Age-specific differences in influenza virus type and subtype distribution in the 2012/2013 season in 12 European countries.

The epidemiology of seasonal influenza is influenced by age. During the influenza season, the European Influenza Surveillance Network (EISN) reports weekly virological and syndromic surveillance data [mostly influenza-like illness (ILI)] based on national networks of sentinel primary-care providers. Aggregated numbers by age group are available for ILI, but not linked to the virological data. At the end of the influenza season 2012/2013, all EISN laboratories were invited to submit a subset of their virological data for this season, including information on age. The analysis by age group suggests that the overall distribution of circulating (sub)types may mask substantial differences between age groups. Thus, in cases aged 5-14 years, 75% tested positive for influenza B virus whereas all other age groups had an even distribution of influenza A and B viruses. This means that the intepretation of syndromic surveillance data without age group-specific virological data may be misleading. Surveillance at the European level would benefit from the reporting of age-specific influenza data.

Influenza season 2012-2013 in Europe: moderate intensity, mixed (sub)types.

This paper summarizes influenza activity in the European Union/European Economic Area (EU/EEA) in 2012-2013. The influenza season 2012-2013 in Europe lasted from early December to late April. Overall the severity of the season could be described as moderate, based on the ILI/ARI consultation rates and the percentage of sentinel specimens positive for influenza compared to previous seasons. Both influenza A and B viruses circulating accounted for 47% and 53% of positive sentinel specimens, respectively, with both A(H1) and A(H3) varying for dominance. Compared to outpatients, the proportion of laboratory-confirmed influenza hospitalized cases infected by A(H1N1)pdm09 was significantly higher in middle-aged patients (33% vs. 17%, χ 2 = 66·6, P < 0·01). Despite a relatively good match between vaccine and circulating strains, vaccine effectiveness was estimated to be moderate.

Drug resistance among tuberculosis cases in the European Union and European Economic Area, 2007 to 2012.

The European Union and European Economic Area (EU/EEA) tuberculosis (TB) surveillance system collects detailed information on resistance to TB drugs. Using this information, we provide an overview of the current TB drug resistance situation and trends in the EU/EEA by performing a descriptive analysis, including analysis of treatment outcomes, of the TB cases reported between January 2007 and December 2012. The percentages of TB cases with different drug resistance patterns have been stable with about 90% of the new laboratory-confirmed cases pan-susceptible, 6% monodrug-resistant, 2% polydrug-resistant, 2% multidrug drug-resistant (MDR) TB - excluding extensively drugresistant (XDR) TB -, and 0.2% XDR-TB. In previously treated laboratory-confirmed TB cases, the percentage with MDR-TB excluding XDR-TB declined until 2010 to 16% and remained stable thereafter. During the study period, the percentages of cases with monodrug- and polydrug-resistant TB remained constant at about 8% and 2% whereas the percentage of XDR-TB cases increased slightly to 2.6%. Treatment outcome results for all cases have been stable with overall 77.9% of the pan-susceptible cases, 69.6% of the monoresistant cases, 68.2% of the polyresistant cases, 32.2% of the MDR-TB cases (excluding XDR-TB), and 19.1% of the XDR-TB cases treated successfully. The treatment success rate target for new pulmonary culture-positive MDR-TB cases of 70% has not been reached. In addition, drug resistance surveillance can be improved by more complete reporting of drug susceptibility results and treatment outcome.

Travel-associated Legionnaires' disease in Europe, 2010.

In 2010, the European surveillance network for travel-associated Legionnaires' disease (ELDSNet, previously EWGLINET) received reports of 864 cases of travel-associated Legionnaires' disease, of whom 24 were reported to have had a fatal outcome. As in previous years, a very low proportion of clinical isolates were obtained (45 cases, 5.6%). In the 2010 dataset, male cases outnumbered female cases by 2.6:1 and had a median age of 61 years (range: 21-96), while the median age for women was 63 years (range: 12-95). The network identified 100 new clusters in 2010, of which 44 involved only one case from each reporting country and would probably not have been detected by national surveillance schemes alone. The largest cluster (having 14 cases) was associated with a cruise ship. Legionella species were detected at 61 of the 100 accommodation site clusters investigated. The names of five accommodation sites were published on the ECDC website.

Legionnaires disease in Europe, 2009-2010.

The surveillance of Legionnaires' disease (LD) in Europe is carried out by the European Legionnaires' Disease Surveillance Network (ELDSNet) and coordinated by the European Centre for Disease Prevention and Control (ECDC). All cases reported in 2009 and 2010 and meeting the European case definition were electronically transmitted to The European Surveillance System (TESSy) database. A total of 5,551 and 6,305 cases were reported by 29 European countries in 2009 and 2010, respectively. The age-standardised rate of all cases was 1.20 per 100,000 inhabitants in 2010, 12% higher than in 2009, which was consistent with the increasing trend observed since 2005. Most of this increase consisted of community-acquired cases reported by France, Germany and the Netherlands with dates of onset in August­September. The exceptionally hot summer of 2010 in some parts of Europe may have played a role in this increase.

Initial surveillance of 2009 influenza A(H1N1) pandemic in the European Union and European Economic Area, April-September 2009.

European Union (EU) and European Economic Area (EEA) countries reported surveillance data on 2009 pandemic influenza A(H1N1) cases to the European Centre for Disease Prevention and Control (ECDC) through the Early Warning and Response System (EWRS) during the early phase of the 2009 pandemic. We describe the main epidemiological findings and their implications in respect to the second wave of the 2009 influenza pandemic. Two reporting systems were in place (aggregate and case-based) from June to September 2009 to monitor the evolution of the pandemic. The notification rate was assessed through aggregate reports. Individual data were analysed retrospectively to describe the population affected. The reporting peak of the first wave of the 2009 pandemic influenza was reached in the first week of August. Transmission was travel-related in the early stage and community transmission within EU/EEA countries was reported from June 2009. Seventy eight per cent of affected individuals were less than 30 years old. The proportions of cases with complications and underlying conditions were 3% and 7%, respectively. The most frequent underlying medical conditions were chronic lung (37%) and cardio-vascular diseases (15%). Complication and hospitalisation were both associated with underlying conditions regardless of age. The information from the first wave of the pandemic produced a basis to determine risk groups and vaccination strategies before the start of the winter wave. Public health recommendations should be guided by early capture of profiles of affected populations through monitoring of infectious diseases.

Experience and lessons from surveillance and studies of the 2009 pandemic in Europe.

Surveillance and studies in a pandemic is a complex topic including four distinct components: (1) early detection and investigation; (2) comprehensive early assessment; (3) monitoring; and (4) rapid investigation of the effectiveness and impact of countermeasures, including monitoring the safety of pharmaceutical countermeasures. In the 2009 pandemic, the prime early detection and investigation took place in the Americas, but Europe needed to undertake the other three components while remaining vigilant to new phenomenon such as the emergence of antiviral resistance and important viral mutation. Laboratory-based surveillance was essential and also integral to epidemiological and clinical surveillance. Early assessment was especially vital because of the many important strategic parameters of the pandemic that could not be anticipated (the 'known unknowns'). Such assessment did not need to be undertaken in every country, and was done by the earliest affected European countries, particularly those with stronger surveillance. This was more successful than requiring countries to forward primary data for central analysis. However, it sometimes proved difficult to get even those analyses from European counties, and information from Southern hemisphere countries and North America proved equally valuable. These analyses informed which public health and clinical measures were most likely to be successful, and were summarized in a European risk assessment that was updated repeatedly. The estimate of the severity of the pandemic by the World Health Organization (WHO), and more detailed description by the European Centre for Disease Prevention and Control in the risk assessment along with revised planning assumptions were essential, as most national European plans envisaged triggering more disruptive interventions in the event of a severe pandemic. Setting up new surveillance systems in the midst of the pandemic and getting information from them was generally less successful. All European countries needed to perform monitoring (Component 3) for the proper management of their own healthcare systems and other services. The information that central authorities might like to have for monitoring was legion, and some countries found it difficult to limit this to what was essential for decisions and key communications. Monitoring should have been tested for feasibility in influenza seasons, but also needed to consider what surveillance systems will change or cease to deliver during a pandemic. International monitoring (reporting upwards to WHO and European authorities) had to be kept simple as many countries found it difficult to provide routine information to international bodies as well as undertaking internal processes. Investigation of the effectiveness of countermeasures (and the safety of pharmaceutical countermeasures) (Component 4) is another process that only needs to be undertaken in some countries. Safety monitoring proved especially important because of concerns over the safety of vaccines and antivirals. It is unlikely that it will become clear whether and which public health measures have been successful during the pandemic itself. Piloting of methods of estimating influenza vaccine effectiveness (part of Component 4) in Europe was underway in 2008. It was concluded that for future pandemics, authorities should plan how they will undertake Components 2-4, resourcing them realistically and devising new ways of sharing analyses.

Start of the influenza season 2008-9 in Europe - increasing influenza activity moving from West to East dominated by A(H3N2).

The influenza season 2008-9 started in week 49 of 2008 and is so far characterised by influenza virus type A subtype H3N2. Isolates of this subtype that were tested proved susceptible to neuraminidase inhibitors, but resistant to M2 inhibitors. The circulating A(H3N2) viruses are antigenically similar to the component in the current northern hemisphere influenza vaccine.

A European survey on public health policies for managing cases of meningococcal disease and their contacts.

In 2007, a European survey was conducted to compare national policies on public health management of cases of meningococcal disease and their contacts. The results revealed differences in definitions of close contacts and prophylactic regimens between countries. These differences can be attributed to a lack of evidence on optimal prevention and treatment strategies. The development of guidance for best practice in priority areas, based on evidence or consensus, is therefore recommended.

Shigellosis - a re-emerging sexually transmitted infection: outbreak in men having sex with men in Berlin.

In December 2001, the Robert Koch-Institut (RKI) was informed about a cluster of 10 Shigella sonnei infections in men who have sex with men (MSM), diagnosed in Berlin since September 2001. A retrospective investigation on sexual risk factors for infection in all shigella cases from Berlin from 2001 was initiated by sending a questionnaire to all patients without known travel history. Simultaneously laboratories were asked to send new shigella isolates from patients to the National Reference Centre at the RKI. Out of 29 responders, 24 self-identified as MSM. Seventeen of these reported sexual contacts as the most likely potential risk of infection. Almost all MSM reported direct or indirect oral-anal sexual contacts in the week before they fell ill. Fifteen of 27 shigella isolates collected during the prospective sampling period showed identical plasmid profiles, PFGE- and resistance patterns and can therefore be regarded as clonally identical. Asymptomatic and/or prolonged shedding in the reconvalescent phase may contribute to the transmission risk of shigella infection during oral-anal sexual practices. Awareness among practitioners and among MSM about the risk of sexual transmission of orally transmitted agents needs to be raised.

Diagnosis of ornithosis by cell culture and polymerase chain reaction in a patient with chronic pneumonia.

We report the case of a woman who had pneumonia due to Chlamydia psittaci. A Chlamydia species was determined to be the causative agent of the pneumonia because it was isolated from bronchoalveolar lavage fluid, because it could be detected in lung biopsy specimens by the direct immunofluorescence technique, and because Chlamydia-specific antibodies could be detected by ELISA and microimmunofluorescence. The infectious agent could not be identified at the species level with use of serological techniques, but the isolate was determined to be C. psittaci by PCR with use of species- and genus-specific sequences within the chlamydial lipopolysaccharide biosynthesis gene gseA. The case reported herein exemplifies the problems encountered in diagnosing ornithosis and shows that isolation of the etiologic agent followed by identification of the species by PCR is helpful in diagnosing this rare disease. In addition, the findings in our case show that laboratory personnel who are conducting tests for Chlamydia pneumoniae should be aware of the risk of accidentally isolating highly infectious C. psittaci organisms.