Tularaemia in southwest Germany: Three cases of tick-borne transmission.

Tularaemia, caused by Francisella tularensis, is an endemic zoonosis frequently occurring in southwest Germany. Since 2005 there is an increase in the number of reported cases of tularaemia in Germany. We report on two cases of ulceroglandular tularaemia and one case of glandular tularaemia that occurred in the summer of 2012 and 2013 in two counties in the Federal State of Baden-Wuerttemberg. Bacteria were transmitted through tick bites, which to date has only rarely been reported in Germany. Inadequate treatment of the patients and an aggravation of clinical symptoms were caused by a delay between disease onset and the detection of the pathogen. Although contact to or consumption of infected hares are the most often reported transmission routes of tularaemia in Germany, tick-bites should also be taken into account. Health professionals should include Francisella tularensis in the differential diagnosis of patients with fever and/or ulcerative lymphadenopathy following a tick bite.

Measles virus spread initiated at international mass gatherings in Europe, 2011.

Three parallel transmission chains of measles virus (MV) variant 'D8-Villupuram' (D8-V) originated from two coinciding international mass gathering (MG) events in Rimini, Italy, in June 2011. MV D8-V was independently introduced into Germany by two unvaccinated persons, and into Slovenia by one unvaccinated person who had attended these events. Secondary spread of D8-V was restricted to two generations of transmission in Slovenia as well as in Germany where the virus was further disseminated at another MG. Serological and epidemiological investigation of the D8-V-associated German and Slovenian cases revealed different antibody responses and age distributions. Primary infected young persons between 11 and 27 years-old were affected in Germany, whereas the group of Slovenian cases comprised adults aged from 28 to 47 years and a high proportion (9/14; 64%) of patients with secondary vaccine failure (SVF). Our study demonstrates that monitoring of MV transmission chains in an international context and adequate serological investigation of cases with remote vaccination can contribute to identify susceptibility gaps.

Rise in the number of notified human hantavirus infections since October 2011 in Baden-Wurttemberg, Germany.

From October 2011 to April 2012, 852 human hantavirus infections were notified in Germany, of which 580 (68%) were in Baden-Württemberg. Case numbers started to rise earlier than they did before the previous outbreaks in 2007 and 2010, and are the largest ever reported in this state during October to April of any year. The early rise could be due to a beech mast year in 2011, followed by an early and massive reproduction of the reservoir bank vole populations during winter 2011 and spring 2012.

Steep rise in notified hantavirus infections in Germany, April 2010.

From January to April 2010, 396 hantavirus infections were notified in Germany, a considerable increase compared with previous years (mean: 83 for January-April 2004-2009) including the record-setting year, 2007 (n=232 January-April). Most patients are residents of known Puumala virus endemic areas in southern Germany. The recent increase in notified hantavirus infections is probably due to an increased population density of the main animal reservoir, the bank vole (Myodes glareolus).

Update: Multinational listeriosis outbreak due to 'Quargel', a sour milk curd cheese, caused by two different L. monocytogenes serotype 1/2a strains, 2009-2010.

We previously reported an outbreak of listeriosis in Austria and Germany due to consumption of Quargel cheese. It comprised 14 cases (including five fatalities) infected by a serotype 1/2a Listeria monocytogenes (clone 1), with onset of illness from June 2009 to January 2010. A second strain of L. monocytogenes serotype 1/2a (clone 2) spread by this product could be linked to further 13 cases in Austria (two fatal), six in Germany (one fatal) and one case in the Czech Republic, with onset of disease from December 2009 to end of February 2010.

Listeriosis outbreak caused by acid curd cheese Quargel , Austria and Germany 2009.

We report an outbreak of listeriosis in Austria and Germany due to the consumption of Quargel cheese produced by an Austrian manufacturer. At the time of writing this report, the outbreak was known to account for 14 outbreak cases in 2009, including four cases with lethal outcome. On 23 January 2010, the cheese product was voluntarily withdrawn from the market.

Prolonged hospital and community-based listeriosis outbreak caused by ready-to-eat scalded sausages.

Listeria monocytogenes is a foodborne bacterial pathogen. Immunocompromised patients are at higher risk of developing invasive listeriosis with high fatality rates. After notification of two patients with Listeria that had stayed in the same hospital (hospital A) before the onset of infection, we began an investigation to ascertain the extent of the outbreak, identify its source and prevent further infections. We conducted active case finding by contacting hospital A, reviewing medical records and retrospectively investigating listeriosis notifications from the German surveillance system (SurvNet). The kitchen (hospital A) and its meat supplier (company X) were inspected and environmental and food samples were taken for microbiological testing. All isolates of L. monocytogenes, together with patient and food-related isolates from Baden-Württemberg 2006 to 2008, were characterised by pulsed-field gel electrophoresis (PFGE). Altogether, 16 cases of listeriosis were identified. Serotype 4b with the indistinguishable PFGE patterns (AscI 17a/ApaI 10) was detected from nine patients, five environmental and three ready-to-eat scalded sausage samples from company X, and two food samples from hospital A. All 11 patient cases linked to hospital A were immunosuppressed and were regularly served food during their hospital stay. Ten of these patients received corticosteroids and proton pump inhibitors (PPIs). Five cases were fatal. Our investigations indicate that ready-to-eat scalded sausages from company X caused this outbreak of listeriosis. Hospital food suppliers should guarantee the absence of L. monocytogenes in ready-to-eat meat products, controlled through optimised quality assurance.

Survey and case-control study during epidemics of Puumala virus infection.

In Baden-Wuerttemberg, a federal state in south-west Germany, a large outbreak of 1089 laboratory-confirmed human Puumala virus (PUUV) infections occurred in 2007. We conducted a survey to describe the disease burden and a case-control study to identify risk factors for acquiring PUUV. Case-patients were interviewed about clinical outcome and both case-patients and randomly recruited controls were interviewed about exposure. We calculated matched odds ratios (mOR) using a conditional logistic regression model. Multivariable analysis of 191 matched case-control pairs showed that case-patients were more likely than controls to have seen small rodents/their droppings (mOR 1.9, 95% CI 1.2-3.0), cleaned utility rooms (mOR 1.8, 95% CI 1.0-3.4) and visited forest shelters (mOR 3.9, 95% CI 1.1-14.3). Two thirds of case-patients required hospitalization. During PUUV epidemics rodent control measures and use of protective equipment should be considered in utility rooms and shelters.

[Differences in European influenza pandemic preparedness plans, how important are they and what are the underlying reasons?]. / Wie gross sind die Differenzen zwischen den europäischen Pandemieplänen, sind sie relevant und woher stammen sie?

The coordination of influenza pandemic preparedness planning within Europe is especially important for Germany with 10 out of 16 Länder (regions) bordering neighbouring countries. The language barrier presents only one of the challenges to overcome. Creating a European early warning system by linking national surveillance structures and the development of a communication network are important initial achievements. Several instruments have been designed and the European Centre for Disease Prevention and Control has already played a major role in the coordination of this process. It has also led the assessment of preparedness and planning by Member States. The speed of the European Member States in preparing for and the foci they have chosen when dealing with an influenza outbreak are heterogeneous. The simultaneous analysis presented here from European, national and regional points of view aims to identify both opportunities and risks of this diversity in Europe for coping with a new pandemic. Regional and local initiatives for cross-border measures and crisis management will play a central role in achieving successful influenza pandemic preparedness in Europe.

Emergence of hantavirus in South Germany: rodents, climate and human infections.

Human hantavirus (serotype Puumala) infections are prevalent throughout Europe. The bank vole is the main reservoir of the Puumala virus (PUUV). Between 2001 and 2006, the annual incidences in Germany ranged from 0.1 to 0.5 per 100,000 inhabitants. About half of the cases were reported from the state of Baden-Württemberg (BW) in southwest Germany. In 2007, 1,089 PUUV infections were reported from BW. This reflects an incidence of 10.1:100,000, which is more than 11 times higher than the mean incidence of the previous 6 years. Spatial analysis highlights incidences up to 90:100,000 in the most affected district. The winter season 2006/2007 showed an all time high in reported mean temperature. The previous summer and autumn led to a beech mast year, resulting in favourable feed conditions for bank voles in the winter season 2006/2007. The causes of the observed increase in PUUV infections in 2007 cannot be restricted to known cycles in the bank vole population. Favourable feed conditions, a mild winter and an early onset of spring may have influenced bank vole population size as well as human exposure to infectious rodent excretions. Further epidemiologic studies are necessary to better understand the interaction between environmental factors, occurrence of Puumala virus in bank voles and the risk for human disease.

No increase in the prevalence of asthma, allergies, and atopic sensitisation among children in Germany: 1992-2001.

BACKGROUND: From 1970 to 1990 increasing rates of asthma and allergic sensitisation were observed in several countries. The aim of this study was to investigate time trends in the prevalence of asthma and allergic sensitisation among school children in Germany between 1992 and 2001. METHODS: Parental reports of asthma, hay fever, and wheezing and measurements of specific serum IgE antibodies were investigated in six serial cross sectional surveys of 9-11 year old school children in three study areas in south west Germany. RESULTS: A total of 6762 school children of mean age 10 years (mean participation rate 77.9%) took part in the investigation in the three study areas. Over the 9 year study period no increase in the prevalence of current wheezing and asthma was observed. In addition, the prevalence of atopic sensitisation remained unchanged during the observation period. CONCLUSIONS: These data, using parental reports and objective measures of allergy, suggest that there has been no further increase in the prevalence of asthma and atopy since 1992. The epidemic may thus have reached a plateau.

[Application of the Breuer-Weuffen Discrimination test as a preschool screening test in Baden-Württemberg]. / Anwendung der Differenzierungsprobe nach Breuer und Weuffen als Screeningverfahren bei Einschulungsuntersuchungen in Baden-Württemberg.

From 1997 to 2002 a total of 597 school children aged 6-7 years and 41,919 preschool children (5-7 years) were examined using the Breuer-Weuffen Discrimination test (DP). For 20 to 23% of all children a further training of perceptual and language abilities was found necessary to avoid or reduce learning difficulties at school. The DP can be used as a screening method in an average time of 7 minutes. The results obtained were well comparable for different samples of preschool children. Further, the DP allows the derivation of specific needs for the training of children who fail to meet the test criteria. Mild perceptual disturbances or light graphomotoric problems can be improved by specific training before school offered by parents and kindergarten teachers, whereas severe problems should be treated by professionals.

[Quality circles in expert assessment as an instrument in quality management]. / Ringversuche in der Begutachtung als Instrument im Qualitätsmanagement.

An intercomparison programme was carried out as part of the quality management of medical assessments in the public health service in Baden-Württemberg. All physicians who performed medical assessments in January 1997 were invited to participate. They received a case description adopted from medical records of a precedent case (56-year-old head of a department in an administrative authority, severely disabled after left-sided stroke with residual right-sided partial hemiparesis, reduced work performance), and were asked to assess whether the patient was permanently unable to work. Access to medical expert opinions was requested. Participation was voluntary. Assessments were reviewed twice as to whether five prospectively defined evaluation criteria were fully met, or only partially or not at all. Participants and reviewers remained unknown to each other. Among 246 eligible physicians, 103 returned an assessment (43%). Forty-five respondents had requested additional expert opinions. Anticipations for five criteria were met to their full extent with regard to: formal construction, all submissions; case description, 84%; sociomedical diagnosis, 65%; description of ability to work, 53%; and response to the question posed, 75% of submissions. The programme required considerable work time in its preparatory, field, and evaluation phases. The procedure was however found to be practicable, and a suitable element within a quality management programme can contribute towards motivation, quality assurance and the identification of possible deficits, and thus indicate possible topics and issues for continuing education and quality control programmes.

Pharmacokinetics of ampicillin/sulbactam in patients undergoing spinal microneurosurgical procedures.

The fixed combination of ampicillin (2 g)/sulbactam (1 g) was administered as perioperative prophylaxis at induction of anesthesia in 20 patients undergoing spinal microneurosurgery. It was noteworthy that after the short infusion ampicillin and sulbactam penetrated rapidly from blood into the different tissues affected by the surgical procedures. The following mean concentrations were measured in tissues: muscle 32.3+/-6.5 mg/kg ampicillin and 18.6+/-2.9 mg/kg sulbactam (11.1 min), ligament 39.5+/-11.1 mg/kg ampicillin and 25+/-6.5 mg/kg sulbactam (13.8 min), bone 12+/-3.6 mg/kg ampicillin and 7+/-0.8 mg/kg sulbactam (20.6 min), disk 10.2+/-3.3 mg/kg ampicillin and 7.3+/-1.8 mg/kg sulbactam (44.2 min). The mean time of sampling is given in brackets. For a period of at least 2 h the levels of both drugs measured in serum and in the different tissues were above the MICs for bacteria involved in postoperative wound infections. The administration of ampicillin/sulbactam apparently achieved sufficiently, high antibiotic concentrations, even in bradytrophic tissues such as ligament, bone, and disk, and seemed to meet the pharmacological criteria for perioperative prophylaxis in spinal microneurosurgery.

[Effects of a proprioceptive training program on sensorimotor capacities of the lower extremity in patients with anterior cruciate ligament instability]. / Auswirkungen eines propriozeptiven Trainingsprogramms auf die sensomotorischen Fähigkeiten der unteren Extremität bei Patienten mit einer vorderen Kreuzbandinstabilität.

Sensomotory function after ACL-reconstruction was tested prior and after a proprioceptive rehabilitation program with the Kinesthetic Ability Trainer (KAT 2000) which documented the static balance index (SBI). A control group consisting of healthy subjects was also tested two times with a time interval of six weeks. The results showed an adaptation effect to the testing device in the control group with an 17.12% increase of the SBI. There were no differences between the dominant and non dominant extremity. The active sensomotory function in the healthy knee of the operated patients showed no difference to the control group. Proprioceptive capabilities of the acl-reconstructed knee joints was significant reduced 6.42 weeks after surgery. A special proprioceptive rehabilitation program for six weeks significantly reduced this deficit. In the patient group sensomotory function of both knee joints could be increased to a level higher than in the control group. In the operated extremity the static balance index increased 27.75% and in the non injured extremity the SBI increased 16.88%.

Pharmacokinetics of ampicillin, sulbactam and cefotiam in patients undergoing orthopedic surgery.

As perioperative prophylaxis for major orthopedic operations 81 patients were given the fixed combination of ampicillin (1 g)/sulbactam (0.5 g) or cefotiam (2 g) as short infusions. The three beta-lactams were rapidly distributed into the different tissues and their pharmacokinetic profiles were found to be very similar. It was noteworthy that ampicillin, sulbactam and cefotiam penetrated within minutes, not only into skin, fat and muscles, but also into bone. Thus 0.25 h after starting the infusion the following mean concentrations were measured in bone: 21.8 +/- 10.5 mg/kg ampicillin, 4.9 +/- 2.2 mg/kg sulbactam and 19.4 +/- 10.6 mg/kg cefotiam. For a period of at least 2 h the concentrations measured in serum and in the different tissues affected by the operation (skin, fat, muscle, bone) were above the MICs for pathogens which are involved in postoperative wound infections. On the basis of pharmacokinetic data, ampicillin/sulbactam and cefotiam seem about equally suitable for perioperative prophylaxis in major orthopedic operations.