or component resolved diagnosis (CRD). In contrast to conventional sIgE antibody assays, molecular allergy diagnosis makes it possible to discriminate between genuine allergy and merely sensitisation, to establish personalized sensitization patterns and to assess the individual risk of severity of an allergic reaction and finally it helps us to predict the natural course. In this review the use of CRD in inhalant, food, latex and hymenoptera venom allergy will be discussed. The primary focus will be on the most relevant clinical applications of CRD rather than to describe all the currently available allergen components and epitopes. Appropriate experience of our own research group is provided.

QCD and strongly coupled gauge theories: challenges and perspectives

We highlight the progress, current status, and open challenges of QCD-driven physics, in theory and in experiment. We discuss how the strong interaction is intimately connected to a broad sweep of physical problems, in settings ranging from astrophysics and cosmology to strongly coupled, complex systems in particle and condensed-matter physics, as well as to searches for physics beyond the Standard Model. We also discuss how success in describing the strong interaction impacts other fields, and, in turn, how such subjects can impact studies of the strong interaction. In the course of the work we offer a perspective on the many research streams which flow into and out of QCD, as well as a vision for future developments.

Large multistate outbreak of norovirus gastroenteritis associated with frozen strawberries, Germany, 2012

Binary file ES_Abstracts_Final_ECDC.txt matches