Eurosurveillance - Volume 11, Issue 7, 01 July 2006

In this issue of Eurosurveillance, Rouaud et al report a protracted outbreak of meningococcal B invasive diseases (BMD) in the northern French department of Seine-Maritime, linked to the local expansion of a clonal strain of B:14:P1.7,16 phenotype, belonging to the ST32/ET5 clonal complex.

Between January 2003 and June 2005, an outbreak of meningococcal disease occured in the department of Seine-Maritime in northern France. Eighty six cases were notified, giving an average annual incidence of 2.7 cases per 100 000 inhabitants, compared with 1.6 in France. An especially affected area was defined as the city of Dieppe and its surrounding area (26 cases, giving an annual incidence of 12 cases per 100 000). This outbreak was due to N. meningitidis phenotype B:14:P1.7,16 belonging to the clonal complex ST-32/ET-5. Over the 31 B14:P1.7,16 cases confirmed by phenotyping methods at the national reference centre for meningococci (CNR, Centre National de Référence des méningocoques) the case-fatality rate (19%) and the proportion of purpura fulminans (42%) were especially high. Teenagers aged between 15 and 19 years and children aged 1 to 9 years were the most affected. In 2003, health authorities put in place enhanced epidemiological surveillance and informed practitioners and population about the disease. In 2004, the national vaccination advisory board studied the opportunity of using a non licensed outer membrane vesicle vaccine developed in Norway which may be effective against the B14:P1.7,16 strain. The Ministry of health decided in 2006 to offer vaccination with this vaccine to people aged 1 to 19 years in Seine- Maritime.

In September 2005, the first national food-related outbreak of Shiga toxin (Stx)-producing Escherichia coli (STEC) O157 was investigated in the Netherlands. A total of 21 laboratory-confirmed cases (including one secondary case), and another 11 probable cases (two primary and nine secondary cases) were reported in patients who became ill between 11 September and 10 October 2005. Preliminary investigation suggested consumption of a raw beef product, steak tartare (in the Netherlands also known as 'filet américain'), and contact with other symptomatic persons as possible risk factors. A subsequent case-control study supported the hypothesis that steak tartare was the source of the outbreak (matched odds ratio (OR) 272, 95% confidence interval (CI) 3 - 23211). Consumption of ready-to-eat vegetables was also associated with STEC O157 infection (matched OR 24, 95% CI 1.1 – 528), but was considered a less likely source, as only 40% of the cases were exposed. Samples of steak tartare collected from one chain of supermarkets where it is likely that most patients (67%) bought steak tartare, all tested negative for STEC O157. However, sampling was done three days after the date of symptom onset of the last reported case. Since 88% of the cases became ill within a two week period, point source contamination may explain these negative results. It is concluded that steak tartare was the most likely cause of the first national food-related outbreak of STEC O157 in the Netherlands.

Epidemic conjunctivitis can be associated with viral or bacterial pathogens, whereas epidemic keratoconjunctivitis is caused mainly by adenoviruses type 8,19 and 37. In Germany, the incidence of adenovirus conjunctivitis cases increased from 0.2 per 100 000 inhabitants (in 2001 and 2002) eventually to 0.5 in 2003 and 0.8 in 2004. The detection of adenovirus in conjunctival swabs is notifiable to the local health departments. Data about cases with positive conjunctival swabs are then transmitted to the Robert Koch-Institut. Quality control of data takes place and national surveillance data of confirmed cases with adenovirus conjunctivitis are published. From January to April 2004 the national surveillance system captured an outbreak with 1024 cases (131 laboratory confirmed). Analysis of the national surveillance data showed that in March 2004 the group primarily affected by epidemic keratoconjunctivitis was young men between 18 -29 years old followed by an increased number of notifications from women in the same age group. Meanwhile the German Armed Forces experienced an outbreak of conjunctivitis, almost exclusively without laboratory confirmation, affecting 6378 soldiers. Despite the small number of laboratory confirmed cases it became clear from the analysis of the national surveillance data that person-to-person transmission between young men and similar age groups of the population did occur. Whether the outbreak started within the garrisons of the German Armed Forces or whether it was triggered within these accommodations, there is clearly a need for the national and the military public health institutions to work together on guidelines to handle future challenges.

The aim of this study is to evaluate the range, quality and availability of diagnostic services for non-viral sexually transmitted infections (STIs), i.e. C. trachomatis, N. gonorrhoeae, T. vaginalis and T. pallidum, in Lithuania from September 2002 to December 2003. Surveillance data describing the organisation and performance characteristics of non-viral STI diagnostic services in Lithuania were collected using a questionnaire and subsequent site-visits. International evidence-based recommendations for non-viral STI diagnosis were used to evaluate the quality of the STI diagnostics. There were 171 facilities providing non-viral STI diagnostic services for the 3.5 million inhabitants of Lithuania. However, only 6% (n=9) of the respondents (n=153) could provide a confirmatory diagnosis, in accordance with international recommendations, for the full minimum range of relevant non-viral STIs in Lithuania, i.e. C. trachomatis, N. gonorrhoeae, T. pallidum, and T. vaginalis. In addition, accessibility to STI diagnostic services differed significantly among the different counties in Lithuania. Several of the respondents analysed low numbers of samples each year, and overall the sampling size was extremely low, especially for C. trachomatis diagnostics. In Lithuania, optimisation of non-viral STI diagnostics as well as of epidemiological surveillance and management of STIs is crucial. It may be worth considering a decrease in the number of laboratories, with those remaining having the possibility of performing STI diagnostic services that are optimised, in concordance with international recommendations, standardised, and quality assured using systematic internal and external quality controls and systems. In addition, establishment of national inter-laboratory networks and reference centres for non-viral STIs is recommended.

Sporadic reports from centres in the south and east of the Mediterranean have suggested that the prevalence of antibiotic resistance in this region appears to be considerable, yet pan-regional studies using comparable methodology have been lacking in the past. Susceptibility test results from invasive isolates of Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Enterococcus faecium and faecalis routinely recovered from clinical samples of blood and cerebrospinal fluid within participating laboratories situated in Algeria, Cyprus, Egypt, Jordan, Lebanon, Malta, Morocco, Tunisia and Turkey were collected as part of the ARMed project. Preliminary data from the first two years of the project showed the prevalence of penicillin non-susceptibility in S. pneumoniae to range from 0% (Malta) to 36% (Algeria) [median: 29%] whilst methicillin resistance in Staphylococcus aureus varied from 10% in Lebanon to 65% in Jordan [median: 43%]. Significant country specific resistance in E. coli was also seen, with 72% of isolates from Egyptian hospitals reported to be resistant to third generation cephalosporins and 40% non-susceptible to fluoroquinolones in Turkey. Vancomycin non-susceptibility was only reported in 0.9% of E. faecalis isolates from Turkey and in 3.8% of E. faecium isolates from Cyprus. The preliminary results from the ARMed project appear to support previous sporadic reports suggesting high antibiotic resistance in the Mediterranean region. They suggest that this is particularly the case in the eastern Mediterranean region where resistance in S. aureus and E. coli seems to be higher than that reported in the other countries of the Mediterranean.

Surveillance of healthcare associated infections is an overlooked parameter of good clinical practice in most healthcare institutions, due to the workload demanded in the absence of adequate IT-systems. The aim of the present study was to investigate whether a simple protocol could be used to estimate the burden of healthcare associated infections in three university hospitals in Huddinge in Sweden, Riga in Latvia and Vilnius in Lithuania and form the basis for initiating a long term follow up system. The medical records of all patients receiving antibiotics were reviewed according to a standardised protocol, focusing on the indications for the drugs and on the frequency of hospital acquired infection (HAI) in a point-prevalence survey. Only comparable specialities were included. The proportion of patients treated with antibiotics (prophylaxis not included) were 63/280 (22%) in Huddinge, 73/649 (11%) in Riga and 99/682 (15%) in Vilnius. The proportion of admitted patients treated for a HAI were 15%, 3% and 4%, respectively, (both comparisons Huddinge versus other centres P<0.001). Surgical site infections were most common, followed by infections with an onset more than 2 days after admission without any of the other registered risk factors present. Our inexpensive and simple method showed that healthcare associated infections were a significant problem among patients admitted to Huddinge. The figures obtained can be used for further discussion and form a baseline for follow up at the local level. The comparison of figures between centres was far less relevant than the process the study created.