Workplace-related risk of tick bites in military personnel stationed in Northern Germany.

PURPOSE: There are more than 500,000 employees in Germany alone who are at risk of being bitten by a tick at their workplace and thus also at risk of being infected with Borrelia burgdorferi s.l. or the tick-borne meningoencephalitis virus. So far, there are only a small number of studies on the risk of tick bites in Central Europe, in particular, for military personnel during relevant training activities. METHODS: During a total of 36 months of training in 2008/2009 and from 2012 to 2014, the number of tick bites and any resulting diseases of 1156 recruits under comparable conditions of exposure and prevention were documented based on their medical records. The incidence of tick bites was calculated with each recruit's individual exposure time for field training. RESULTS: There were a total of 66 tick bites during an exposure time of 317,059 h of field training (0.21 tick bites per 1000 h of training). The risk of tick bites was found to have a seasonal dependency. In 6 out of the 66 cases in which someone was bitten, the patients consulted a physician for a follow-up examination, and in one of these cases the bite resulted in an infection requiring treatment. CONCLUSIONS: It turns out that there is a rather low but relevant risk of being exposed to tick bites for military personnel during their field training. Under the given study conditions, months with a high risk of tick bites can be distinguished from months with a low risk of tick bites, which is of vital importance, in particular, for guidance and prevention.

[Blister beetle dermatitis: Dermatitis linearis]. / Blasenkäfer-Dermatitis: Dermatitis linearis.

Several families of beetles cause toxic reactions on exposed human skin. Cantharidin provokes nearly asymptomatic vesicles and blisters, while pederin leads to itching and burning erythema with vesicles and small pustules, later crusts. Paederi are attracted by fluorescent light especially after rain showers and cause outbreaks in regions with moderate climate. Clinical findings and patient history lead to the diagnosis: dermatitis linearis.

[Epidemiology and prevention of leishmaniasis in northern Afghanistan]. / Epidemiologie und Prophylaxe der Leishmaniasis in Nordafghanistan.

BACKGROUND: Leishmaniasis is estimated to cause the ninth largest disease burden among infectious diseases worldwide and it is not preventable by vaccination or chemoprophylaxis, but only by personal protective measures preventing bites of infectious arthropod vectors. OBJECTIVES: Which leishmania species are endemic in northern Afghanistan, what are the clinical characteristics of skin lesions produced by cutanizing leishmania species, what are their epidemiological characteristics, and which preventive measures are feasible? METHODS: The medical literature was reviewed, knowledge gaps were analyzed and completed by our own data collected locally. RESULTS: Four Leishmania species are considered endemic in northern Afghanistan, of which Leishmania tropica, L. major, and L. donovani can produce skin lesions while L. donovani and L. infantum visceralize. Transmission modes and seasons vary markedly among focally epidemic urban anthroponotic L. tropica and rural enzootic L. major. Combined preventive measures may reduce the infection rate by more than 10,000-fold. CONCLUSION: Cutaneous as well as visceral leishmaniasis can occur among returnees from Afghanistan. Atypical, poorly healing skin lesions can be caused by L. donovani. Extensive use of personal protective measures against arthropod vectors is strongly recommended for all travelers.

[Public health pests. Arthropods and rodents as causative disease agents as well as reservoirs and vectors of pathogens]. / Gesundheitsschädlinge. Arthropoden und Nagetiere als Krankheitsverursacher sowie Überträger und Reservoire von Krankheitserregern.

Globally, infectious diseases pose the most important cause of death. Among known human pathogenic diseases, approximately 50 % are zoonoses. When considering emerging infectious diseases separately 73 % currently belong to the group of zoonoses. In Central Europe, hard ticks show by far the biggest potential as vectors of agents of human disease. Lyme borreliosis, showing an estimated annual incidence between 60,000 and 214,000 cases is by far the most frequent tick-borne disease in Germany. Continually, formerly unknown disease agents could be discovered in endemic vector species. Additionally, introduction of new arthropod vectors and/or agents of disease occur constantly. Recently, five mosquito species of the genus Aedes have been newly introduced to Europe where they are currently spreading in different regions. Uncommon autochthonous transmission of dengue and chikungunya fever viruses in Southern Europe could be directly linked to these vector species and of these Ae. albopictus and Ae. japonicus are currently reported to occur in Germany. The German Protection against Infection Act only covers the control of public health pests which are either active hematophagous vectors or mechanical transmitters of agents of diseases. Use of officially recommended biocidal products aiming to interrupt transmission cycles of vector-borne diseases, is confined to infested buildings only, including sewage systems in the case of Norway rat control. Outdoor vectors, such as hard ticks and mosquitoes, are currently not taken into consideration. Additionally, adjustments of national public health regulations, detailed arthropod vector and rodent reservoir mapping, including surveillance of vector-borne disease agents, are necessary in order to mitigate future disease risks.

The sandflies (Diptera: Psychodidae, Phlebotominae) in military camps in northern Afghanistan (2007-2009), as identified by morphology and DNA 'barcoding'.

As part of a continuous, standardized programme of monitoring the Leishmania vectors in German military camps in northern Afghanistan between 2007 and 2009, a detailed taxonomic analysis of the endemic sandfly fauna, as sampled using light and odour-baited traps, was conducted. Of the 10 sandfly species that were recorded, six may serve as enzootic and/or zooanthroponotic vectors of parasites causing human leishmaniasis. The use of a simple DNA-'barcoding' technique based on the mitochondrial cyt b gene, to identify the collected sandflies to species level, revealed (1) a clear discrimination between the potential vector species, (2) clustering of species within most subgenera, and (3) particularly high heterogeneity within the subgenus Paraphlebotomus (Phlebotomus alexandri being grouped with Ph. papatasi rather than with other Paraphlebotomus species). The data also indicate a high level of genetic heterogeneity within the subgenus Sergentomyia but close similarity between Sergentomyia sintoni and Sergentomyia murgabiensis. The morphological similarity of many medically important sandflies can make species identification difficult, if not impossible. The new DNA-barcoding techniques may provide powerful discriminatory tools in the future.

[Genotoxic effects of insecticides in current use on mucosal epithelial cells from human tonsil tissue]. / Genotoxische Effekte aktuell gebräuchlicher Insektizide auf humane Tonsillenschleimhautepithelien.

BACKGROUND: Vector control is of critical medical importance in disease prevention, as reflected in sections 17 and 18 of the German Protection Against Infection Act. In the past, a large number of biocides were found to be hazardous to human health and were banned from the market, subsequently being replaced by new active ingredients and galenic forms. Many of these new insecticides are available in spray or nebuliser form. Whether these preparations have genotoxic effects on mucosal epithelial cells of the upper aerodigestive tract has thus far not been investigated. MATERIALS AND METHODS: We used the comet assay, as a well-established genotoxicity test, to investigate whether malathion, diazinon, pyridostigmine bromide, piperonyl butoxide, silafluofen, and fipronil had genotoxic effects on tonsil specimens taken from 85 patients. RESULTS: All substances tested proved to have a strong genotoxic effect on mucosal epithelial cells taken from human tonsil tissue. We found clear differences between substance groups. CONCLUSIONS: Sufficient doses of a wide range of insecticides are indispensable in many areas of human life, especially for the prevention of diseases. Depending on the method of application, however, ingestion or inhalation of these substances can damage mucosal epithelial cells of the upper aerodigestive tract. Further epidemiological studies should be undertaken to investigate whether this involves potential health hazards in at-risk populations.

Hospital infestation by the cluster fly, Pollenia rudis sensu stricto Fabricius 1794 (Diptera: Calliphoridae), and its possible role in transmission of bacterial pathogens in Germany.

The potential of the cluster fly, Pollenia rudis sensu stricto, to transmit bacterial pathogens was investigated during a mass infestation that took place in a German hospital. Cluster flies were individually examined for mesophilic bacteria carried on the exoskeleton. Bacterial growth could only be detected by using the enrichment culture technique to increase sensitivity, but not by direct intoculation of fly samples to agar plates. All 50 cluster fly samples that were tested carried opportunistic aerobic mesophilic Bacillus spp., whereas 41 fly samples were positive for Erwinia spp., 16 samples for Erwinia amylovara, 24 samples for Stenotrophomonas maltophilia, and 4 samples for Flavobacterium odoratum. Staphylococcus lugdunensis and Pseudomonas aeruginosa were found in 5 samples. No bacteriologically sterile cluster fly samples were obtained. The whole bacterial pattern found on P. rudis s. s. is known for its potential to cause opportunistic and/or nosocomial infections in humans. The results obtained led to the assumption that mass infestations of cluster flies occurring in sensitive areas, especially in hospitals, may cause a low, but not neglectable health threat due to mechanical transmission of bacterial pathogens.

Role of the moth fly Clogmia albipunctata (Diptera: Psychodinae) as a mechanical vector of bacterial pathogens in German hospitals.

BACKGROUND: The formerly Mediterranean moth fly species Clogmia albipunctata (Diptera: Psychodidae) is now present in Germany, where it has become a common, year-round pest in hospital buildings. AIM: To investigate the potential of C. albipunctata to transport and transmit bacterial pathogens in infested German hospitals. METHODS: From June 2011 to May 2012, 271 adult C. albipunctata were collected from four infested hospitals and analysed qualitatively and, in part, quantitatively, for bacterial colonization. Antimicrobial susceptibility testing was performed for selected nosocomial pathogens. FINDINGS: Forty-five bacterial species representing 40 genera were found to be colonizing C. albipunctata. Among the bacteria isolated were Acinetobacter baumannii, Aeromonas hydrophila, Alcaligenes faecalis, Bacillus cereus, Escherichia coli, Klebsiella pneumoniae ssp. pneumoniae, Pseudomonas aeruginosa, P. fluorescens and Stenotrophomonas maltophilia, with colonization rates of 0-17.5%, 0-16.7%, 0-12.5%, 0-62.1%, 0-2.5%, 0-4.1%, 0-12.5%, 0-7.6% and 0-10%, respectively. Additionally, one strain of both Yersinia frederiksenii and Nocardia spp. was detected. Unlike 11 strains of multi-drug-resistant (MDR) S. maltophilia collected from one hospital, no MDR Enterobacteriaceae were isolated. Acinetobacter spp. colonized C. albipunctata at rates from 2.9% to 36.8%, and revealed a high affinity for the exoskeleton, with up to 2080 colony-forming units per moth fly for A. baumannii. CONCLUSION: C. albipunctata is a potential mechanical vector of bacterial pathogens associated with nosocomial infections.

Hospital infestations by the moth fly, Clogmia albipunctata (Diptera: Psychodinae), in Germany.

The moth fly Clogmia albipunctata, formerly a Mediterranean species, is now present in Germany, at latitudes exceeding 53°N. Its synanthropic behaviour allows frequent, year-round infestations in hospital buildings. Hospital infestations have been most common in shower and rest rooms in patient wards, followed by cellar storage rooms, and then rest and shower rooms in hospital kitchens. Preferred breeding sites included hair-clogged sinks in patient shower cubicles, infrequently used toilets and urinals as well as water sources stemming from neglected leaking pipes, suggesting that enhanced hospital water and pest management are necessary for control.

The past and present threat of vector-borne diseases in deployed troops.

From time immemorial, vector-borne diseases have severely reduced the fighting capacity of armies and caused suspension or cancellation of military operations. Since World War I, infectious diseases have no longer been the main causes of morbidity and mortality among soldiers. However, most recent conflicts involving Western armies have occurred overseas, increasing the risk of vector-borne disease for the soldiers and for the displaced populations. The threat of vector-borne disease has changed with the progress in hygiene and disease control within the military: some diseases have lost their military significance (e.g. plague, yellow fever, and epidemic typhus); others remain of concern (e.g. malaria and dengue fever); and new potential threats have appeared (e.g. West Nile encephalitis and chikungunya fever). For this reason, vector control and personal protection strategies are always major requirements in ensuring the operational readiness of armed forces. Scientific progress has allowed a reduction in the impact of arthropod-borne diseases on military forces, but the threat is always present, and a failure in the context of vector control or in the application of personal protection measures could allow these diseases to have the same devastating impact on human health and military readiness as they did in the past.

The past and present threat of vector-borne diseases in deployed troops

From time immemorial, vector-borne diseases have severely reduced the fighting capacity of armies and caused suspension or cancellation of military operations. Since World War I, infectious diseases have no longer been the main causes of morbidity and mortality among soldiers. However, most recent conflicts involving Western armies have occurred overseas, increasing the risk of vector-borne disease for the soldiers and for the displaced populations. The threat of vector-borne disease has changed with the progress in hygiene and disease control within the military: some diseases have lost their military significance (e.g. plague, yellow fever, and epidemic typhus); others remain of concern (e.g. malaria and dengue fever); and new potential threats have appeared (e.g. West Nile encephalitis and chikungunya fever). For this reason, vector control and personal protection strategies are always major requirements in ensuring the operational readiness of armed forces. Scientific progress has allowed a reduction in the impact of arthropod-borne diseases on military forces, but the threat is always present, and a failure in the context of vector control or in the application of personal protection measures could allow these diseases to have the same devastating impact on human health and military readiness as they did in the past

Western blot as a tool in the diagnosis of Lyme borreliosis.

Borrelia burgdorferi is the causative agent of Lyme borreliosis, a multisystem disorder, which can mimic numerous immune disorders and inflammatory diseases. Laboratory diagnosis of Borrelia infection relies on immunodiagnostic assays, which, however, are hampered by unsatisfactory specificity. The Western blot technique has been employed to analyze the humoral immune response in Lyme borreliosis and is used as a serodiagnostic confirmation test. The most important immunodominant proteins of Borrelia burgdorferi are the 94 kDa, 60 kDa, 41 kDa (flagellin), 34 kDa (Osp B), 31 kDa (Osp A), 30 kDa, 21 kDa (Osp C), and 17/18 kDa proteins. Whereas the 60 kDa, 41 kDa, and 34 kDa constituents reveal a marked cross-antigenicity with other spirochetes and even more distantly related bacteria, antibodies against the 94 kDa, 31 kDa and 21 kDa proteins are largely species-specific. The early immune response in Lyme borreliosis is triggered mainly by the flagellin. In the later stage a wide range of immunogenic proteins is involved, with the 94 kDa antigen being the best marker for late immune response. If the Western blot is used for diagnostic purposes the differences between early and late-stage immunogenicity of Borrelia proteins must be taken into account. Interpretation criteria for blot positivity in early-stage borreliosis are primarily based on the presence of the 21 kDa band and the semiquantitatively recorded intensity of the 41 kDa band. In the diagnosis of late-stage infection, blot positivity relies on the presence of the 94 kDa, 39 kDa, 31 kDa, 30 kDa and 21 kDa bands.

Humoral immune response against Helicobacter pylori as determined by immunoblot.

An immunoblot method has been evaluated to diagnose Helicobacter pylori infection serologically by comparing 69 serum specimens from patients with a positive Gram stain and/or culture result and a positive urease test on biopsy material, as well as 51 serum specimens from patients with at least 4 negative urease tests, and negative microscopy and culture results. Sensitivity and specificity was found to be 100%. Recognition of the cross-reacting flagellin (66 kDa), flagellar sheath protein (51 kDa), and a 14 kDa protein are not a criterion for a current H. pylori infection. On the other hand, any combination of at least two of the 180, 120, 90, 75, 67, 29.5 and 19 kDa bands were diagnostic of infection. Three H. pylori strains, which were compared with both gel electrophoretic analyses and immunoblot reactivity, exhibited in part strong qualitative and quantitative differences that particularly affect the 120 kDa pathogenic factor, the large urease subunit and other proteins especially in the molecular mass range from 50 to 67 kDa. IgG immunoblot patterns showed that the choice of H. pylori strain, as well as a reproducible and standardizable antigen preparation, is of great importance for the reliability of serodiagnostic tests. The immunoblot method was found to be a valuable tool for the semi-quantitative confirmation of results achieved with other serological methods as well as optimization and quality control of the antigens used for serodiagnostic purposes.

Immunoblotting of Yersinia plasmid-encoded released proteins: a tool for serodiagnosis.

The plasmid-encoded, released proteins (RPs) of Yersinia enterocolitica serotypes 09 and 03 were separated by sodium dodecyl sulfate (SDS)-pore gradient gel electrophoresis. The RP-patterns of both serotypes proved to be identical. Five major proteins of M(r) 27,000, 34,700, 35,600, 45,800, and 46,800 were detected. Spontaneously plasmid-cured derivatives of the two serotypes lost the feature of protein release. By immunoblotting of RP with sera from patients suffering from acute Yersinia infections, specific and reproducible band patterns were obtained. Laser scan densitometry was applied to record the immunoreactions quantitatively. Predominant bands were detected at an M(r) of 34,700 and 35,600. IgA and IgM antibodies appeared as acute-phase markers rapidly decreasing in the reconvalescent phase. In contrast, immunoblots of patients with supposed chronic yersiniosis were characterized by a persisting IgA and elevated IgG reactivity. The application of RP as diagnostic antigens proved to be advantageous because they are naturally separated from cross-reacting proteins, common to pathogenic and nonpathogenic strains of Yersinia enterocolitica and Y. pseudotuberculosis.

Serodiagnosis of Helicobacter pylori infections by detection of immunoglobulin G antibodies using an immunoblot technique and enzyme immunoassay.

A transferable solid phase enzyme immunoassay (TSP-EIA) and an immunoblot technique were evaluated for the detection of IgG antibodies against Helicobacter pylori. Using the biopsy urease test as reference method, the sensitivity and specificity of the EIA were 96% and 100%, respectively. Immunoblot analysis was carried out by testing sera from patients with a positive urease test who suffered from type B gastritis, gastric and duodenal ulcers, and a negative control group. The immunoblotted Helicobacter pylori proteins showed reproducible immunoreactive bands at molecular weights of 130, 93, 75 and 67 kDa. The molecular weight protein fractions of Helicobacter pylori of 180 kDa and higher were found to be of minor immunological significance. Proteins of less than 60 kDa exhibited wide serum-specific variations in reactivity after immunostaining. No correlation between specific immunoblot patterns and clinical signs induced by Helicobacter pylori infection was observed.

Evaluation of an immunofluorescence assay for specific detection of immunoglobulin G antibodies directed against Helicobacter pylori, and antigenic cross-reactivity between H. pylori and Campylobacter jejuni.

An immunofluorescence assay (IFA) for the detection of immunoglobulin G antibodies directed against Helicobacter pylori was evaluated by comparing 20 serum specimens from patients with a positive urease test on biopsy material and 20 serum specimens from patients with a negative test and with defined clinical symptoms. The resulting anti-H. pylori titers were classified as follows: negative, less than or equal to 64; borderline, 128; and positive, greater than or equal to 256. By using these criteria, the IFA was subsequently tested, using 100 serum specimens from patients with gastric complaints. Overall, the titers were 71% positive, 10% borderline, and 19% negative. Depending on the patients' biopsy urease test results, the sensitivity and specificity of the assay were calculated to be 96%. Furthermore, these sera were classified into three subgroups on the basis of clinical manifestations: gastritis with 74% positive and 10% borderline titers, duodenal ulcer with 84% positive and 4% borderline titers, and gastric ulcer with 52% positive and 16% borderline titers. A serologic follow-up study was carried out with three patients with gastric ulcers who had been treated with colloidal bismuth subcitrate for 4 weeks and erythromycin for the final 2 weeks. The results indicate that a significant decrease in titer could be expected within 9 to 12 months after successful therapy, as determined by repeated negative CLO tests. Absorption experiments demonstrated that possible cross-reactivity between H. pylori and C. jejuni did not influence serodiagnosis.

Genotoxicity studies on permethrin, DEET and diazinon in primary human nasal mucosal cells.

Possible genotoxic effects exerted by three widely used pesticides, permethrin, N,N-diethyl-m-toluamide (DEET) and diazinon, in primary human nasal mucosal cells were investigated. Primary nasal mucosa cells were prepared from tissue biopsies taken from 21 patients who underwent nasal surgery. Cells were exposed to 0.5-1.0 mM concentrations of permethrin, DEET and diazinon for 60 min. Genotoxic effects were detected by the alkaline microgel electrophoresis assay ("comet assay"). Within the concentration range, no significant cytotoxic effects were observed, but all three tested pesticides showed a significant genotoxic response that was concentration dependent. More pronounced genotoxic effects were observed in mucosal cells from the middle turbinate than in the inferior turbinate. The results provide some evidence for the potential carcinogenicity of these agents to human nasal mucosal cells. This should be further investigated.

[Imported Anopheles: in the luggage or from the airplane? A case of severe autochthonous malaria tropica near an airport]. / Importierte Anopheles: im Gepäck oder aus dem Flugzeug? Ein Fall von schwerer autochthoner Malaria tropica in Flughafennähe.

HISTORY AND ADMISSION FINDINGS: A 67-year-old woman was admitted with pyrexia of unknown cause preceded by transitory peripheral pareses. She had not been to any malaria-infested regions. Within 4 days a "sepsis syndrome" developed with acute respiratory and renal failure. INVESTIGATIONS: Initially there were no pointers to organ involvement, either clinically or by ultrasound, in the electrocardiogram, radiographically or by computed tomography. Haematological and other laboratory tests indicated a bacterial infection. But 6 days after starting intensive treatment a blood smear revealed Plasmodium falciparum. TREATMENT AND COURSE: Administration of mefloquine and quinine quickly reduced the parasite count (from 10% to 1%), no parasite being found in the blood smear on the 5th day. But severe complications developed: perforation of a duodenal ulcer, exudative pancreatitis, cholangitis, diffuse bleeding into the large intestine and a chronic capillary leakage syndrome. But the patient was finally cured and discharged to a convalescent home after 160 days in hospital, 135 of them in intensive care. CONCLUSION: The source of the malaria could not be identified. "Baggage malaria" is more likely than the bite of a mosquito expelled from the "plane's undercarriage" well as it approached Frankfurt airport (the patient lived under one of the approach sectors, 30 km from the airport). As there are no screening procedures, imported malaria should be thought of in case of fever of unknown cause without history of foreign travel; a blood smear should be done.