Eurosurveillance - Volume 12, Issue 11, 01 November 2007

Travel and tourism is an increasingly important economic activity throughout Europe and the rest of the world.

For several years, over 50% of the cases of travel-associated Legionnaires' disease (TALD) reported to the European Working Group for Legionella Infections (EWGLINET) have been among travellers to France, Italy, and Spain. We describe clusters of TALD cases reported in these countries during a four-year period. We analysed data from EWGLINET and from the individual countries. In all three countries, upon notification of a cluster, local health authorities are alerted by the national collaborator and immediately begin an environmental investigation at the accommodation site, which includes risk assessments and analysis of water samples. From July 1, 2002 to June 30, 2006, 2,101 accommodation sites were associated with TALD cases and reported by EWGLINET to Italian, Spanish and French collaborators. Of these, 252 sites (12%) were associated with clusters: 13.8% (96/697) in Italy, 13.2% (81/615) in Spain and 9.5% (75/789) in France. Overall, 641 cases were reported. Hotels, camping sites and ships and other sites represented respectively 83%, 10% and 7% of the total accommodation sites, with similar proportions in the three countries. In 99% of the sites, samples were collected; 62% of them were found to be positive for Legionella. The findings of this study highlight that disinfection and long-term preventive measures were correctly implemented by the large majority of sites. However, additional efforts must be made to further reduce the percentage of re-offending sites so as to reduce the number of accommodations that are contaminated by Legionella.

Since 1993, the reporting of listeriosis has been mandatory in Italy. The surveillance system based on case notifications from physicians is managed by the Ministry of Health. The information collected includes only gender, age and case distribution by region. To gather more information, an active surveillance was conducted for 12 months (2002-2003). All hospital microbiological laboratories in Italy (n=103) were given clinical and food questionnaires and were requested to report positive cases and send strains for testing. A higher number of cases of listeriosis were reported by this active surveillance compared to the mandatory notifications. In addition, information on risk factors, clinical symptoms and outcomes of 77 reported cases were analysed. In one case it was possible to trace the source of infection. Of the 77 cases of listeriosis, 41 Listeria monocytogenes isolates were characterised by serotype and pulsotype. More than 95% of the strains belonged to serotypes 1/2a, 4b and 1/2b; molecular analysis revealed 23 different AscI pulsotypes. The information collected is very important for understanding the real situation of listeriosis in Italy. It can be used to take effective actions in improving food safety and to provide dietary advice to individuals at greater risk of infection.

This study was prompted by two rubella outbreaks that occurred in northern Greece in the last decade (1993 and 1999) and by periodic changes to the immunisation strategy. It was designed to determine the current status of rubella immunity and vaccination coverage in this region, eight years after the last outbreak in 1999 and seven years after the last epidemiological study in the area. Among the 685 subjects studied the seroprevalence was 83.7% and the total vaccination rate was 31.3%. In people born before the introduction in 1989 of the measles/mumps/rubella (MMR) vaccine into the national immunisation programme, higher rates of rubella seropositivity (88.1%) were observed compared to those born after 1989 (77.1%). The vaccination rates for these age groups were 14.8% and 58.1%, respectively. The reason for this difference is the lack of vaccination at the time these people were children, and it underlines the need for a vaccination strategy targeting older people as well. Among women of reproductive age (16-40 years), who represented 44.8% of the study population, 13.9% were susceptible to rubella and only 18.5% were vaccinated. These results indicate that there is a great need for a comprehensive policy designed to protect mostly young adults and women of childbearing age in order to prevent congenital rubella infections. This policy should also include competent surveillance systems for rubella and congenital rubella syndrome and an evaluation of existing immunisation programmes.

Pertussis is not a notifiable disease in France. In addition to a paediatric hospital sentinel surveillance system, pertussis epidemiological data have, since 1996, been gathered through the voluntary notification of community clusters by general practitioners, and since 2001 by the statutory notification of nosocomial infection to the relevant local health authority. The local health authority forwards the information to the French National Institute for Surveillance (InVS). The objective of this study was to analyse pertussis data outside the routine paediatric hospital sentinel surveillance system. We gathered all the information concerning healthcare-associated infections and community clusters of pertussis (specific forms, investigation reports, emails etc.) reported to the InVS between 2000 and 2005. The InVS received and analysed 67 reports with a total of 595 cases. Almost half of the reports (n=31) came from hospitals, and healthcare workers were usually first affected. Control measures were put in place in 22 healthcare facilities and the average duration of an outbreak episode was 48 days. Outside healthcare facilities, clusters were reported also from 17 daycare facilities or schools and five workplaces. Among the 595 cases, six deaths occurred in children under seven months of age. Pertussis is still occurring in France and affects those who are not or who are no longer protected by the vaccine. Infection of infants within the household could be prevented if their parents and siblings were immunised. The number and size of pertussis clusters in hospitals could be reduced through immunisation of health staff, and timely and adequate outbreak management.

General practitioners (GPs) have an essential role in notification of communicable diseases. The main aim of the study described here was to assess the GPs' awareness of and attitudes towards the notification system in Malta, with special focus on infectious intestinal disease (IID). A questionnaire collecting demographic data, information on reporting practices, opinions on the existing notification system and suggestions for improvement was sent to 256 GPs working in either private or public health sector. In all, 150 GPs took part in the survey (response rate 58.6%). The responses revealed that Maltese GPs were aware of their obligations to notify communicable diseases but often did not report them, relying on the hospitals or laboratories to do so. The Disease Surveillance Unit (DSU) website and medical school training were the main sources of information on notification. Notification forms were obtained from health centres and usually kept at the place of work. Most GPs reported filling in the forms during the patients' visits. Private GPs tended to notify earlier than GPs working in public health centers. Among IID, food-borne illness was reported more frequently than person-to-person transmitted gastroenteritis and was considered to be of a higher priority with regard to public health importance (p < 0.001). The survey highlighted also some areas for improvement, including need of feedback especially by direct communication or a newsletter.

The largest outbreak of salmonellosis in 25 years in Stockholm County occurred during September - October 2006. A total of 115 persons who had a meal at a restaurant in Stockholm were notified as cases of salmonellosis through the Swedish surveillance system. The probable vehicle of the outbreak was mung beans, soaked in lukewarm water for 24 hours before being served at the restaurant. These mung beans had been included in all dishes served in the restaurant and the outbreak was terminated when they were excluded from the menu. Either Salmonella Bareilly or Salmonella Virchow were isolated from affected persons. No person was found to have an infection with both serotypes. The majority of affected persons were females with a median age of 34 years.This and similar outbreaks associated with consumption of vegetables and fruits highlight the increasing importance of fresh produce as vehicle for foodborne outbreaks in Europe.