Large multistate outbreak of norovirus gastroenteritis associated with frozen strawberries, Germany, 2012.

From 20 September through 5 October 2012, the largest recorded food-borne outbreak in Germany occurred. Norovirus was identified as the causative agent. We conducted four analytical epidemiological studies, two case­control studies and two surveys (in total 150 cases) in secondary schools in three different federal states. Overall, 390 institutions in five federal states reported nearly 11,000 cases of gastroenteritis. They were predominantly schools and childcare facilities and were supplied almost exclusively by one large catering company. The analytical epidemiological studies consistently identified dishes containing strawberries as the most likely vehicle, with estimated odds ratios ranging from 2.6 to 45.4. The dishes had been prepared in different regional kitchens of the catering company and were served in the schools two days before the peaks of the respective outbreaks. All affected institutions had received strawberries of one lot, imported frozen from China. The outbreak vehicle was identified within a week, which led to a timely recall and prevented more than half of the lot from reaching the consumer. This outbreak exemplifies the risk of large outbreaks in the era of global food trade. It underlines the importance of timely surveillance and epidemiological outbreak investigations for food safety.

The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009.

Tuberculosis (TB) surveillance commonly focuses on pulmonary (PTB) where the main organ affected is the lung. This might lead to underestimate extrapulmonary TB (EPTB) forms, where in addition to the lung other sites are affected by TB. In Germany, TB notification data provide the main site and the secondary site of disease. To gain an overview of all the different EPTB forms, we analysed German TB notification data between 2002 and 2009 using information on both main and secondary disease site to describe all individual EPTB forms. Further, we assessed factors associated with meningitis using multivariable logistic regression. Solely analysing the main site of disease, lead to one third of EPTB manifestations being overlooked. Case characteristics varied substantially across individual extrapulmonary forms. Of 46,349 TB patients, 422 (0.9%) had meningitis as main or secondary site. Of those, 105 (25%) of the 415 with available information had died. Multivariable analysis showed that meningitis was more likely in children younger than five years and between five and nine years-old (odds ratio (OR): 4.90; 95% confidence interval (CI): 3.40­7.07 and OR: 2.65; 95% CI: 1.40­5.00), in females (OR: 1.42; 95% CI: 1.17­1.73), and in those born in the World Health Organization (WHO) regions of south-east Asia (OR: 2.38; 95% CI: 1.66­3.43) and eastern Mediterranean (OR: 1.51; 95% CI: 1.02­2.23). Overall, EPTB manifestations, including meningitis, which is often fatal, were underestimated by routine analysis. We thus recommend using all information on disease manifestation generated by surveillance to monitor severe forms and to transfer the gained knowledge to TB case management where awareness of EPTB is most important.

Large hospital outbreak of KPC-2-producing Klebsiella pneumoniae: investigating mortality and the impact of screening for KPC-2 with polymerase chain reaction.

BACKGROUND: Multi-drug-resistant Klebsiella pneumoniae carbapenemase (KPC)-2-producing K. pneumoniae are an increasing cause of healthcare-associated infections worldwide. AIMS: To investigate the impact of clinical infection on mortality, and examine the effect of use of KPC-2-specific polymerase chain reaction (PCR) on the time to contact isolation during an outbreak. METHODS: Cases were defined as patients clinically infected or colonized with KPC-2-producing K. pneumoniae between June 2010 and July 2012. Cases were described by demographic and health characteristics, and the association between infection and mortality, adjusted for comorbidities and demographic characteristics, was determined using Poisson regression with robust standard errors. A comparison was made between the time to contact isolation with a culture-based method and PCR using Wilcoxon's rank sum test. FINDINGS: Of 72 cases detected, 17 (24%) had undergone transplantation and 21 (29%) had a malignancy. Overall, 35 (49%) cases were clinically infected, with pneumonia and sepsis being the most common infections. Infection was an independent risk factor for mortality (risk ratio 1.67, 95% confidence interval 0.99-2.82). The median time to contact isolation was 1.5 days (range 0-21 days) using PCR and 5.0 days (range 0-39 days) using culture-based methods (P = 0.003). Intermittent negative tests were observed in 48% (14/29) of cases tested using culture-based methods. CONCLUSION: KPC-2-producing K. pneumoniae mainly affect severely ill patients. Half of the cases developed clinical infection, associated with increased risk of death. As PCR accelerates isolation and provides the opportunity for preventive measures in colonized cases, its use should be implemented promptly during outbreaks. Further studies are needed to enhance knowledge about KPC detection patterns and to adjust screening guidelines.