[Exercise scenario of a highly contagious, life-threatening disease in intercontinental aviation : a case report in the context of the International Health Regulations (IHR)]. / Übungsszenario für eine hochkontagiöse, lebensbedrohliche Erkrankung in der interkontinentalen Personenluftfahrt : Eine Kasuistik vor dem Hintergrund der internationalen Gesundheitsvorschriften (IGV).

BACKGROUND: The International Health Regulations (IHR) 2005 were conformed to German law on July 20, 2007 and described in detail by the Implementing Act (IHR DG). According to these legal bases, "designated airports" must maintain special capacities for protection against health threats, and are also responsible for performing regular IHR exercises. OBJECTIVES: Representation of the optimization of established operational concepts of various professions to manage infectious biological threats without obstruction of international travel, and mediation of experience to IHR professionals. MATERIALS AND METHODS: An exercise based on the case scenario of a travel-related febrile illness was performed at Munich International Airport on November 11, 2013. Preparations took 6 months and the exercise itself lasted nearly 12 h. The follow-up lasted an additional 9 months. A qualitative and quantitative evaluation of the exercise was completed. RESULTS: From an Individual Medicine and Public Health perspective, modular work structures and risk communication functioned adequately. The medical examination of passengers was also well managed. Areas requiring further optimization included arrival/departure times of external actors, transport of the index patient to hospital and protective measures for individual participants. Overall, a defined biological threat scenario representing a double infection with two highly pathogenic germs was handled satisfactorily without affecting international air travel. CONCLUSIONS: Modular supply components are an effective and forward-looking means in protection against threats occurring at airports. Key success factors include sufficient staff mobility, immediate self-protection of actors involved, effective risk communication and a strong overall coordination and monitoring of the situation.

First isolation of Coxiella burnetii from clinical material by cell-free medium (ACCM2).

A disadvantage in Q fever diagnostics and research is the insensitive and difficult culture of Coxiella burnetii. This intracellular organism can only be isolated using embryonated eggs, animal hosts, or mammalian cell culture. In consequence, it has only been possible to isolate a few strains from human patients. Here, we describe the first isolation of C. burnetii from a clinical specimen using the recently developed cell-free medium acidified citrate cysteine medium 2 (ACCM2). We screened the sera of 217 patients who had undergone valvular transplantation but detected one serum with an antibody constellation indicating chronic Q fever. Polymerase chain reaction (PCR) of the corresponding heart valve revealed 3.1 × 10(5) copies/rxn. The strain was successfully isolated using ACCM2. Genomic investigation by multilocus variable-number of tandem repeat (VNTR) analysis (MLVA) revealed the strain to be a new genotype, A10, closely related to one from sheep. As the sensitivity of ACCM2 for different human strains is unknown, we also investigated combining a robust test, egg propagation, with ACCM2. This combination produced four to six logs of growth of the bacteria. The use of ACCM2 in this combination simplified the otherwise elaborate purification steps. Cultivation in ACCM2 has the potential to simplify the isolation of C. burnetii in a clinical setting. As the success rates of cell culture for virulent C. burnetii strains are variable, the sensitivity of ACCM2 for different strains is unknown, and many specimens may contain much fewer bacteria than in our case, the combination of the robust method of egg propagation with ACCM2 is a good alternative to existing single methods for investigating critical specimens.

Coxiella burnetii (Q fever) as a cause of community-acquired pneumonia during the warm season in Germany.

Q fever is a notifiable disease in Germany. The majority of the reported cases are related to outbreaks. The objective of our study was to evaluate the general role of Q fever in community-acquired pneumonia (CAP). We investigated respiratory samples and sera from 255 patients with CAP, who were enrolled into a CAPNETZ cohort in summer 2005. Altogether, our data showed a significant prevalence of Q fever as CAP (3·5%). If a patient's condition leads to a diagnostic test for Chlamydophila sp., Mycoplasma sp. or Legionella sp., then a Q fever diagnostic test should also be included. In particular, ELISA as a first diagnostic step is easy to perform. PCR should be performed at an early stage of the disease if no antibodies are detectable. Because of our highly promising findings we suggest performing PCR in respiratory samples.

Fatal anthrax infection in a heroin user from southern Germany, June 2012.

Blood cultures from a heroin user who died in June 2012, a few hours after hospital admission, due to acute septic disease, revealed the presence of Bacillus anthracis. This report describes the extended diagnosis by MALDI-TOF and real-time PCR and rapid confirmation of the anthrax infection through reference laboratories. Physicians and diagnostic laboratories were informed and alerted efficiently through the reporting channels of German public health institutions, which is essential for the prevention of further cases.

MLVA and SNP analysis identified a unique genetic cluster in Bulgarian Bacillus anthracis strains.

A collection of 40 Bacillus anthracis strains mostly isolated from soil in Bulgaria between 1960 and 1980 were investigated. All strains were proven to be B. anthracis by culture and amplification of a B. anthracis-specific chromosomal marker. PCR demonstrated that in nine strains both virulence plasmids (pX01+/pX02+) and in four strains only one plasmid (pX02+) were present, whereas the majority of strains (n = 27) lacked both plasmids (pX01-/pX02-). Multi-locus-variable number of tandem repeat-analysis (MLVA) using 15 markers differentiated three genotypes. Comparison with typing data of more than 1,000 different B. anthracis strains revealed that Bulgarian genotypes affiliated with the A1.a cluster and form their own unique cluster different from clusters containing strains isolated in geographical proximity, e.g., Turkey, Georgia, Hungary, Albania or Italy. In addition, a new allele of one marker (vrrC2) was identified. Canonical single nucleotide polymorphisms analysis allocated 31 Bulgarian strains into the A.Br.008/009 and nine strains into the A.Br.WNA group, which is the first description of B. anthracis strains of the A.Br.WNA group on the Eurasian continent.

Tularemia in Germany: the tip of the iceberg?

Tularemia is a rare, notifiable zoonosis in Germany. Since November 2004, several lines of evidence including outbreaks in humans or animals and confirmed infections in indigenous hare and rodent populations have indicated a re-emergence of tularemia in different German federal states. Unfortunately, reliable basic information on the seroprevalence in different geographical regions, permitting the identification of risk factors, does not exist. Combining a sensitive screening assay with a highly specific confirmative immunoblot test, we performed a serological investigation on 2416 sera from a population-based, cross-sectional health survey of the city population of Leutkirch, Baden-Wuerttemberg. A total of 56 sera gave positive results indicating a seroprevalence of 2.32%. Thus, the seroprevalence is tenfold higher than that previously reported in a nationwide study in 2004. Francisella tularensis can cause a wide variety of clinical syndromes including severe, sometimes fatal disease. Missing epidemiological data on its spatial and temporal distribution in an endemic country complicate an appropriate risk assessment necessary for public health authorities to be prepared for an adequate outbreak management. This is of special concern regarding the extraordinary potential of F. tularensis as an agent of bioterrorism. Our investigation performed in a presumed low-risk area demonstrated that tularemia might be seriously underestimated in Germany and probably in other central European countries as well.

'Imported' melioidosis in Germany: relapse after 10 years.

A 62-year-old German patient with insulin-dependent diabetes and diverticulitis was hospitalized for abdominal pain of the left lower quadrant. Further examination revealed an abdominal abscess, which was punctured. Presumptively a Pseudomonas species was identified, but further examination revealed Burkholderia pseudomallei as the causative agent. Most probably this infection was acquired in 1996 during a trip to Thailand, where the patient had been hospitalized. After combined chemotherapy and surgical revision of the abscess, the patient's condition improved. Clinicians and microbiologists have to keep in mind that in some tropical infections such as melioidosis relapse may occur after such a long time.

Immune electron-microscopy study of the trimeric glycoprotein (CD 103) of hairy cell leukemia using the Ber-ACT8 monoclonal antibody.

We describe a method which makes it possible to study the expression of the trimeric glycoprotein (TGP, CD 103) on the surface of hairy cells (HCs) by electron microscopy (e.m.). The monoclonal antibody (mAb) Ber-ACT8 was used to identify the TGP. By testing mucosa of the small intestine, we found that a prefixation incubation with Ber-ACT8 was necessary. After isolation with a density gradient, Ber-ACT8 incubation, and fixation, the peroxidase-anti-peroxidase (PAP) method was used to make the TGP visible. The HCs showed a clearly discernible stain on their surface, a fairly constant distribution of the TGP, and a very good ultrastructural preservation. This method makes it possible to demonstrate the TGP or other unfixable antigens by e.m.