Summer increase of Legionnaires' disease 2010 in The Netherlands associated with weather conditions and implications for source finding.

During August and September 2010 an unexpected high number of domestic cases of Legionnaires' disease (LD) were reported in The Netherlands. To examine this increase, patient characteristics and results of source finding and environmental sampling during the summer peak were compared to other domestic cases in 2008-2011. This analysis did not provide an explanation for the rise in cases. A similar increase in LD cases in 2006 was shown to be associated with warm and wet weather conditions, using an extended Poisson regression model with adjustment for long-term trends. This model was optimized with the new data from 2008 to 2011. The increase in 2010 was very accurately described by a model, which included temperature in the preceding 4 weeks, and precipitation in the preceding 2 weeks. These results confirm the strong association of LD incidence with weather conditions, but it remains unclear which environmental sources contributed to the 2010 summer increase.

Ectopic pregnancy through a caesarean scar in a ewe.

CASE HISTORY: A routine ultrasonographic examination for pregnancy diagnosis in a 3-year-old ewe revealed a normal embryo located in the uterine cavity and an abnormal mass located in the abdomen. At the time of examination, the ewe was 4.5 months pregnant, but 10 months previously she had undergone a caesarean section due to dystocia. CLINICAL FINDINGS: The abnormal mass (12 cm × 8 cm) was located outside the uterine cavity; it was anechoic at the periphery, and in the centre there was an echogenic embryo-like structure. Exploratory laparotomy was performed, which revealed an ectopic pregnancy through the caesarean scar. TREATMENT: The ectopic foetus was excised and the caesarean scar was repaired. The ewe made a complete recovery and the intrauterine pregnancy was completed to full-term, resulting in the birth of a healthy female lamb 35 days after the removal of the ectopic foetus. CLINICAL RELEVANCE: Ectopic pregnancies have previously been described in ewes. As far as the authors are aware, this is the first report of an ectopic pregnancy through a caesarean scar in sheep or any other farm animal species.

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.

Outbreak investigation of brucellosis in Thassos, Greece, 2008.

In spring 2008, the Hellenic Center for Disease Control and Prevention was notified about human brucellosis cases in Thassos, a Greek island that had been up to that point under a brucellosis eradication programme. Following the verification of the outbreak a 1:1 case­ control study was conducted in the island. The study revealed that consumption of locally produced raw cheese was a risk factor for Brucella melitensis infection (odds ratio (OR): 15.1, 95% confidence interval (CI): 6.56­34.7). Brucella melitensis biotype 3 was identified in two clinical samples. As a result of the outbreak, the island is no longer officially considered as an area with farms free of brucellosis and is currently under a brucellosis control programme. The investigation of this outbreak demonstrated that control and eradication of brucellosis is not only a question of designing a strategy, but rather of ensuring its continuous, strict implementation. Furthermore, it revealed the lack of appropriate education of the public regarding the risks associated with raw, non heat-treated cheese consumption.

Evaluation of Precision Xceed® meter for on-site monitoring of blood ß-hydroxybutyric acid and glucose concentrations in dairy sheep.

The accuracy of the Precision Xceed® hand-held meter as an on-site method for measuring blood ß-hydroxybutyric acid (BHBA) and glucose concentrations, for the diagnosis of pregnancy toxemia and ketosis in dry and lactating dairy sheep, was assessed. Five to eight hours after the start of the morning feed, blood was collected once from 193 clinically healthy sheep (143 dry and 50 lactating). BHBA and glucose analyses were performed with serum in the laboratory, and with whole blood with the Precision Xceed®. Overall, BHBA and glucose determinations by the two methods were not statistically different (P>0.05). Strongly significant positive correlations were found for glucose and BHBA concentrations between the Precision Xceed® and laboratory results (r=0.76, n=150, P<0.01 and r=0.99, n=193, P<0.01, respectively). The Precision Xceed® was highly sensitive (98.6%) and specific (98.2%), and had excellent test agreement for the detection of pregnancy toxemia and ketosis.

A waterborne Campylobacter jejuni outbreak on a Greek island.

A case-control and a case-crossover study were performed to investigate a Campylobacter jejuni outbreak in Crete in 2009. Most cases originated from rural areas, served by a different water-supply system from that of the adjacent town. Thirty-seven cases and 79 controls were interviewed; cases were interviewed for two different time periods for the case-crossover study. Stool cultures, PFGE and MLST subtyping were run in human samples. Univariately, consumption of tap water was associated with C. jejuni infection. Stratified analysis revealed that water-supply system was an effect modifier of this association. In the multivariable analysis, the rural areas' water supplier and drinking tap water were risk factors. No risk factors were revealed in the case-crossover study. No Campylobacter were isolated in the tested water samples. There is strong epidemiological evidence that tap water was the vehicle of the outbreak.

Compliance with boil water advice following a water contamination incident in the Netherlands in 2007.

In May 2007, Escherichia coli was detected in tap water supplied by a company in North Holland. The company issued advice through mass media to boil tap water before consumption; this advice was lifted six days later. A cross-sectional study was implemented to investigate compliance among residents in this area. Based on postcode, a total of 300 households, chosen randomly from a database of a private company performing internet-based surveys for different marketing purposes, were sent a self-administered questionnaire for this study. The questionnaire contained questions on demographic information, source of information regarding the advice, response to it and personal opinions on the company's reaction and the advice. Ninety-nine (66%) households of the affected area and 90 (60%) households from non-affected areas served by the same company replied to the survey. All respondents knew about the advice. 81.8% of the respondents in the affected area and 5.6% of the non-affected areas reported complying with the advisory. Most respondents from the affected area still used unboiled water to brush teeth, wash salads and wash fruit. There was no difference in compliance between men and women. Using the mass media was proved to be efficient to inform the public and could be used in the future in similar settings. However, more detailed wording of boiling advice should be considered in the future.

Investigation of a Q fever outbreak in a rural area of The Netherlands.

A Q fever outbreak occurred in the southeast of The Netherlands in spring and summer 2007. Risk factors for the acquisition of a recent Coxiella burnetii infection were studied. In total, 696 inhabitants in the cluster area were invited to complete a questionnaire and provide a blood sample for serological testing of IgG and IgM phases I and II antibodies against C. burnetii, in order to recruit seronegative controls for a case-control study. Questionnaires were also sent to 35 previously identified clinical cases. Limited environmental sampling focused on two goat farms in the area. Living in the east of the cluster area, in which a positive goat farm, cattle and small ruminants were situated, smoking and contact with agricultural products were associated with a recent infection. Information leaflets were distributed on a large scale to ruminant farms, including hygiene measures to reduce the risk of spread between animals and to humans.

Warm, wet weather associated with increased Legionnaires' disease incidence in The Netherlands.

It has been suggested that warm and humid weather is related to a high incidence of Legionnaires' disease (LD), but no data on this association existed in The Netherlands. The objective of this study was to investigate the short-term effects of the weather on LD in The Netherlands. National LD surveillance and meteorological data were obtained. We analysed the data using Poisson regression, adjusting for long-term trends, and using principal components analysis. The highest weekly incidence of LD occurred when the mean weekly temperature was +17.5 degrees C. Mean weekly relative humidity, temperature and precipitation intensity were associated with LD incidence in the multivariable model. Warm, humid and showery summer weather was found to be associated with higher incidence of LD in The Netherlands. These results may be used to predict an increase in the number of cases of LD in The Netherlands during the summer.

Factors influencing influenza vaccination rates among healthcare workers in Greek hospitals.

Influenza vaccination rates are generally low among healthcare workers (HCWs) worldwide. In September 2005, the Hellenic Center for Disease Control and Prevention conducted a nationwide campaign to promote influenza vaccination in hospital HCWs. During the 2005-2006 influenza season, the overall vaccination rate among HCWs was 16.36% (range: 0-85.96%). The self-reported vaccination rate during the previous season was 1.72%, indicating a 9.5-fold increase. Compared with physicians, significantly fewer technical personnel were vaccinated, whereas administrative personnel were more likely to receive the vaccine. Among clinicians, rates for internal medicine departments exceeded those of surgical departments by a factor of 2.71 and laboratory medicine departments by a factor of 2.36. Multivariate analysis showed lower vaccination rates in large hospitals (>200 beds) than in smaller hospitals and lower rates in hospitals with specialist services (intensive care unit, psychiatry or dermatology) than in general hospitals. Factors associated with higher rates included working in northern Greece, in a paediatric or an oncology hospital, or in a prefecture with avian influenza H5N1 activity. In conclusion, in Greece influenza vaccination rates among HCWs remain low, but the implementation of a nationwide campaign had a considerable impact. Efforts should focus on hospital- and HCW-associated factors to increase vaccination uptake.