Eurosurveillance - Volume 12, Issue 6, 01 June 2007

Recent outbreaks of Clostridium difficile-associated diarrhoea (CDAD) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America, Japan and Europe. Definitions have been proposed by the European Centre of Disease Prevention and Control (ECDC) to identify severe cases of CDAD and to differentiate community-acquired cases from nosocomial CDAD (http://www.ecdc.europa.eu/documents/pdf/Cl_dif_v2.pdf). CDAD is mainly known as a healthcare-associated disease, but it is also increasingly recognised as a community-associated disease. The emerging strain is referred to as North American pulsed-field type 1 (NAP1) and PCR ribotype 027. Since 2005, individual countries have developed surveillance studies to monitor the spread of this strain. C. difficile type 027 has caused outbreaks in England and Wales, Ireland, the Netherlands, Belgium, Luxembourg, and France, and has also been detected in Austria, Scotland, Switzerland, Poland and Denmark. Preliminary data indicated that type 027 was already present in historical isolates collected in Sweden between 1997 and 2001.

Toscana virus infection is endemic in Italy, but has also been documented in other Mediterranean countries. Our aim was to investigate the occurrence of Toscana virus (TOSV) meningitis in children and young adults in a metropolitan area in the north of Portugal. Cerebrospinal fluid samples from 308 patients with the diagnosis of meningitis and with negative bacterial culture were tested for enteroviruses and herpesviruseses by reverse transcription PCR. Those samples that proved negative for enterovirus and herpesvirus were tested for Toscana virus with a commercial reverse transcription nested PCR assay. In total, we investigated 106 samples, collected between May and September during the four-year period between 2002 and 2005 from patients younger than 30 years old. Toscana virus was the cause of meningitis in six (5.6%) of the cases, three children and three young adults. All had a benign course and self-limited disease. Since a first case report of TOSV infection 1985 and another in 1996, both in foreign tourists, these six cases of Toscana virus meningitis are, to our knowledge, the first diagnosed in Portuguese inhabitants, and they underline the need for more studies on the prevalence of this virus in Portugal.

The last case of poliomyelitis in Portugal caused by indigenous wild poliovirus occurred in 1986 and the country was declared polio-free in 2002. High levels of immunity must be maintained to prevent the importation of wild poliovirus. In this study, we determined the immunity against poliomyelitis of the Portuguese population in order to identify possible immunity gaps. A representative sample of 1,133 individuals older than two years residing in mainland Portugal was studied. Logistical difficulties regarding quick sample transportation precluded the Portuguese islands (Madeira and the Azores) from this study. Sera were collected in 2002 from individuals attending health clinics throughout the 18 districts of Portugal. Levels of neutralizing antibodies against poliovirus types 1, 2 and 3 were determined and a titre of >= 1:8 was defined as indicative of protected immunity. Results were expressed in international units. The antibody prevalence and the geometric mean antibody concentration (GMAC) was 91.6% (GMAC: 2.96 IU/ml), 94.2% (GMAC: 5.03 IU/ml) and 75% (GMAC: 0.53 IU/ml) for poliovirus types 1, 2 and 3, respectively. For poliovirus types 1 and 2, antibody prevalence was close to or above 90% in the majority of age groups. For poliovirus type 3, antibody prevalence was below 80% in teenagers and young adults. Our study shows that the Portuguese are well protected against poliovirus types 1 and 2. For poliovirus type 3, the suboptimal antibody levels observed in teenagers and young adults suggest the need for a booster dose to minimise the risk of wild poliovirus importation.

The SARS epidemic, the threat of bioterrorism, and recent examples of imported highly infectious diseases (HID) in Europe have all highlighted the importance of competent clinical and public health management of infectious disease emergencies. Although the European Union of Medical Specialists in Europe and the Infectious Diseases Society of America have developed curricula for training in infectious disease medicine, neither of those mentions training in the management of HIDs. The European Network for Infectious Diseases (EUNID, http://www.eunid.com) is a European Commission co-funded network of experts in HID management, created to help improve the preparedness for HID emergencies within Europe. One of EUNID's agreed tasks is the development of a curriculum for such a training. Between April 2005 and September 2006, EUNID developed a curriculum and accompanying training course on the basis of a questionnaire that was sent to all country representatives and discussion, followed by amendment of drafts shared through the project website, and a final consensus meeting. The resulting curriculum consists of a two-module course covering the core knowledge and skills that healthcare workers need to safely treat a patient who has, or who may have, an HID. The first module introduces theoretical aspects of HID management, including disease-specific knowledge, infection control, and the public health response, through didactic teaching and class-based discussion. The second module involves a 'skill station' and a clinical scenario, and equips trainees with relevant practical skills, including the use of specialised equipment and teamwork practice in patient management. Together, the curriculum and course contribute to the creation of a common framework for training healthcare professionals in Europe, and although they are designed primarily for clinicians that are directly involved in patient care, they are relevant also to public health professionals and others who may be involved in HID management and emergency response. .

Previous outbreaks of Salmonella Enteritidis in Canada and the United States have been associated with the consumption of almonds. From December 2005 to August 2006 a cluster of 15 cases of Salmonella Enteritidis NST 3+ was reported in Sweden. A case-control study was performed to identify the source of transmission. Three controls per case were randomly selected, matched on sex, age and place of residence. Cases and controls were interviewed by telephone and data were analysed with a conditional logistic model. The results showed that eating almonds was a risk factor for infection with Salmonella Enteritidis NST3+ (unmatched odds ratio 45.0, 95% confidence interval: 4.8-421.8). No Salmonella was isolated from almonds tested in the study. In conclusion, almonds could be the source of the outbreak and should be considered when investigating outbreaks as well as sporadic cases of Salmonella Enteritidis.

A monophasic Salmonella enterica serovar 4,[5],12:i:- phage type DT193 emerged as the dominant serovar in Luxembourg in 2006, when it caused two major outbreaks involving 133 laboratory-confirmed human cases, 24 hospitalisations, and one death. The outbreak strain had an uncommon pulsed-field gel electrophoresis pattern STYMXB.0031 and antibiotic resistance profile ASSuT. A high proportion of cases were clustered in institutions for the elderly and in day-care centers. Strains identical to the outbreak strain were recovered from two control meals, a nappy changing table, retail sausages and caecal porcine samples at an abattoir. Locally produced pork meat is strongly suspected to have been the vehicle for the outbreaks, although the precise mechanisms remain unclear.