14-year-old Schoolchildren can Consent to Get Vaccinated in Tyrol, Austria: What do They know about Diseases and Vaccinations?

In Austria, consent to receiving vaccines is regulated at the federal state level and in Tyrol, children aged 14 years are allowed to consent to receiving vaccination. In August 2017, we investigated determinants associated with vaccine hesitancy, having been vaccinated against measles and human papillomavirus (HPV) and the intention to vaccinate among schoolchildren born in 2002 and 2003. Those who consider measles and HPV a severe disease had a significantly higher intention to be vaccinated (prevalence ratio (PR) of 3.5 (95% CI 1.97-6.32) for measles and a PR of 3.2 (95% CI 1.62-6.35) for HPV). One-third of the participants (32.4%; 95% CI 27.8-37.4) were not aware that they are allowed to consent to receiving vaccines. The most common trusted source reported by respondents (n = 311) was the medical doctor (80.7%; 95% CI 75.7-84.7). The main finding related to the aim of the study was that the proportion of objectors is below 4% and therefore it should still be possible to reach measles elimination for which a 95% uptake is necessary. Although the proportion of objectors is not higher compared to adults, we recommend to intensify health education to increase health literacy.

Emergence of coronavirus disease 2019 (COVID-19) in Austria.

This is a report on the first identified cases of coronavirus disease 2019 (COVID-19) in Austria. The first documented case was a person who stayed in Kühtai, Tyrol, from 24 to 26 January 2020, and had been infected by a Chinese instructor in Starnberg (Germany) between 20 and 22 January. This counts as a German case since her diagnosis was eventually made in Munich (Germany) on 28 January. On 25 February, two cases imported from Italy were diagnosed in Innsbruck but again no secondary cases were identified in Austria. The first three infections of Austrian inhabitants were detected on 27 February in Vienna. The two resulting clusters finally included 6 (source of initial infection unknown) and 61 cases. Most likely, Italy was the source of the latter cluster. On 12 March the first fatal case of COVID-19 in Austria was reported, a 69-year-old Viennese who died in a Vienna hospital after returning from a cruise ship tour in Italy. On 6 March three autochthonously acquired cases were reported in the Tyrol, all related to the ski resort Ischgl. Of the first 14 Islandic COVID-19 cases infected in Ischgl, 11 had already returned to Iceland on 29 February. We consider that the incriminated barkeeper, who tested PCR positive on 7 March, was neither the primary case nor a superspreader. In our opinion, undetected transmission of SARS-CoV­2 had been ongoing in Ischgl prior to the first laboratory confirmed cases. Our data also underline that the introduction of SARS-CoV­2 into Austria was not one single event.

Clinical Usefulness of Susceptibility Breakpoints for Yeasts in the Treatment of Candidemia: A Noninterventional Study.

This prospective noninterventional study evaluated whether antifungal susceptibility data (MIC) provided for Candida clinical isolates on the basis of recently established breakpoints are taken into account by clinicians to guide their treatment decision making process, and assessed the response in MIC- and non-MIC-based treatment groups. During a six month period, the usage of systemic antifungals was recorded in detail and compared with mycological data (Candida species and MICs) in candidemia patients. Patients were assigned to a susceptible or resistant infection group based on European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints; treatment decisions were under the professional discretion of the treating physicians. 123 patients were evaluated with Candida albicans accounting for 59%, Candida glabrata for 19%, Candida parapsilosis for 15%, Candida tropicalis for 4% and Candida krusei for 3%. Antifungal treatment correlated with species and MICs in 80% (n = 99 patients), high MICs and species-dependent guideline recommendations were ignored in 20% (n = 24 patients); the overall outcome of candidemia cases in our study population was excellent, as by day 14, all patients were cleared from fungal blood stream infection (mean 5.6 days, range 2-12). The current variability in antifungal usage and the delay in initiating appropriate therapy indicate a need for antifungal stewardship to improve the management of invasive fungal infections.

Antibiotic resistance of blood cultures in regional and tertiary hospital settings of Tyrol, Austria (2006-2015): Impacts & trends.

Blood stream infections rank among the top seven causes of death of the general population. The aim of our study was to better understand the epidemiology of BSI in order to improve diagnostics and patient outcome. We used retrospective aggregated laboratory data of blood samples received from all public hospitals in Tyrol, Austria between 2006 and 2015. Microorganisms were categorized into obligatory, facultative, unusual pathogens and contaminants. The distribution, the cumulative incidence and antimicrobial susceptibility patterns were compared between the tertiary (TH) and regional peripheral hospitals (PH). Among 256,364 blood samples, 76.1% were from the TH The incidence of obligatory pathogens was 1.7 fold, and up to 3 times higher for facultative, unusual pathogens and contaminants in the TH and increased mainly due to an increase of E.coli, which was the most common isolated pathogen (n = 2,869), followed by Staphylococcus aureus (n = 1,439), Enterococcus sp. (n = 953) and Klebsiella sp. (n = 816). The distribution of obligatory pathogens differed between the hospital settings: In the TH Enterococcus sp. accounted for 40.8% and E.coli for 70.4%, respectively, whereas in the PH for 25.4% (p<0.0001) and 57.8%, respectively (p<0.0001) Antibiotic resistance of Gram negative bacteria and Staphylococcus aureus did not change during the observation period. Carbapenem resistance of Klebsiella sp. and vancomycin and linezolid resistance of Enterococcus faecium showed a non-significant increase since 2010 in the TH setting. We concluded that the incidence of BSI in TH was higher compared to PH. We observed higher contamination rates in the TH. We could not interpret the data of coagulase negative staphylococci due to lack of clinical data. We strongly recommend enhancement of training on blood culture sampling to decrease the rate of contamination. Due to differences in pathogen distribution and antimicrobial resistance between different hospital settings we recommend separate treatment guidelines for BSI by hospital setting.

Measles Elimination: Identifying Susceptible Sub-Populations to Tailor Immunization Strategies.

Measles elimination has been identified as a public health priority in Europe for a long time but has not yet been achieved. The World Health Organization (WHO) recommends identification of susceptible sub-populations to target supplementary immunization activities. We used three different sources of information: retrospective samples investigated for measles IgG between 1997 and 2016, vaccine coverage data from the existing electronic registry for birth cohorts 2015 to 1999, and surveillance data from 2009 until 20 July 2019. We calculated susceptibility by birth cohort using seroprevalence data, adjusting vaccine coverage data with reported effectiveness (93% for the first and 97% for the second dose, respectively), and compared it with measles incidence data, aggregated by birth cohorts and districts. Susceptibility levels for persons 10-41 years (birth cohorts 2007-1976) were 10.4% and thus far above the recommended values of WHO (5%). Older birth cohorts were sufficiently protected. Districts with the highest susceptibility estimates corresponded with districts with the highest incidence rates. Birth cohorts with susceptibility levels > 10% showed a 4.7 increased relative risk of having had more than one measles case. We conclude that retrospective serosurveys are a cheap and useful approach in identifying susceptible sub-populations, especially for older birth cohorts whose coverage data remain scarce.

European Pandemic Influenza Preparedness Planning: A Review of National Plans, July 2016.

Pandemic influenza A (H1N1) commenced in April 2009. Robust planning and preparedness are needed to minimize the impact of a pandemic. This study aims to review if key elements of pandemic preparedness are included in national plans of European countries. Key elements were identified before and during the evaluations of the 2009 pandemic and are defined in this study by 42 items. These items are used to score a total of 28 publicly available national pandemic influenza plans. We found that plans published before the 2009 influenza pandemic score lower than plans published after the pandemic. Plans from countries with a small population size score significantly lower compared to national plans from countries with a big population (P <.05). We stress that the review of written plans does not reflect the actual preparedness level, as the level of preparedness entails much more than the existence of a plan. However, we do identify areas of improvement for the written plans, such as including aspects on the recovery and transition phase and several opportunities to improve coordination and communication, including a description of the handover of leadership from health to wider sector management and communication activities during the pre-pandemic phase. (Disaster Med Public Health Preparedness. 2019;13:582-592).

"Enhanced acquisition of antibiotic-resistant intestinal E. coli during the first year of life assessed in a prospective cohort study".

Background: Increasing bacterial resistance to antibiotics is a serious problem worldwide. We sought to record the acquisition of antibiotic-resistant Escherichia coli (E. coli) in healthy infants in Northern Thailand and investigated potential determinants. Methods: Stool samples from 142 infants after birth, at ages 2wk, 2mo, 4 to 6mo, and 1y, and parent stool samples were screened for E. coli resistance to tetracycline, ampicillin, co-trimoxazole, and cefazoline by culture, and isolates were further investigated for multiresistance by disc diffusion method. Pulsed-field gel electrophoresis was performed to identify persistent and transmitted strains. Genetic comparison of resistant and transmitted strains was done by multilocus sequence typing (MLST) and strains were further investigated for extra- and intra-intestinal virulence factors by multiplex PCR. Results: Forty-seven (33%) neonatal meconium samples contained resistant E. coli. Prevalence increased continuously: After 1y, resistance proportion (tetracycline 80%, ampicillin 72%, co-trimoxazole 66%, cefazoline 35%) almost matched those in parents. In 8 infants (6%), identical E. coli strains were found in at least 3 sampling time points (suggesting persistence). Transmission of resistant E. coli from parents to child was observed in only 8 families. MLST showed high diversity. We could not identify any virulence genes or factors associated with persistence, or transmission of resistant E. coli. Full-term, vaginal birth and birth in rural hospital were identified as risk factors for early childhood colonization with resistant E. coli. Conclusion: One third of healthy Thai neonates harboured antibiotic-resistant E. coli in meconium. The proportion of resistant E. coli increased during the first year of life almost reaching the value in adults. We hypothesize that enhancement of infection control measures and cautious use of antibiotics may help to control further increase of resistance.

Outbreak report: a nosocomial outbreak of vancomycin resistant enterococci in a solid organ transplant unit.

Background: Vancomycin resistant enterococci (VRE) are an emerging problem in health care settings. The purpose of the investigation was to assess the extent of the outbreak including environmental contamination and to limit further transmission. Methods: We used retrospective patient and laboratory data including pulse field gel electrophoresis (PFGE) typing and virulence and resistance gene analysis. For comparison of medians the Mann-Whitney and for comparison of proportions the Fisher exact tests were used. Results: PFGE typing of VRE strains of an outbreak of 15 VRE cases in a solid transplant unit revealed that nine of the cases belonged to one identical pattern (A), which was only found twice in the environment. Eleven further positive environmental samples showed a different, but identical PFGE pattern E. Only one patient was infected with this environmental strain.Two of nine (22.2%) PFGE A, but nine of eleven (81.2%) PFGE E samples were positive for gelatinase E (p = 0.01), which is described as enhancing biofilm production, suggesting a survival benefit for this strain on inanimate surfaces. Conclusion: Routine disinfection was not able to stop the cluster, but after repeated enforcement of the infection prevention and control (IPC) bundle such as training, strict adherence to hand hygiene and surface disinfection no further cases were observed. We conclude that certain VRE strains predominate in the environment whereas others predominate in humans. Enforcement of the IPC bundle is essential for controlling VRE outbreaks and reducing further transmission.

Long-sleeved medical workers' coats and their microbiota.

In this study we aimed to assess the contamination rate of long-sleeved medical workers' coats (N = 100) in a point-prevalence study. Ninety-one percent of the coats were contaminated with normal human flora, but only the minority (9%) showed presence of pathogenic non-multiresistant bacteria. The data of this study may implicate that long-sleeved coats harbor low risk for the treated patients to be contaminated with pathogenic bacteria during medical consultation.

Nosocomial outbreak of extensively drug-resistant Pseudomonas aeruginosa associated with aromatherapy.

An increase of extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) in various clinical specimens among intensive care unit patients (n = 7) initiated an outbreak investigation consisting of patient data analyses, control of adherence to infection control guidelines, microbiologic surveys, and molecular-based studies. XDR-PA was detected in a jointly used aroma-oil nursing bottle for aromatherapy. We implemented the restriction of oil sharing among patients. Hence, the outbreak was controlled successfully.

[Must we expect an epidemic of measles in the near future in Southern Tyrol?]. / Müssen wir in naher Zukunft mit einer Masernepidemie in Südtirol rechnen?

Measles, Mumps and Rubella (MMR) vaccination is recommended in Italy. A country-wide study of the 1996 birth cohort revealed that coverage with MMR vaccine in the autonomous Province of Bolzano is the third lowest in Italy (after Campania and Calabria). The aim of the study was to evaluate the situation regarding measles in order to plan and implement necessary strategies. To assess MMR vaccine coverage, routine vaccination data were evaluated for quality and validity, and subsequently MMR coverage rates were calculated by birth cohort (1996-99) and commune. In addition, a descriptive epidemiologic analysis of all reported measles cases was performed. Hospital discharge records were used to estimate the complications and costs of hospital admitted measles cases. MMR vaccine coverage rates vary between rural (40%) and urban (80%) areas. Furthermore, communes with more than 50% Italian speaking inhabitants have higher MMR vaccine coverage than communes mainly populated by German speaking persons. In 1997 and 1999, epidemics with 1,889 and 992 cases, respectively, were reported. Five- to nine-year-old children were the most affected age group. Most cases were reported from communes with vaccine coverage rates below 40%. Six percent of measles cases, reported between January 1996 and October 2001 were admitted to hospital. The mean period of admission for measles cases was 4.6 days (range 1 to 84 days), the mean estimated costs 1,987.18 Euro per patient. The total amount of direct costs was estimated to be 386,437.72 Euros. Due to low vaccine coverage rates, especially in rural areas, and the ongoing circulation of the measles virus in the population, it is likely that an extensive measles epidemic will occur in the near future, resulting in evitable suffering of patients and extensive costs for the public health system. Only an effective immunization campaign will be able to prevent a future epidemic.