Influenza-attributable deaths in south-eastern France (1999 to 2010): mortality predictions were undependable.

BACKGROUND: Following the 2009 influenza pandemic, several studies showed that the mortality pattern associated with the A(H1N1)2009 virus primarily affected children and young adults. In this study, we aimed to estimate the influenza-attributable deaths during the periods from 1999 to 2010, in the Provence-Alpes-Côte-d'Azur (PACA) region of south-eastern France in order to corroborate the hypothesis that (i) influenza-attributable deaths caused by A(H1N1)2009 strain were much lower than initially expected. METHODS: In order to compare our results with published data, we used the same statistical model of an Austrian team, using a Poisson model adjusted on co-circulating respiratory syncytial virus to explain the weekly mortality. RESULTS: We assessed that 5.7% of the respiratory deaths were attributable to influenza virus during the 2009-2010 pandemic season. This mortality was lower than that observed during the ten preceding epidemic periods (13.8% on average). Age group-based analysis revealed that during the pandemic period, the groups under 65 had a systematically higher excess of respiratory mortality while the age group over 65 had a much lower mortality than during the seasonal epidemic seasons. Similarly, among the less specific outcome (non violent and cardiovascular mortality) the age groups over 45 had higher excess of mortality during the seasonal epidemics than during the pandemic period. CONCLUSIONS: Since most of the influenza mortality is commonly observed in the elderly group (>65 year-old), the moderate elderly mortality during the 2009 pandemic period has impacted the total mortality, and has resulted in a reduced total mortality despite an increased mortality in the young age group. Despite using identical parameters and the same approach as in a previously published study using an Austrian population sample, we observed a lower excess respiratory mortality in the south-eastern France than in Vienna. Thus, the pandemic virus caused less death than the epidemic viruses that circulated during the preceding years. In contrast with catastrophic predictions made in the early phase of the pandemic, human lives were saved during the circulation period of A(H1N1)2009 virus, resulting in a lower overall mortality.

Recurrent bilateral Mycobacterium bovis necrotizing epididymitis: a case report.

BACKGROUND: Mycobacterium bovis causing tuberculosis in animals is responsible for zoonotic tuberculosis in patients. Veterinary control measures and milk pasteurization has led to a significant decrease in human cases of M. bovis infections in developed countries. CASE PRESENTATION: We diagnosed recurrent M. bovis epididymitis in a 63-year old Caucasian man without any signs of pulmonary or disseminated disease. Relevant epidemiological expositions included camel milk drinking during prolonged travels in Niger, prior to initial clinical manifestations. The diagnosis was firmly established by mass spectrometry and DNA sequencing on epididymis surgical biopsy specimens. We detail therapeutic management which included surgical epididymectomy and hydrocele repair. CONCLUSION: As for other M. tuberculosis complex species, the genitourinary tract represents a frequent site of secondary dissemination and latency for M. bovis. Isolated epididymis infection is a newly documented manifestation of M. bovis disease.

Paradoxical Effect of Chloroquine Treatment in Enhancing Chikungunya Virus Infection.

Since 2005, Chikungunya virus (CHIKV) re-emerged and caused numerous outbreaks in the world, and finally, was introduced into the Americas in 2013. The lack of CHIKV-specific therapies has led to the use of non-specific drugs. Chloroquine, which is commonly used to treat febrile illnesses in the tropics, has been shown to inhibit CHIKV replication in vitro. To assess the in vivo effect of chloroquine, two complementary studies were performed: (i) a prophylactic study in a non-human primate model (NHP); and (ii) a curative study "CuraChik", which was performed during the Reunion Island outbreak in 2006 in a human cohort. Clinical, biological, and immunological data were compared between treated and placebo groups. Acute CHIKV infection was exacerbated in NHPs treated with prophylactic administration of chloroquine. These NHPs displayed a higher viremia and slower viral clearance (p < 0.003). Magnitude of viremia was correlated to the type I IFN response (Rho = 0.8, p < 0.001) and severe lymphopenia (Rho = 0.8, p < 0.0001), while treatment led to a delay in both CHIKV-specific cellular and IgM responses (p < 0.02 and p = 0.04, respectively). In humans, chloroquine treatment did not affect viremia or clinical parameters during the acute stage of the disease (D1 to D14), but affected the levels of C-reactive Protein (CRP), IFNα, IL-6, and MCP1 over time (D1 to D16). Importantly, no positive effect could be detected on prevalence of persistent arthralgia at Day 300. Although inhibitory in vitro, chloroquine as a prophylactic treatment in NHPs enhances CHIKV replication and delays cellular and humoral response. In patients, curative chloroquine treatment during the acute phase decreases the levels of key cytokines, and thus may delay adaptive immune responses, as observed in NHPs, without any suppressive effect on peripheral viral load.

Sternoclavicular joint infection caused by Coxiella burnetii: a case report.

BACKGROUND: Few cases of Q fever osteoarticular infection have been reported, with chronic osteomyelitis as the most common manifestation of Q fever osteoarticular infection. Here we present the case of a sternoclavicular joint infection caused by Coxiella burnetii and localized by positron emission tomography scanning. CASE PRESENTATION: A 67-year-old French man from south France was hospitalized for fever and confusion. An examination revealed subclavicular and axillary lymph node enlargement. Computed tomography scanning and transesophageal echocardiogram were normal, and magnetic resonance imaging scanning did not reveal signs of infection. An immunofluorescence assay of an acute serum sample was positive for C. burnetii and he was treated with 200 mg doxycycline for 21 days. An immunofluorescence assay of convalescent serum sampled after 2 months revealed very high C. burnetii antibody titers. To localize the site of the infection, we performed positron emission tomography scanning, which revealed intense fluorodeoxyglucose uptake in his right sternoclavicular joint; treatment with 200 mg oral doxycycline daily and 200 mg oral hydroxychloroquine three times daily for 18 months was initiated. CONCLUSIONS: Q fever articular infections may be undiagnosed, and we strongly urge the use of positron emission tomography scanning in patients with high C. burnetii antibody titers to localize the site of C. burnetii infection.

Respiratory viruses within homeless shelters in Marseille, France.

BACKGROUND: Homeless shelters are identified as places where humans are at high risk of acquiring respiratory disease. We previously reported the prevalence of the main respiratory diseases affecting a population of homeless in Marseille, France. Here, we investigated the prevalence of 10 respiratory viruses in a similar homeless population during 2 successive winter seasons. FINDINGS: Following a clinical examination, we collected nasal specimens from which the RT-PCR detection of 10 respiratory viruses was performed through snapshot investigations. Among the 265 patients included, 150 (56.6%) reported at least one respiratory symptom of which 13 (8.7%) had positive swabs for at least one respiratory virus, and 115 patients reported any respiratory symptom of which 10 (8.7%) had positive swabs for respiratory virus. Overall, 23 patients had positive swabs for at least one respiratory virus. Human rhinovirus (HRV) was the predominant virus (13 isolates) followed by enteroviruses (3), human metapneumovirus (2), human coronavirus OC43 (2), 229E virus (2) and human respiratory syncytial virus subtype B (1). Among the patients infected with HRV, 10 were collected during the same snapshot. CONCLUSIONS: Although one half of the patients reported respiratory symptoms, the prevalence of respiratory viruses was within the range of that previously described in adult asymptomatic patients outside the homeless community. Most HRV-positive swabs were collected during the same snapshot suggesting a local outbreak. No influenza viruses were found despite the fact that one half of the patients were investigated during the peak of the seasonal influenza epidemic in Marseille.

Widespread circulation of a new echovirus 30 variant causing aseptic meningitis and non-specific viral illness, South-East France, 2013.

BACKGROUND: Human enteroviruses (HEVs) are major cause of aseptic meningitis. A new outbreak of E-30 occurred between April and September 2013 in Marseille, South-East France. OBJECTIVES: Better understand what happen locally when an E-30 outbreak occurs. STUDY DESIGN: Laboratory data (identification and characterization of circulating E-30 strains by partial/complete genome sequencing) were analyzed together with clinical data from emergency ward of the public hospital of Marseille. RESULTS: Compared with data from previous years, we observed an excess of HEV infections between April and September 2013. A total of 202 patients were tested positive of which 79% (160/202) had a cerebrospinal fluid tested positive. Because we performed genotyping using clinical specimens, we obtained representative molecular data related to patients tested positive and found a majority (105/119) of echoviruses 30 (E-30). Phylogenetic analysis revealed that E-30 circulating in Europe since 2000 belong to a unique lineage and showed at the intra-genogroup level the temporal circulation of E-30. Molecular data also indicated that majority of E-30 detected (92%) were almost identical. Compared with data from previous years, this outbreak was finally associated with an excess of patients admitted to an emergency ward for meningitis but also for non-specific viral illness. CONCLUSIONS: Our data provide new insights into microevolution of E-30: almost all E-30 emerged from local circulation of one parental virus. Moreover, our findings showed that HEV outbreaks cause an excess of emergency ward consultations but probably also an excess of consultations to general practitioners who receive majority of the non-specific viral illness.

First reported chikungunya fever outbreak in the republic of Congo, 2011.

BACKGROUND: Chikungunya is an Aedes -borne disease characterised by febrile arthralgia and responsible for massive outbreaks. We present a prospective clinical cohort study and a retrospective serological study relating to a CHIK outbreak, in the Republic of Congo in 2011. METHODOLOGY AND FINDINGS: We analysed 317 suspected cases, of which 308 (97.2%) lived in the city of Brazzaville (66.6% in the South area). Amongst them, 37 (11.7%) were CHIKV+ve patients (i.e., biologically confirmed by a real-time RT-PCR assay), of whom 36 (97.3%) had fever, 22 (66.7%) myalgia and 32 (86.5%) arthralgia. All tested negative for dengue. The distribution of incident cases within Brazzaville districts was compared with CHIKV seroprevalence before the outbreak (34.4% in 517 blood donors), providing evidence for previous circulation of CHIKV. We applied a CHIK clinical score to 126 patients recruited within the two first day of illness (including 28 CHIKV+ves (22.2%)) with sensitivity (78.6%) and specificity (72.4%) values comparing with those of the referent study in Reunion Island. The negative predictive value was high (92%), but the positive predictive value (45%) indicate poor potential contribution to medical practice to identify CHIKV+ve patients in low prevalence outbreaks. However, the score allowed a slightly more accurate follow-up of the evolution of the outbreak than the criterion "fever+arthralgia". The complete sequencing of a Congolase isolate (Brazza_MRS1) demonstrated belonging to the East/Central/South African lineage and was further used for producing a robust genome-scale CHIKV phylogenetic analysis. CONCLUSIONS/SIGNIFICANCE: We describe the first Chikungunya outbreak declared in the Republic of Congo. The seroprevalence study conducted amongst blood donors before outbreak provided evidence for previous CHIKV circulation. We suggest that a more systematic survey of the entomological situation and of arbovirus circulation is necessary in Central Africa for better understanding the environmental, microbiological and sociological determinants of emergence.

Chikungunya fever: a clinical and virological investigation of outpatients on Reunion Island, South-West Indian Ocean.

BACKGROUND: Chikungunya virus (CHIKV) is responsible for acute febrile polyarthralgia and, in a proportion of cases, severe complications including chronic arthritis. CHIKV has spread recently in East Africa, South-West Indian Ocean, South-Asia and autochthonous cases have been reported in Europe. Although almost all patients are outpatients, medical investigations mainly focused on hospitalised patients. METHODOLOGY/PRINCIPAL FINDINGS: Here, we detail clinico-biological characteristics of Chikungunya (CHIK) outpatients in Reunion Island (2006). 76 outpatients with febrile arthralgia diagnosed within less than 48 hours were included by general practitioners during the CuraChik clinical trial. CHIK was confirmed in 54 patients and excluded in 22. A detailed clinical and biological follow-up was organised, that included analysis of viral intrahost diversity and telephone survey until day 300. The evolution of acute CHIK included 2 stages: the 'viral stage' (day 1-day 4) was associated with rapid decrease of viraemia and improvement of clinical presentation; the 'convalescent stage' (day 5-day 14) was associated with no detectable viraemia but a slower clinical improvement. Women and elderly had a significantly higher number of arthralgia at inclusion and at day 300. Based on the study clinico-biological dataset, scores for CHIK diagnosis in patients with recent febrile acute polyarthralgia were elaborated using arthralgia on hands and wrists, a minor or absent myalgia and the presence of lymphopenia (<1G/L) as major orientation criteria. Finally, we observed that CHIKV intra-host genetic diversity increased over time and that a higher viral amino-acid complexity at the acute stage was associated with increased number of arthralgia and intensity of sequelae at day 300. CONCLUSIONS/SIGNIFICANCE: This study provided a detailed picture of clinico-biological CHIK evolution at the acute phase of the disease, allowed the elaboration of scores to assist CHIK diagnosis and investigated for the first time the impact of viral intra-host genetic diversity on the disease course.

Comparative analysis of rodent tissue preservation methods and nucleic acid extraction techniques for virus screening purposes.

The polymerase chain reaction (PCR) has become an essential method for the detection of viruses in tissue specimens. However, it is well known that the presence of PCR inhibitors in tissue samples may cause false-negative results. Hence the identification of PCR inhibitors and evaluation and optimization of nucleic acid extraction and preservation methods is of prime concern in virus discovery programs dealing with animal tissues. Accordingly, to monitor and remove inhibitors we have performed comparative analyses of two commonly used tissue storage methods and five RNA purification techniques using a variety of animal tissues, containing quantified levels of added MS2 bacteriophages as the indicator of inhibition. The results showed (i) no significant difference between the two methods of sample preservation, viz. direct storage at -80°C or 4°C in RNAlater, (ii) lung rodent tissues contained lower levels of inhibitor than liver, kidney and spleen, (iii) RNA extraction using the EZ1+PK RNA kit was the most effective procedure for removal of RT-PCR inhibitors.

Chikungunya fever: epidemiology, clinical syndrome, pathogenesis and therapy.

Chikungunya virus (CHIKV) is the aetiological agent of the mosquito-borne disease chikungunya fever, a debilitating arthritic disease that, during the past 7years, has caused immeasurable morbidity and some mortality in humans, including newborn babies, following its emergence and dispersal out of Africa to the Indian Ocean islands and Asia. Since the first reports of its existence in Africa in the 1950s, more than 1500 scientific publications on the different aspects of the disease and its causative agent have been produced. Analysis of these publications shows that, following a number of studies in the 1960s and 1970s, and in the absence of autochthonous cases in developed countries, the interest of the scientific community remained low. However, in 2005 chikungunya fever unexpectedly re-emerged in the form of devastating epidemics in and around the Indian Ocean. These outbreaks were associated with mutations in the viral genome that facilitated the replication of the virus in Aedes albopictus mosquitoes. Since then, nearly 1000 publications on chikungunya fever have been referenced in the PubMed database. This article provides a comprehensive review of chikungunya fever and CHIKV, including clinical data, epidemiological reports, therapeutic aspects and data relating to animal models for in vivo laboratory studies. It includes Supplementary Tables of all WHO outbreak bulletins, ProMED Mail alerts, viral sequences available on GenBank, and PubMed reports of clinical cases and seroprevalence studies.

Isolation of Toscana virus from the cerebrospinal fluid of a man with meningitis in Marseille, France, 2010.

Toscana virus (TOSV; Bunyaviridae, Phlebovirus) is an emerging arthropod-borne virus transmitted by phlebotomine sandflies. TOSV is a frequent cause of central nervous system infection during the warm season in several countries bordering the Mediterranean Sea. Here, we report a case of TOSV aseptic meningitis diagnosed in 2012 in Marseille, France. The virus strain was recovered in cell culture from the cerebrospinal fluid. New-generation sequencing based on Ion Torrent technology was used to determine its complete genome sequence. Phylogenetic analysis based on the partial L segment revealed that this isolate belongs to the lineage B together with other French, Spanish, and Moroccan strains. Although several cases of TOSV meningitis are reported in the literature, few of them are diagnosed by RT-PCR combined with virus isolation and further sequence characterization. This case report supports that virus isolation should be attempted whenever possible because this remains the gold standard technique for diagnosis of arthropod-borne viral infections.

Diagnostic issues and capabilities in 48 isolation facilities in 16 European countries: data from EuroNHID surveys.

BACKGROUND: Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. The sampling, handling and transport of specimens from patients with HIDs present specific bio-safety concerns. FINDINGS: The European Network for HID project aimed to record, in a cross-sectional study, the infection control capabilities of referral centers for HIDs across Europe and assesses the level of achievement to previously published guidelines. In this paper, we report the current diagnostic capabilities and bio-safety measures applied to diagnostic procedures in these referral centers. Overall, 48 isolation facilities in 16 European countries were evaluated. Although 81% of these referral centers are located near a biosafety level 3 laboratory, 11% and 31% of them still performed their microbiological and routine diagnostic analyses, respectively, without bio-safety measures. CONCLUSIONS: The discrepancies among the referral centers surveyed between the level of practices and the European Network of Infectious Diseases (EUNID) recommendations have multiple reasons of which the interest of the individuals in charge and the investment they put in preparedness to emerging outbreaks. Despite the fact that the less prepared centers can improve by just updating their practice and policies any support to help them to achieve an acceptable level of biosecurity is welcome.