Enteropathisches hämolytisch-urämisches Syndrom: Sporadischer Einzelfall oder Teil eines Krankheitsausbruchs?

Das hämolytisch-urämische Syndrom (HUS) ist ein lebensbedrohlicher Zustand, charakterisiert durch akutes Nierenversagen, hämolytische Anämie und Thrombozytopenie. In >80% der Fälle liegen gastrointestinale Infektionen mit enterohämorrhagischen Escherichia coli (EHEC) zugrunde. Diese enterisch-infektiöse (enteropathische) Form des HUS tritt meist bei Kindern unter 6 Jahren auf. Da u. U. rasch eine Blutreinigung eingeleitet werden muss, sollten die Betroffenen in spezialisierten Kinderdialysezentren behandelt werden. Aufgrund der überwiegend enterisch-infektiösen Ätiologie können vereinzelt auftretende Fälle wichtige Hinweise auf Erkrankungshäufungen liefern. In Deutschland treten Infektionen mit einer seltenen Sorbitol fermentierenden Variante von EHEC O157 auf, die schon mehrfach in HUS-Krankheitsausbrüchen mit Todesfällen resultierten. Bereits der Verdacht sowie die Erkrankung oder der Tod an enteropathischem HUS sind durch den feststellenden Arzt unverzüglich an das zuständige Gesundheitsamt zu melden. Dadurch können zeitnah Maßnahmen zur Verhinderung der Ausbreitung der Infektion getroffen werden. Die epidemischen Aspekte des EHEC-assoziierten HUS werden dargestellt, und Kinderärzten Hilfestellungen im Hinblick auf eine frühzeitige Diagnose und Meldung gegeben.Hemolytic uremic syndrome (HUS) is a life-threatening condition characterized by acute renal failure, hemolytic anemia and thrombocytopenia. More than 80% of pediatric HUS is caused by infection with enterohemorrhagic Escherichia coli (EHEC). EHEC-associated HUS mainly affects children under six years of age. HUS patients should be treated in specialized clinics, which are able to provide dialysis. Importantly, sporadic cases of HUS can signalize outbreaks of EHEC infections. In Germany, a rare sorbitol-fermenting variant of EHEC O157 caused several large HUS outbreaks with fatal cases. Physicians are required to notify every suspected, confirmed or fatal case of HUS to their local health department, thereby enabling public health authorities to intervene promptly. This article describes the epidemic aspects of EHEC-associated HUS and assists physicians and pediatricians in terms of timely diagnosis and notification

Timeliness of Surveillance during Outbreak of Shiga Toxin–producing Escherichia coli Infection, Germany, 2011

In the context of a large outbreak of Shiga toxin–producing Escherichia coli O104:H4 in Germany, we quantified the timeliness of the German surveillance system for hemolytic uremic syndrome and Shiga toxin–producing E. coli notifiable diseases during 2003–2011. Although reporting occurred faster than required by law, potential for improvement exists at all levels of the information chain

Measles transmission from an anthroposophic community to the general population, Germany 2008

<p>Abstract</p> <p>Background</p> <p>In Germany, measles vaccination coverage with two doses is not yet sufficient to prevent regional outbreaks. Among the 16 German federal states, vaccination coverage was lowest in Bavaria with 85% in 2008. From March to mid-April 2008, four neighbouring Bavarian counties reported 55 measles-cases mostly linked to an ongoing measles outbreak in an anthroposophic school in Austria. We investigated this outbreak to guide future public health action.</p> <p>Methods</p> <p>We applied the German national case-definition for measles and collected data using the national surveillance system and a questionnaire. Measles cases with disease onset a maximum of 18 days apart and spatial contact (e.g. same household, same school) were summed up in clusters. Two different interventions, which were implemented in schools and kindergartens in Bavaria, were compared by their impact on the size and duration of measles clusters. Susceptible persons were excluded from schools or kindergartens either with the first (intervention A) or second (intervention B) measles case occurring in the respective institution.</p> <p>Results</p> <p>Among the 217 Bavarian measles cases identified from March-July 2008, 28 (13%) cases were attendees of the anthroposophic school in Austria. In total, vaccination status was known in 161 (74%) cases and 156 (97%) of them were not vaccinated. The main factor for non-vaccination was "fear of vaccine-related adverse events" (33%). Twenty-nine (18%) of 161 cases suffered complications. Exclusively genotype D5 was detected. Overall, 184 cases could be epidemiologically grouped into 59 clusters. Of those, 41 clusters could be linked to households and 13 to schools or kindergartens. The effect of intervention A and B was analysed in 10 school or kindergarten clusters. Depending on the respective intervention A or B, the median number of cases per cluster was 3 versus 13 (p = 0.05), and the median duration of a cluster was 3 versus 26 days (p = 0.13).</p> <p>Conclusions</p> <p>Introduction of measles virus into a pocket of susceptible persons (e.g. vaccination opponents or sceptics) may lead to large outbreaks in the general population, if the general population's vaccination coverage is below the WHO recommended level. Education on the safety of measles vaccine needs to be strengthened to increase measles vaccination coverage. Early intervention may limit spread in schools or kindergartens. Suspected measles has to be reported immediately to the local health authorities in order to allow intervention as early as possible.</p

Increasing Occurrence of Multidrug-Resistance in Acinetobacter baumannii Isolates From Four German University Hospitals, 2002–2006

Background: Acinetobacter baumannii can cause severe infections, mainly in critically ill inpatients. Treatment is complicated by multidrug-resistance (MDR). In Germany, to date, little is known on the extent of MDR in A. baumannii isolated from inpatients in German hospitals and potential factors influencing the emergence of MDR. Materials and Methods: We retrospectively analysed the data of A. baumannii isolates from the inpatients of four German university hospitals, tested for antimicrobial resistance with the broth dilution method between 2002 and 2006. We defined MDR as resistance to three or more classes of recommended drugs. After calculating the proportions of MDR in A. baumannii isolates, we investigated the association between MDR in A. baumannii and year of pathogen isolation, hospital, ward type, specimen and demographics. We performed descriptive analysis and multivariable logistic regression. Additionally, proportions of in vitro drug effectiveness against multidrug-resistant and non-multidrugresistant A. baumannii isolates were determined. Results: MDR was found in 66 of 1,190 (5.6%) A. baumannii isolates and increased from 2.1% in 2002 to 7.9% in 2006. The highest proportions of MDR were found in hospital A (8.9%), in intensive care units (7.3%), in isolates from blood (7.6%) and in male patients aged 60 years or older (6.6%). In multivariable analysis, the chance of MDR in A. baumannii isolates increased with the successive years of pathogen isolation (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1–1.5) and there was a higher risk of MDR in A. baumannii in intensive care units (OR 1.8, 95% CI 1.1–2.9). The lowest in vitro antibiotic resistance was found in meropenem, imipenem and ampicillin/sulbactam, with 33, 37 and 39% for multidrugresistant and 0.4, 1 and 3% in non-multidrug-resistant A. baumannii isolates, respectively. Conclusions: The increase of MDR in A. baumannii isolates from 2002 to 2006 in four hospitals suggests that clinicians in Germany may expect a rising proportion of MDR in A. baumannii isolates among inpatients. The antimicrobial susceptibility testing of A. baumannii isolates against recommended drugs, combined with in-house antimicrobial resistance surveillance, is needed to ensure appropriate treatment

Food-borne norovirus-outbreak at a military base, Germany, 2009

Background: Norovirus is often transmitted from person-to-person. Transmission may also be food-borne, but only few norovirus outbreak investigations have identified food items as likely vehicles of norovirus transmission through an analytical epidemiological study. During 7-9 January, 2009, 36 persons at a military base in Germany fell ill with acute gastroenteritis. Food from the military base’s canteen was suspected as vehicle of infection, norovirus as the pathogen causing the illnesses. An investigation was initiated to describe the outbreak’s extent, to verify the pathogen, and to identify modes of transmission and source of infection to prevent further cases. Methods: For descriptive analysis, ill persons were defined as members of the military base with acute onset of diarrhoea or vomiting between 24 December 2008, and 3 February 2009, without detection of a pathogen other than norovirus in stools. We conducted a retrospective cohort study within the headquarters company. Cases were military base members with onset of diarrhoea or vomiting during 5-9 January. We collected information on demographics, food items eaten at the canteen and contact to ill persons or vomit, using a self-administered questionnaire. We compared attack rates (AR) in exposed and unexposed persons, using bivariable and multivariable logistic regression modelling. Stool specimens of ill persons and canteen employees, canteen food served during 5-7 January and environmental swabs were investigated by laboratory analysis. Results: Overall, 101/815 (AR 12.4%) persons fell ill between 24 December 2008 and 3 February 2009. None were canteen employees. Most persons (n = 49) had disease onset during 7-9 January. Ill persons were a median of 22 years old, 92.9% were male. The response for the cohort study was 178/274 (72.1%). Of 27 cases (AR 15.2%), 25 had eaten at the canteen and 21 had consumed salad. Salad consumption on 6 January (aOR: 8.1; 95%CI: 1.5-45.4) and 7 January (aOR: 15.7; 95%CI: 2.2-74.1) were independently associated with increased risk of disease. Norovirus was detected in 8/28 ill persons’ and 4/25 canteen employees’ stools, 6/55 environmental swabs and 0/ 33 food items. Sequences were identical in environmental and stool samples (subtype II.4 2006b), except for those of canteen employees. Control measures comprised cohort isolation of symptomatic persons, exclusion of norovirus- positive canteen employees from work and disinfection of the canteen’s kitchen. Conclusions: Our investigation indicated that consumption of norovirus-contaminated salad caused the peak of the outbreak on 7-9 January. Strict personal hygiene and proper disinfection of environmental surfaces remain crucial to prevent norovirus transmission

Update on the ongoing outbreak of haemolytic uraemic syndrome due to Shiga toxin-producing Escherichia coli (STEC) serotype O104, Germany, May 2011

Since early May 2011, a large outbreak of haemolytic uraemic syndrome (HUS) and bloody diarrhoea related to infections with Shiga toxin-producing Escherichia coli (STEC) has been observed in Germany. The outbreak is focused in the north, but cases have been reported from all German states and other countries. Since our report last week, the number of HUS cases has increased to 470 and STEC serotype O104 has been confirmed in many cases