Mass gathering events and undetected transmission of SARS-CoV-2 in vulnerable populations leading to an outbreak with high case fatality ratio in the district of Tirschenreuth, Germany.

In early March 2020, a COVID-19-outbreak occurred in the district of Tirschenreuth, Germany. The outbreak was characterised by a rapid increase in case numbers and a comparatively high crude case fatality ratio (CFR; 11%). Until the beginning of May 2020, 1122 cases were reported in the district. To investigate the outbreak, we analysed surveillance and other data available at the district health department, including data on cases living in care facilities and public health measures applied. Furthermore, we compared the number of tests performed in Tirschenreuth and in Germany as a whole. We interviewed the first 110 cases in order to investigate potential exposures at the beginning of the outbreak. We found that returning ski-travellers from Austria and Italy and early undetected community transmission likely initiated the outbreak which was then accelerated by Bavarian beer festivities. Testing of mainly acute cases in the district of Tirschenreuth resulted in a higher rate of positive tests compared to the whole of Germany. Despite adjustment for age, the CFR continued to exceed the German mean which was due to spread to vulnerable populations. Strict public health measures likely contributed to control the outbreak by mid-April 2020.

Influenza vaccine effectiveness estimates in Europe in a season with three influenza type/subtypes circulating: the I-MOVE multicentre case-control study, influenza season 2012/13.

In the fifth season of Influenza Monitoring Vaccine Effectiveness in Europe (I-MOVE), we undertook a multicentre case-control study (MCCS) in seven European Union (EU) Member States to measure 2012/13 influenza vaccine effectiveness against medically attended influenza-like illness (ILI) laboratory confirmed as influenza. The season was characterised by substantial co-circulation of influenza B, A(H1N1)pdm09 and A(H3N2) viruses. Practitioners systematically selected ILI patients to swab ≤7 days of symptom onset. We compared influenza-positive by type/subtype to influenza-negative patients among those who met the EU ILI case definition. We conducted a complete case analysis using logistic regression with study as fixed effect and calculated adjusted vaccine effectiveness (AVE), controlling for potential confounders (age, sex, symptom onset week and presence of chronic conditions). We calculated AVE by type/subtype. Study sites sent 7,954 ILI/acute respiratory infection records for analysis. After applying exclusion criteria, we included 4,627 ILI patients in the analysis of VE against influenza B (1,937 cases), 3,516 for A(H1N1)pdm09 (1,068 cases) and 3,340 for influenza A(H3N2) (730 cases). AVE was 49.3% (95% confidence interval (CI): 32.4 to 62.0) against influenza B, 50.4% (95% CI: 28.4 to 65.6) against A(H1N1)pdm09 and 42.2% (95% CI: 14.9 to 60.7) against A(H3N2). Our results suggest an overall low to moderate AVE against influenza B, A(H1N1)pdm09 and A(H3N2), between 42 and 50%. In this season with many co-circulating viruses, the high sample size enabled stratified AVE by type/subtype. The low estimates indicate seasonal influenza vaccines should be improved to achieve acceptable protection levels.

Contact investigation of a case of human novel coronavirus infection treated in a German hospital, October-November 2012.

On 24 October 2012, a patient with acute respiratory distress syndrome of unknown origin and symptom onset on 5 October was transferred from Qatar to a specialist lung clinic in Germany. Late diagnosis on 20 November of an infection with the novel Coronavirus (NCoV) resulted in potential exposure of a considerable number of healthcare workers. Using a questionnaire we asked 123 identified contacts (120 hospital and three out-of-hospital contacts) about exposure to the patient. Eighty-five contacts provided blood for a serological test using a two-stage approach with an initial immunofluorescence assay as screening test, followed by recombinant immunofluorescence assays and a NCoV-specific serum neutralisation test. Of 123 identified contacts nine had performed aerosol-generating procedures within the third or fourth week of illness, using personal protective equipment rarely or never, and two of these developed acute respiratory illness. Serology was negative for all nine. Further 76 hospital contacts also tested negative, including two sera initially reactive in the screening test. The contact investigation ruled out transmission to contacts after illness day 20. Our two-stage approach for serological testing may be used as a template for similar situations.

[Informations and recommendations of the German Respiratory Society and the Paul-Ehrlich-Society for chemotherapy concerning the outbreak of influenza A(H7N9) virus infections in humans]. / Informationen und Empfehlungen der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. und der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. zum Ausbruch der Influenza A(H7N9)-Virus-Infektion beim Menschen.

In March 2013, the first cases of avian influenza virus infections in humans were reported by the authorities of the PR of China to the World Health Organization. This influenza A(H7N9) virus comprises genes of at least four different avian influenza viruses, some segments mimicking human-like influenza-signatures. Until 11 August, 2013 135 humans were infected, 44 (33%) died. The clinical course is characterized by fever, cough, gastrointestinal symptoms, lympho- and thrombopenia as well by the rapid onset of an acute respiratory distress syndrome in nearly 25% of the cases. Although human to human transmission may have occurred only in the context of three clusters, strict hygiene measures should be instituted and any suspect case should be reported to the local health authorities immediately. The detection of influenza A(H7N9) is based on real-time polymerase chain reaction (PCR). Antiviral treatment should be initiated as early as possible for suspect, probable or confirmed cases, even when 48 hours have passed after symptom onset. At present the future development of this epidemic cannot be predicted.

Enhanced surveillance and investigation of coronavirus: what is required?

Following the discovery in September 2012 of 2 patients, both with links to the Eastern Mediterranean Region, with serious respiratory illness due to novel coronavirus, all countries have instigated surveillance and laboratory activities to detect further cases, with intensive case-contact investigations undertaken on laboratory confirmation of cases. A total of 30 cases, of whom 18 have died, and at least 3 clusters have been detected to date (1 cluster among health-care workers and another 2 clusters among family members). To date, transmission studies have shown a low risk of onward human transmission, with clinical presentation remaining severe for the majority. Many questions remain including the zoonotic source and geographical extent of infection. Surveillance has been extended to include clusters of cases or health-care workers with severe, undiagnosed respiratory illness regardless of travel history. Environmental studies, on-going surveillance and linked case-contact investigations will provide a critical role in answering some of these issues.

Facemasks and intensified hand hygiene in a German household trial during the 2009/2010 influenza A(H1N1) pandemic: adherence and tolerability in children and adults.

Non-pharmaceutical interventions (NPI) such as facemasks and intensified hand hygiene may be effective in preventing influenza infections in households. It may be equally important that household members, especially children, can learn to use, maintain and tolerate these measures. We monitored adherence and tolerability of these NPI within a cluster-randomized trial in households with influenza index patients. We recruited 147 participants in 41 households, 39 (95%) out of 41 index patients were children (aged <14 years). In households assigned to wear facemasks, their use peaked on day 4 after symptom onset of the index patient at 73% and at 65% for children and adults, respectively. Mean daily frequency of hand disinfection in households assigned to intensified hand hygiene measures peaked at 7·7 (day 6) for children and at 10·1 (day 5) for adults. The majority of participants reported no problems with mask wearing. Data suggest that usage of NPI can be taught and that measures are well tolerated by adults and even sick children alike.

Avian influenza A(H5N1) in humans: new insights from a line list of World Health Organization confirmed cases, September 2006 to August 2010.

The threat of avian influenza (AI) viruses to humans in Europe in 2005 prompted the Robert Koch Institute to establish a routine monitoring instrument condensing information on all human AI cases worldwide reported from the World Health Organization (WHO) and other sources into a line list for further analysis. The 235 confirmed AI cases captured from September 2006 to August 2010 had a case fatality rate of 56% (132/235), ranging from 28% (27/98) in Egypt to 87% (71/82) in Indonesia. In a multivariable analysis, odds of dying increased by 33% with each day that passed from symptom onset until hospitalisation (OR: 1.33, p=0.002). In relation to children of 0­9 years, odds of fatal outcome were more than six times higher in 10­19 year-olds and 20­29 year-olds (OR: 6.06, 95% CI: 1.89­19.48, p=0.002 and OR: 6.16, 95% CI: 2.05­ 18.53, p=0.001, respectively), and nearly five times higher in patients of 30 years and older (OR: 4.71, 95% CI: 1.56­14.27, p=0.006) irrespective of the country, which had notified WHO of the cases. The situation in Egypt was special in that case number and incidence in children were more than twice as high as in any other age group or country. With this study, we show that data from the public domain yield important epidemiological information on the global AI situation. This approach to establish a line list is time-consuming but a line list is a prerequisite to such evaluations. We thus would like to encourage the placing of a publicly accessible line list of anonymised human AI cases, e.g. directly by WHO. This might enhance our understanding of AI in humans and permit the rapid detection of changes in its epidemiology with implications for human health.

[Epidemiology of Legionnaires' disease in Germany]. / Epidemiologie der Legionärskrankheit in Deutschland.

Legionnaires' disease (LD) is a severe form of pneumonia which is caused by bacteria of the genus Legionella. They are widespread in fresh water and can also colonize technical water systems where they might present an infection risk. Since 2001, notification of laboratory-confirmed LD is mandatory in Germany. From 2001-2009, a total of 3672 cases of LD were registered. During the first 7 years, case numbers increased (2001: 127; 2007: 536 cases) but have remained stable during the past 2 years (2008: 525; 2009: 503 cases). In 2009, 49.6% of cases were attributed to an infection in the community, 33.2% were travel associated, and 13.6% were nosocomial. The average case fatality rate between 2001 and 2009 was 6.5%. However, the case fatality rate of nosocomial cases was three times as high compared to cases with non-nosocomial exposure. The network for community-acquired Legionnaires' disease (CAPNETZ) estimates that there are 20,000 cases per year in Germany. Thus, the number of reported cases represents only a small proportion of the actually occurring cases. It is likely that specific LD-diagnostics are insufficiently used. Hence, physicians should test more patients with pneumonia for LD. In particular, because of the high case fatality, nosocomial pneumonia cases need to be tested; identified LD cases require rigorous investigational and corrective action. In order to obtain evidence-based data on the relationship of water contamination and the risk for LD, it would be desirable, if (in addition to the patients' epidemiological data) the results of water texts relating to a given case were also reported systematically.

Household transmissibility and other characteristics of seasonal oseltamivir-resistant influenza A(H1N1) viruses, Germany, 2007-8.

During the influenza season 2007-8, the proportion of seasonal influenza A(H1N1) viruses resistant to the neuraminidase inhibitor oseltamivir increased worldwide. We conducted an investigation to compare patients infected with oseltamivir-resistant (ose-R) and oseltamivir- susceptible (ose-S) influenza A(H1N1) viruses regarding risk factors for resistance and the capability to transmit in the household setting. Within a cohort of 396 laboratory confirmed influenza patients from sentinel physicians we conducted a nested case-control study among patients infected with A(H1N1). Thirty patients in the cohort were infected with influenza B, none with influenza A(H3N2) and 366 with A(H1N1). Of the 366 A(H1N1) viruses 52 (14%) were ose-R. Demographic characteristics, oseltamivir exposure, travel history and outcome were not significantly different between ose-S and ose-R patients. Among 133 households in the nested case-control study, secondary household attack rates in households with ose-R cases and households with ose-S cases were similar (23 versus 26%; p-value=0.54). Ose-R household status and occurrence of secondary cases were associated with an odds ratio of 0.85 (95% confidence interval 0.38-1.88). We conclude that seasonal ose-R influenza A(H1N1) viruses have transmitted well in the household setting.

Oseltamivir-resistant influenza A(H1N1) viruses detected in Europe during season 2007-8 had epidemiologic and clinical characteristics similar to co-circulating susceptible A(H1N1) viruses.

During the 2007-08 influenza season, high levels of oseltamivir resistance were detected among influenza A(H1N1) viruses ina number of European countries. We used surveillance data to describe influenza A(H1N1) cases for whom antiviral resistance testing was performed. We pooled data from national studies to identify possible risk factors for infection with a resistant virus and to ascertain whether such infections led to influenza illness of different severity. Information on demographic and clinical variables was obtained from patients or their physicians. Odds ratios for infection with an oseltamivir resistant virus and relative risks for developing certain clinical outcomes were computed and adjusted through multivariable analysis. Overall, 727 (24.3%) of 2,992 tested influenza A(H1N1) viruses from 22 of 30 European countries were oseltamivir-resistant. Levels of resistance ranged from 1% in Italy to 67% in Norway. Five countries provided detailed case-based data on 373 oseltamivir resistant and 796 susceptible cases. By multivariable analysis, none of the analysed factors was significantly associated with an increased risk of infection with anoseltamivir-resistant virus. Similarly, infection with an oseltamivir-resistant virus was not significantly associated with a different risk of pneumonia, hospitalisation or any clinical complication. The large-scale emergence of oseltamivir-resistant viruses in Europe calls for a review of guidelines for influenza treatment.

[Investigation of a family cluster of influenza A/H1N1 infections in Germany, 2009]. / Untersuchungen zu einem familiären Cluster von Infektionen durch Influenza A/H1N1 in Deutschland, 2009.

INTRODUCTION: On May 3, 2009, a first case of influenza A/H1N1 infection occurred in the federal state of Saxony-Anhalt, Germany. In order to stop the possible spread of the virus and to study the epidemiological and clinical characteristics of the infection, an investigation was launched by the local health authorities and the RKI. METHODS: Standardised questionnaires were used to assess demographic and clinical data. Specimens were collected from case patients and close contacts and were analysed for influenza A/H1N1 using real-time PCR. RESULTS: The index patient showed fever and coughing 3.5 days after returning from a holiday in Mexico. The local health authorities were informed on May 3, and measures were rapidly implemented. These measures included a trace-back of possible contact persons, isolation of the case and close contacts, prophylactic treatment with Oseltamivir. Virological investigations showed that the case shedded viral genome up until the last day of antiviral therapy. Viral genome was also detected in the spouse and the son of the patient. Both showed no symptoms under a prophylactic treatment with antiviral medication. No viral genome was detected in three other family members, and in six other contact persons outside of the family. DISCUSSION: The spread of the virus was contained due to the fast response of the local health authorities. Two secondary cases occurred in the family. These cases remained asymptomatic, possibly due to antiviral prophylaxis. Epidemiological and virological results suggest that the influenza A/H1N1 virus has a longer incubation period and that viral shedding may probably be prolonged when compared with seasonal influenza.

[Nosocomial Legionnaires' disease--results from the analysis of Germany's surveillance data; 2004-2006]. / Legionärskrankheit in Deutschland unter besonderer Berücksichtigung der im Krankenhaus oder in einer Pflegeeinrichtung erworbenen Erkrankungen, 2004-2006.

Legionella bacteria colonize drinking water systems and can cause severe pneumonia in humans (Legionnaires' disease (LD)). The German network for community-acquired pneumonia (CAPNETZ) estimates 15,000-30,000 new cases of LD per year in Germany. LD cases are divided into those that were acquired in the context of a stay in a hospital or nursing home (healthcare-associated; HCA), in the community (community-acquired (CA)) or during travel (travelassociated (TA)). According to the recommendations of the Communicable Disease Surveillance Centre (CDSC; UK) and the Healthcare Infection Control Practices Advisory Committee (HICPAC; USA) a single case of nosocomial LD should prompt an epidemiologic and, depending on its results, also technical investigation of the institution. In this study we present data from nosocomial cases of LD in the context of all cases of LD that were reported to the Robert Koch Institute (RKI) within the mandatory surveillance system from 2004 through 2006. We calculated the number of cases per population (incidence), the number of cases per person-days at risk (incidence rate) and case fatality. The analysis comprised 1,339 cases of LD. Among the 942 cases with one of the three categories of exposure CALD was reported in 58 % (547 cases), TALD in 29 % (270 cases) and HCA-LD in 13 % (125 cases). The incidence rate of TALD was 9-fold, but that of HCA-LD 15-fold higher than that of CALD. Case fatality of HCA-LD was 13 % and thus higher than that of CALD (9 %) and TALD (5 %). HCA-LD cases were reported from all states and included 77 different counties. Reporting counties represent the place of residence of the LD case-patients. German notification data show that cases of LD, and likely also HCALD, are underreported. Incidence rate and case fatality are highest in HCA-LD. HCA-LD occurs widespread. These results and the preventability of HCA-LD support the recommendation to thoroughly investigate single cases of HCA-LD in hospitals and nursing homes.

ATP-dependent transport of glutathione S-conjugates by the multidrug resistance-associated protein.

The ATP-dependent transport of the endogenous glutathione conjugate leukotriene C4 (LTC4) was more than 25-fold higher in membrane vesicles prepared from human leukemia cells (HL60/ADR) overexpressing the multidrug resistance-associated protein than from drug-sensitive parental HL60 cells or revertant cells. Similar results were obtained with S-(2,4-dinitrophenyl)glutathione as substrate. Photoaffinity labeling detected preferentially in the HL60/ADR membranes a 190-kilodalton protein binding [3H]LTC4 and 8-azido[alpha-32P]ATP. The [3H]LTC4-labeled 190-kilodalton protein was immunoprecipitated by an antiserum against the COOH-terminal sequence of multidrug resistance-associated protein. Our results indicate that multidrug resistance-associated protein mediates the ATP-dependent transport of LTC4 and structurally related anionic amphiphilic conjugates.

Transport of glutathione, glucuronate, and sulfate conjugates by the MRP gene-encoded conjugate export pump.

Previous studies have identified the ATP-dependent export of glutathione conjugates as a physiological function of the multidrug resistance protein (MRP). The involvement of MRP in the transport of endogenous and xenobiotic conjugates was investigated further using membrane vesicles from MRP-transfected HeLa cells. The ATP-dependent transport of the glutathione conjugates [(3)H]leukotriene C(4), S-(2,4-dinitrophenyl)-[(3)H]glutathione, and (3)H- labeled oxidized glutathione was characterized by determination of the transport efficiency V(max):K(m) amounting to 1031, 114, and 7.1 ml multiplied by min(-1), respectively. Additional endogenous substrates for MRP-mediated transport included the steroid conjugate 17 beta- glucuronosyl [(3)H]estradiol and the bile salt conjugates [6 alpha-(14)C]glucuronosylhyodeoxycholate and 3 alpha-sulfatolithocholyl [(3)H]taurine. The K(m) value of MRP for 17-beta-glucuronosyl [(3)H]estradiol was 1.5 +/- 0.3 microM, with a V(max):K(m) ratio of 42 ml multiplied by mg protein(-1) multiplied by min(-1), and a K(i) value of 0.7 microM for the leukotriene receptor antagonist MK 571. MRP-mediated ATP-dependent transport was observed for the anticancer drug conjugates glucuronosyl [(3)H]etoposide and monocholoro-mono[(3)H]glutathionyl melphalan, but not for unmodified [(14)C]doxorubicin, [(3)H]daunorubicin, or [(3)H]vinblastine. Our results establish that MRP functions as an ATP-dependent export pump not only for glutathione conjugates but also for glucuronidated and sulfated endogenous as well as exogenous compounds.

An outbreak of Salmonella München in Germany associated with raw pork meat.

In summer 2001, an outbreak of Salmonella München occurred in Germany. We conducted descriptive epidemiology and hypothesis-generating interviews among case patients, two retrospective cohort studies, and a case-control study of suboutbreaks. We performed pulsed-field gel electrophoresis (PFGE) from selected patient isolates and a limited trace-back investigation for analytical purposes. Four states were consecutively affected: Saxonia (SX), Brandenburg (BB), Berlin (BE), and Baden-Württemberg (BW). Although hypothesis-generating interviews failed to identify a plausible food item, descriptive data and investigations of the suboutbreaks suggested pork meat as a probable source in three states (SX, BB, and BE) but not in BW. The PFGE profiles from isolates of case patients in the first three states were indistinguishable but differed from PFGE profiles of case patients in BW. Trace-back investigation suggested that contamination of pork meat occurred early in the rearing-production chain. This outbreak demonstrates how contamination early in the production process that can yield different end products may complicate multistate outbreaks. Investigation of suboutbreaks and use of the trace-back method as investigational tools may be useful adjuncts in solving the problem of multistate outbreaks.

Induction of apoptosis in human cancer cells by targeting mitochondria with gold nanoparticles.

A major challenge in designing cancer therapies is the induction of cancer cell apoptosis, although activation of intrinsic apoptotic pathways by targeting gold nanoparticles to mitochondria is promising. We report an in vitro procedure targeting mitochondria with conjugated gold nanoparticles and investigating effects on apoptosis induction in the human breast cancer cell line Jimt-1. Gold nanoparticles were conjugated to a variant of turbo green fluorescent protein (mitoTGFP) harbouring an amino-terminal mitochondrial localization signal. Au nanoparticle conjugates were further complexed with cationic maltotriose-modified poly(propylene imine) third generation dendrimers. Fluorescence and transmission electron microscopy revealed that Au nanoparticle conjugates were directed to mitochondria upon transfection, causing partial rupture of the outer mitochondrial membrane, triggering cell death. The ability to target Au nanoparticles into mitochondria of breast cancer cells and induce apoptosis reveals an alternative application of Au nanoparticles in photothermal therapy of cancer.

Human members of the SCO1 gene family: complementation analysis in yeast and intracellular localization.

Cytochrome c oxidase is a multiprotein complex in the mitochondrial membrane whose biogenesis requires a number of proteins besides the structural subunits. Several yeast proteins as well as a human disease-related protein have been reported which are involved in cytochrome c oxidase assembly. The S. cerevisiae Sco1p protein has been implicated in the transfer of copper to cytochrome c oxidase subunits Cox1p and/or Cox2p. Here we report on the complementation behavior in yeast of two recently identified ScSco1p homologs of chromosome 17 and chromosome 22 from human. When allotropically expressed in yeast, both genes fail to complement the lack of the ScSCO1 gene. However, a chimera of the N-terminal half of ScSco1p and the C-terminal half of the chromosome 17 homolog does substitute for the ScSco1p function. Interestingly, the respective chimera with the human homolog of chromosome 22 is not able to complement. Expression of EGFP fusions in HeLa cells shows that both human ScSco1p homologs are located in the mitochondria of human cells.

Varicella outbreaks after vaccine licensure: should they make you chicken?

In 1998, 3 years after vaccine licensure, child care centers (CCC) in Los Angeles County continued to report varicella outbreaks. We investigated outbreaks at 2 CCCs to determine the cause for them, such as low vaccination coverage levels or unexpected low vaccine effectiveness. We collected information on past history of varicella, illness during the outbreak, and prior varicella vaccination among CCC attendees. We found that CCC "H" had a vaccination coverage of 87% (34/39) compared with 30% (6/20) in CCC "L." The overall attack rate was lower in CCC "H" (31%) than in "L" (61%; P value =.03). Vaccine effectiveness for any varicella was 71% in "H" and 100% in "L." Vaccinated children with varicella had milder disease than unvaccinated. In conclusion, we found varicella outbreaks in CCCs with both high and low vaccination coverage. Vaccine effectiveness was within the range predicted by the literature. Vaccination led to a lower attack rate in the highly vaccinated CCC and appeared to protect from severe disease.