Ecological and clinical evidence of the establishment of West Nile virus in a large urban area in Europe, Berlin, Germany, 2021 to 2022.

BackgroundWest Nile virus (WNV), found in Berlin in birds since 2018 and humans since 2019, is a mosquito-borne virus that can manifest in humans as West Nile fever (WNF) or neuroinvasive disease (WNND). However, human WNV infections and associated disease are likely underdiagnosed.AimWe aimed to identify and genetically characterise WNV infections in humans and mosquitoes in Berlin.MethodsWe investigated acute WNV infection cases reported to the State Office for Health and Social Affairs Berlin in 2021 and analysed cerebrospinal fluid (CSF) samples from patients with encephalitis of unknown aetiology (n = 489) for the presence of WNV. Mosquitoes were trapped at identified potential exposure sites of cases and examined for WNV infection.ResultsWest Nile virus was isolated and sequenced from a blood donor with WNF, a symptomatic patient with WNND and a WNND case retrospectively identified from testing CSF. All cases occurred in 2021 and had no history of travel 14 days prior to symptom onset (incubation period of the disease). We detected WNV in Culex pipiens mosquitoes sampled at the exposure site of one case in 2021, and in 2022. Genome analyses revealed a monophyletic Berlin-specific virus clade in which two enzootic mosquito-associated variants can be delineated based on tree topology and presence of single nucleotide variants. Both variants have highly identical counterparts in human cases indicating local acquisition of infection.ConclusionOur study provides evidence that autochthonous WNV lineage 2 infections occurred in Berlin and the virus has established an endemic maintenance cycle.

A shift from travel-associated cases to autochthonous transmission with Berlin as epicentre of the monkeypox outbreak in Germany, May to June 2022.

By 22 June 2022, 521 cases of monkeypox were notified in Germany. The median age was 38 years (IQR: 32-44); all cases were men. In Berlin, where 69% of all cases occurred, almost all were men who have sex with men. Monkeypox virus likely circulated unrecognised in Berlin before early May. Since mid-May, we observed a shift from travel-associated infections to mainly autochthonous transmission that predominantly took place in Berlin, often in association with visits to clubs and parties.

[Healthcare-associated infections and antimicrobial use in long-term care facilities. German results of the third European point prevalence survey HALT-3]. / Nosokomiale Infektionen und Antibiotikaanwendung in Langzeitpflegeeinrichtungen. Deutsche Ergebnisse der dritten europäischen Punkt-Prävalenz-Erhebung HALT-3.

BACKGROUND AND OBJECTIVE: The essential role of infection prevention in long-term care facilities has become evident during the current SARS-CoV­2 pandemic. In order to obtain a reliable database on nosocomial infections and antibiotic use, the European Centre for Disease Prevention and Control (ECDC) initiated the third point prevalence survey in European long-term care facilities from 2016 to 2017 (HALT-3). MATERIAL AND METHODS: In Germany, 131 facilities with 10,565 residents participated voluntarily. On a single day in 2016, the number of nosocomial infections and/or uses of antibiotics as well as care characteristics and risk factors of the residents were recorded. Infections were documented based on symptoms using an algorithm in accordance with the McGeer surveillance criteria for long-term care facilities. RESULTS: A nosocomial infection was documented in 177 residents, which corresponds to a prevalence of 1.7% (95% CI: 1.3-2.1), still low in comparison with the European prevalence (mean value 3.9%). Urinary tract infections were the most common infections at almost 50%, followed by respiratory, skin, and soft-tissue infections. The type of infection was consistent with the most common indications for antibiotic use. Antibiotic use was documented in 143 residents (prevalence of 1.4%, 95% CI: 1.1-1.7). The frequent use of fluoroquinolones with over 20% of all prescriptions was noticeable. CONCLUSIONS: The establishment of facility-based surveillance of the most common infections and antibiotic consumption, together with the creation of guidelines specifically tailored to the geriatric population, could contribute to improving infection prevention and control as well as a more rational use of antibiotics, thus increasing the quality and safety of care.

Severe Acute Respiratory Syndrome Coronavirus 2 Outbreak Related to a Nightclub, Germany, 2020.

We report an outbreak of coronavirus disease with 74 cases related to a nightclub in Germany in March 2020. Staff members were particularly affected (attack rate 56%) and likely caused sustained viral transmission after an event at the club. This outbreak illustrates the potential for superspreader events and corroborates current club closures.

Resurgence of an international hepatitis A outbreak linked to imported frozen strawberries, Germany, 2018 to 2020.

Following outbreaks linked to frozen strawberries in Sweden and Austria in 2018, 65 cases linked to the same hepatitis A virus strain were detected in Germany between October 2018 and January 2020, presenting in two waves. Two case-control studies and a comparison of cases' consumption frequencies with purchase data from a large consumer panel provided strong evidence for frozen strawberry cake as the main vehicle of transmission. Of 46 cases interviewed, 27 reported consuming frozen strawberry cake and 25 of these identified cake(s) from brand A spontaneously or in product picture-assisted recall. Trace back investigations revealed that the Polish producer involved in the previous outbreaks in Sweden and Austria had received frozen strawberries from Egypt via a wholesaler that also delivered frozen strawberries to manufacturer of brand A. Phylogenetic analyses linked the outbreak strain to similar strains formerly isolated from sewage, stool and strawberries in Egypt. Complete trace back and timely recall of products with strong evidence of contamination is important to control an outbreak and prevent later resurgence, particularly for food items with a long shelf life. Continued molecular surveillance of hepatitis A is needed to identify outbreaks and monitor the success of food safety interventions.

Dating apps and websites as tools to reach anonymous sexual contacts during an outbreak of hepatitis A among men who have sex with men, Berlin, 2017.

BackgroundIn an outbreak of hepatitis A among men who have sex with men (MSM) in Berlin (2016 and 2017), patients frequently reported anonymous sex and use of dating applications to meet sexual contacts, hampering tracing and vaccination of contacts.AimOur objective was to evaluate dating apps and websites as a means of spreading prevention messages among MSM during the ongoing outbreak.MethodsAdvertisements in different formats were placed on three MSM dating apps and eight websites for anonymous dating during three weeks in March and April 2017. We calculated frequency of ads shown and click-through rates (CTR) and investigated the independent effect of format and platform on the number of clicks using a negative binomial regression model. We evaluated the campaign's impact using a survey among visitors of a large gay-lesbian street-festival in Berlin.ResultsOverall, 1,920,180 ads were shown and clicked on 8,831 times (CTR = 0.46%). The multivariable model showed significantly more clicks on one dating app (incidence rate ratio (IRR) = 9.5; 95% confidence interval (CI): 7.7-12.2) than on websites and on full-screen ads (IRR = 3.1; 95% CI: 2.5-3.8) than on banner ads. Of 266 MSM who participated in the survey, 190 (71%) knew about the outbreak and 39 (15%) declared to have been vaccinated recently because of the campaign.ConclusionsDating apps provided a means to rapidly reach and influence a substantial number of MSM in Berlin and should complement case-based contact tracing among MSM in outbreak settings. Clicking on ads depended on platform and format used.

[Healthcare-associated infections and antimicrobial use in long term care facilities (HALT-2): German results of the second European prevalence survey]. / Healthcare-associated infections and antimicrobial use in long term care facilities (HALT-2) : Deutsche Ergebnisse der zweiten europäischen Prävalenzerhebung.

Prevention of infections and strategies for the prudent use of antimicrobials in long-term care facilities have gained importance in view of the demographic changes, not only in Germany. To generate appropriate data and to identify relevant aspects of infection prevention in this field, the European Centre for Disease Prevention and Control (ECDC) launched the second point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities in 2013 (HALT-2). Despite methodical adjustments in the collection of data on healthcare-associated infections, in this second survey healthcare workers in the participating facilities were intensively trained in methodology and data collection. Overall, 221 German facilities participated and collected data from 17,208 residents. Well-established structures of regional networks facilitated the recruitment of participants as well as the preparations for training and survey. The median prevalence of residents receiving at least one antimicrobial agent was 1.1% (95 %-CI 0,7-1,6)), which is remarkably low. However, the most frequently used antimicrobials in German facilities beside beta-lactams (penicillins 18.2%, other beta-lactams 17.2%) were quinolones (28.2%). Data collection of infections was performed based on signs and symptoms in detailed decision algorithms according to the recently updated McGeer surveillance criteria and yielded a median prevalence of 1.7% (95 %-CI 1,1-2,2). Symptomatic urinary tract infections (28.4%), skin and soft tissue infection (27.9%), and respiratory tract infections (24.7%) were identified both as the most common types of infections and the most common indications for the use of systemic antimicrobials. Clinical implications evolve mainly from the high use of quinolones. In terms of infection prevention measures, compliance of health care workers with a hand hygiene regimen revealed further potential for improvement.

Inguinal skin colonization with multidrug-resistant bacteria among residents of elderly care facilities: frequency, persistence, molecular analysis and clinical impact.

Frequency, persistence and molecular characteristics of multidrug resistant bacteria colonizing inhabitants of long term care facilities are topics of current concern. We performed a point-prevalence survey of 402 residents in 7 elderly care facilities in Berlin, Germany. Inguinal swabs were analyzed for the presence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and multidrug-resistant gram-negative bacteria. Three and six months following the initial investigation, all colonized residents were sampled again and the occurrence of intercurrent infections, hospital admissions and use of antimicrobials were registered. Genetic relatedness of the bacteria was investigated using multi-locus sequence typing (MLST), spa-typing and SmaI/XbaI-macrorestriction analysis. 33 (8.2%) residents were skin-colonized with multidrug-resistant bacteria. MRSA were found in 19 (4.7%) and ESBL-producing Enterobacteriaceae in 16 residents (3.98%). Independent risk factors for colonization with multidrug-resistant bacteria were a high level of care and the presence of chronic wounds. A large proportion of the observed bacteria persisted up to six months and showed a high degree of inter-individual diversity. Outcome analysis revealed that infections tend to occur slightly more often in residents colonized by multiresistant pathogens. We assume that a perceptible population of residents in nursing homes is at risk for individual colonization with multidrug-resistant bacteria as well as healthcare associated infections.

Analysis of two choir outbreaks acting in concert to characterize long- range transmission risks through SARS-CoV-2, Berlin, Germany, 2020.

BACKGROUND: Superspreading events are important drivers of the SARS-CoV-2 pandemic and long-range (LR) transmission is believed to play a major role. We investigated two choir outbreaks with different attack rates (AR) to analyze the contribution of LR transmission and highlight important measures for prevention. METHODS: We conducted two retrospective cohort studies and obtained demographic, clinical, laboratory and contact data, performed SARS-CoV-2 serology, whole genome sequencing (WGS), calculated LR transmission probabilities, measured particle emissions of selected choir members, and calculated particle air concentrations and inhalation doses. RESULTS: We included 65 (84%) and 42 (100%) members of choirs 1 and 2, respectively, of whom 58 (89%) and 10 (24%) became cases. WGS confirmed strain identity in both choirs. Both primary cases transmitted presymptomatically. Particle emission rate when singing was 7 times higher compared to talking. In choir 1, the median concentration of primary cases' emitted particles in the room was estimated to be 8 times higher, exposure at least 30 minutes longer and room volume smaller than in choir 2, resulting in markedly different estimated probabilities for LR transmission (mode: 90% vs. 16%, 95% CI: 80-95% vs. 6-36%). According to a risk model, the first transmission in choir 1 occurred likely after 8 minutes of singing. CONCLUSIONS: The attack rate of the two choirs differed significantly reflecting the differences in LR transmission risks. The pooled proportion of cases due to LR transmission was substantial (81%; 55/68 cases) and was facilitated by likely highly infectious primary cases, high particle emission rates, and indoor rehearsing for an extended time. Even in large rooms, singing of an infectious person may lead to secondary infections through LR exposure within minutes. In the context of indoor gatherings without mask-wearing and waning or insufficient immunity, these results highlight the ongoing importance of non-pharmaceutical interventions wherever aerosols can accumulate.

Hepatitis A outbreak among MSM in Berlin due to low vaccination coverage: Epidemiology, management, and successful interventions.

OBJECTIVES: To describe the characteristics of a large hepatitis A virus (HAV) outbreak among men who have sex with men (MSM) in Berlin and to assess the impact of measures implemented. METHODS: Cases of laboratory-confirmed, symptomatic HAV infection notified in Berlin, Germany between August 2016 and February 2018 were analysed using routine and enhanced surveillance data including genotyping results. Several studies involving different groups of participants were conducted to further investigate the outbreak, including surveys on knowledge and practices of HAV vaccination among physicians and vaccination coverage and determinants of vaccination status among MSM. The measures implemented were categorized by target group in a Gantt chart. To assess their impact, health insurance data on HAV vaccination uptake were analysed, comparing Berlin and other federal states. RESULTS: During the outbreak period, a total of 222 cases were reported (of which 91 were sequence-confirmed), with a peak in case numbers in January 2017. Physicians were aware of the existing vaccination recommendations, but vaccination coverage among 756 MSM was low, with 32.7% being completely vaccinated and 17.3% being incompletely vaccinated before 2017. HAV vaccination before 2017 was associated with being born in Germany (odds ratio 2.36) and HIV-positive (odds ratio 1.80). HAV monovalent vaccination uptake increased by 164% from 2016 to 2017 among males in Berlin, compared to 7% in other federal states. CONCLUSIONS: Multiple measures targeting the MSM community, physicians, and public health to increase HAV vaccination uptake were successfully implemented. To prevent future HAV outbreaks, we recommend monitoring vaccination coverage among MSM, promoting awareness of existing recommendations among physicians, and ensuring access for foreign-born and young MSM.

Comparative molecular analysis substantiates zoonotic potential of equine methicillin-resistant Staphylococcus aureus.

Despite the increasing importance of methicillin-resistant Staphylococcus aureus (MRSA) in veterinary medicine, knowledge about the epidemiology of the pathogen in horses is still poor. The phylogenetic relationship of strains of human and equine origins has been addressed before, usually by analyzing results of common standard classification methods for MRSA. This work intends to go beyond the baseline of typing procedures in order to comparatively characterize equine and human MRSA strains with similar phylogenetic backgrounds. In addition to multilocus sequence typing, pulsed-field gel electrophoresis, spa typing, staphylococcal cassette chromosome mec typing, and a PCR for Panton-Valentine leukocidin gene detection, a microarray analysis of a total of 185 structural, virulence-associated, and resistance loci was applied. The results showed that clonal complex 8 (CC8) was absolutely predominant (16 strains) in 19 investigated equine MRSA strains. Of the CC8 strains, 13 belonged to sequence type 254 (ST254) and the other 3 to ST8. This genotype has been isolated from different equine patients in various regions over several years, substantiating the apparent predominance of CC8 STs in MRSA strains of horses worldwide. Furthermore, comparatively investigated human strains of ST254 displayed molecular-typing results indistinguishable from those for strains of equine origin. Two further equine strains (ST22 and ST1117) showed similarity to ST22 human strains (CC22). One equine strain belonged to ST398, a genotype recently described as being frequently isolated from specimens from pigs and pig farmers. These data provide evidence for the adaptation of certain MRSA genotypes to more than one mammalian species, reflecting their extended host spectra.

Prevalence of Methicillin-resistant Staphylococcus pseudintermedius isolated from clinical samples of companion animals and equidaes.

In this study the prevalence of Methicillin-resistant Staphylococcus pseudintermedius (MRSP) in clinical specimens of different animal species was defined by investigating a total of 16,103 clinical samples originating from veterinary facilities of five German federal states in 2007. Of all samples examined, 72 were positive for MRSP, giving an overall prevalence of 0.45%. In clinical specimens originating from small animals the prevalence was 0.58% (n=67; dogs n=61 and cats n=6), while samples from equidaes revealed a prevalence of 0.10% (n=5; horses n=4, donkey n=1). Forty-six representative phenotypically identified MRSP were further differentiated by DNA-based species assignment, PCR detection of mecA, SCCmec-typing and MIC determination. As expected, all 46 isolates were unambiguously proven to be MRSP by sequencing of housekeeping genes pta and cpn60 and being positive for mecA. Furthermore, all isolates harboured the mobile staphylococcal cassette chromosome mec (SCCmec) SCCmecIII. Antibiotic susceptibility testing for 20 different conventional antimicrobial agents disclosed a high rate of multidrug-resistant isolates (45 of 46) displaying an identical or at least similar resistance pattern for non-beta-lactam antimicrobials. The recognized prevalence of MRSP, which have already been shown to be potential zoonotic agents, reflects the recently emerging development of these serious and often multidrug-resistant pathogens in Germany.

Multidrug- and methicillin resistant Staphylococcus pseudintermedius as a cause of canine pyoderma: a case report.

A case of a dog with a long-term inflammatory skin disorder due to infection with methicillin-resistant Staphylococcus pseudintermedius (MRSP) is described. After initial diagnostics of MRSP, follow-up swabs of the dog (nose, skin) were taken twice after four and seven weeks. MRSP was constantly isolated from the skin and once from the nose. Since infected humans might be a source of reinfection, the owners of the dog were screened (nasal) three times during their pet's therapy. Thereby, the male owner was found to be colonized with MRSP once in the first sampling round. Comparative typing of all MRSP-isolates by pulsed-field gel electrophoresis (PFGE), SCCmec typing, multilocus sequence typing (MLST), spa typing, PCR-detection of the leukotoxin encoding operon (LukI) and the Staphylococcus intermedius-exfoliative toxin (SIET) as well as antimicrobial resistance profiling by broth microdilution revealed that all five MRSP isolates from the dog and the single isolate from the owner were indistinguishable by any of the applied methods. All isolates were assigned to a certain strain, a multidrug-resistant MRSP belonging to sequence type (ST) 71, spa type (t)05, harbouring SCCmecIII as well as the genes encoding LukI and SIET. In this case, a number of reasons might have contributed to therapy failure and re-infection, respectively (e. g. contact to other MRSP-colonized dogs, contact to MRSP-colonized humans, refusal to clip the dog's fur). In addition, MRSP-contaminated objects or surfaces in the household, which were difficult to disinfect or simply not considered as a potential source of MRSP, might have served as a source of re-infection. These results envision the possibility of a dog-to-human transmission of MRSP and the relevance of this aspect as a potential source of re-infection in cases of bacterial-supported long-term skin disorders in canine patients. First cases of MRSP infections in humans have been described only recently. However, the general pathogenic potential of multidrug resistant MRSP in humans is unknown so far and needs further investigation.

Widespread rapid emergence of a distinct methicillin- and multidrug-resistant Staphylococcus pseudintermedius (MRSP) genetic lineage in Europe.

In order to gain a deeper insight into the phylogenetic background and diversity of methicillin-resistant S. pseudintermedius (MRSP) of animal origin, genetic relationships and clonal distribution among 146 European MRSP were examined using different molecular and phenotypical typing approaches. MRSP strains were derived from clinical microbiological specimens (mainly of small animal origin) sent in for diagnostic purposes from various veterinary facilities between 2005 and 2008. Pulsed-field gel electrophoresis (PFGE) of SmaI-macrorestriction fragments allowed differentiation of five PFGE-clusters that were subdivided into further distinct subtypes. Representatives of each PFGE subtype were analyzed by multilocus sequence typing (MLST) for assignment of sequence types (ST). With one exception (ST5), all these MRSP strains belonged to ST71. Furthermore, assessment of spa-typing results revealed that the majority of all strains harboured spa type t02. Further sporadically detected spa types t05 and t06 as well as two new types (t15 and t23), were found to be closely related to t02. According to PCR-based SCCmec-typing, SCCmecIII was the most prevalent type (n=138), and solely one non-typeable variant was identified in several strains (n=8). In addition, all strains were tested positive by PCR for the leukotoxin encoding operon LukI and the Staphylococcus intermedius-exfoliative toxin (SIET), respectively. Our cumulative data indicate a recent emergence of a certain multidrug-resistant MRSP-lineage (ST71) in central and southern European countries during the last few years.