Eurosurveillance - Volume 13, Issue 51, 18 December 2008

Malaria incidence is reportedly declining steadily in many parts of the world, including in at least several African countries. The incidence of imported malaria is also declining in a number of European countries. However, incidence rates in travellers, both European tourists and the so called VFR (visiting friends and relatives) are difficult to estimate, due to problems with the numerator (many cases are not reported) and more importantly with the denominator, for which the information is generally lacking. An exception in the European Union is the United Kingdom (UK), where the International Passenger Survey provides a reliable denominator on the number of travellers to the different countries, duration of stay and reason for travel.

A 4.5 months old, previously healthy Danish girl was admitted to a paediatric department after six days of passive behaviour and weak suck. Over the next days she became increasingly weak, developed bilateral ptosis, the muscle stretch reflexes were lost, and mydriasis with slow pupillary responses was noted. Botulism was suspected and confirmed by testing of patient serum in a bioassay. The condition of the patient improved following administration of botulism antiserum. The clinical picture was suggestive of intestinal (infant) botulism. However, botulism acquired from consumption of food with preformed neurotoxin could not be excluded. The food history revealed consumption of a commercially produced banana/peach puree which was suspected as a possible source, and based on a precautionary principle this product was recalled. The case description illustrates a risk-management dilemma between suspected foodborne versus intestinal botulism. Taking the potentially very serious consequences of foodborne botulism into consideration, the measures taken were justified.

Twelve Finnish tourists contracted falciparum malaria from Gambia in the period between 3 and 27 November 2008. The travellers came from different parts of Finland and all except one had booked the trip from the same travel agency. Ten of them had received information about the risk of malaria in Gambia and protection from mosquito bites but none of them had used adequate malaria chemoprophylaxis.

A cluster of 56 patients returning from Gambia with falciparum malaria has been noted in several countries of the European Union since September this year. TropNetEurop, the European Network on Imported Infectious Disease Surveillance, collected and reported the cases. Lack of awareness and, consequently, of prophylactic measures against malaria were apparent in the majority of patients.

We discuss the investigations and control measures undertaken following the notification of a fatal case of inhalation anthrax in East London. The patient is believed to have acquired the infection from making animal hide drums. Environmental investigations identified one drum and two pieces of animal skins contaminated with anthrax spores.

In September 2008, 21 cases of cryptosporidiosis occurred among guests and staff at a wedding reception in a hotel restaurant in Stockholm county, Sweden. The median incubation period was 7.1 days (range 4-9 days) and 86% of the patients had symptoms for longer than one week. Three patients were hospitalised due to dehydration. The most probable source of the outbreak was béarnaise sauce containing chopped fresh parsley .

In this report, we describe the investigation and management of an outbreak of TB associated with a mosque in Scotland, and consider the implications of large-scale TB contact tracing. In 2005, an Algerian man living in the north-east of Scotland was found to be sputum smear-positive for TB. Initial investigation identified three (18.8%) close contacts with active disease. Due to the high rate of transmission, contact tracing was extended to casual contacts of the index case at a mosque. No sub-group at highest risk of exposure could be defined at the mosque. Screening of mosque attendees identified two cases (0.53%), with a further two identified by review of existing cases and enhanced surveillance. Two additional cases were linked to the outbreak by genetic profile. Response to the screening exercise was initially poor, but after modification of the communication strategy, 438 people were offered screening with 86% attending. The investigation and management of a TB outbreak is challenging and requires a complex message about risk to be communicated. In a mosque setting, there were additional complexities that, to the best of our knowledge, have not been reported previously. It was crucial, in designing the communication strategy, to identify key individuals within the community to assist with tailoring the message to address risk perception and to help to deliver the message. Despite this, approximately 50% of those considered to have the highest exposure (adult males regularly attending Friday lunchtime prayer meetings) did not come forward for screening. The screening of casual contacts in this setting was complex and time-consuming with a low detection rate.

An outbreak of acute gastroenteritis occurred in a nursing home for elderly in Majorca between 4 and 23 February 2008. To know its aetiology and mechanism of transmission a retrospective cohort study was conducted with a fixed cohort including 146 people (96 residents and 50 employees). The data were collected from clinical histories and through a survey by questionnaire. In total 71 cases were identified (53 residents, 18 employees), corresponding to an overall attack rate (AR) of 48.6%. The consumption of tap water, adjusted by age, sex and consumption of meals provided at the nursing home, presented a relative risk (RR) of 4.03 (95%CI, 1.4-11.4). The microbiological analyses confirmed the presence of norovirus and/or rotavirus in five of the seven stool samples submitted. The slow appearance of cases at the beginning of the outbreak is characteristic of a person to person transmission, while the sudden peak in the middle of the month suggests a common source such as the tap water. We therefore concluded that the outbreak likely originated from two sources: an infected employee of the nursing home and the tap water. The high number of dependent residents most probably facilitated the spread of the outbreak.

For several years, the Health Protection Agency on behalf of Department of Health has undertaken routine annual uptake monitoring of the seasonal influenza vaccination programme in England in order to provide an annual estimate of uptake in targeted groups. In 2007-8, 95% of 8,375 GP practices in England took part in data collection. The national mean uptake in those 65 years and above in England was 74%, approaching the WHO target of 75%.

At a closer look, our coverage results for this age group and those reported by the HPA are quite similar for 2003-4 (70% vs. 71%, respectively) and 2005-6 (78% vs. 75%, respectively) while our coverage results for 2004-5 and 2006-7 are indeed substantially lower. Given confidence interval widths, as shown in Figure 2 of our report, chance alone does not appear to be a likely explanation for this discrepancy.