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Eurosurveillance Weekly: Thursday 14 December 2000. Volume 4, Issue 50

Contents:
1. Evidence for increased transmission of syphilis among homosexual men and heterosexual men and
   women in Europe
2. Rapid reporting system for meningitis W135: 2a: P1.2, 5: update
3. Hepatitis A in tourists returning from Spain
4. Tuberculosis in Austria, 1999

Evidence for increased transmission of syphilis among homosexual men and
heterosexual men and women in Europe

Last year, Eurosurveillance Weekly reported an outbreak of syphilis among homosexual men in Norway
(1). Outbreaks of infectious syphilis have been reported to national communicable disease surveillance
centres in France, Ireland, and England this year.

Late in November 2000 the Institute de Veille Sanitaire, France, was informed of 10 cases of syphilis
(three primary, seven secondary) in the Paris area. The cases were diagnosed between February and
November 2000, five of them in the past six weeks. Nine of the cases are homosexual men, and five of
the 10 are HIV positive. An investigation is proceeding, and surveillance of syphilis in the Paris area has
been enhanced.

An investigation has begun into an outbreak of syphilis among gay men presenting to services for sexually
transmitted diseases in Dublin, Ireland. Twenty-one cases of primary or secondary syphilis (aged 23 to 46
years) have been reported in 2000, 15 of them since July 2000. Case ascertainment, contact tracing, and
intervention measures are being implemented.

Several outbreaks of infectious syphilis have arisen in England in 1999 and 2000. These have affected
homosexual men (Brighton, 15 cases) (2); homosexual men, heterosexual men, and women (Manchester,
71 cases – 52 in gay men) (3); and heterosexual men and women (Peterborough and North
Cambridgeshire, 13 cases) (4). A case of congenital syphilis has been linked to the Peterborough incident.
In all of these outbreaks, cases acquired infection in the United Kingdom through unprotected intercourse.
Investigation of these outbreaks has centred on active partner notification, enhanced surveillance of
syphilis at clinics for genitourinary medicine (GUM) in the affected areas, and investigation of social
networks that might facilitate further transmission of syphilis. Interventions that have been implemented
include enhancing public awareness of syphilis and distributing free condoms, alerting general
practitioners in the affected areas and all GUM physicians in England, targeting sexual health promotion,
and offering syphilis testing to GUM clinic attenders at risk.

Effective surveillance systems are needed for the swift identification of syphilis cases. Detailed clinical
information is needed for the formulation of appropriate intervention strategies. Materials for responding to
outbreaks of syphilis and other sexually transmitted infections, developed by the Communicable Disease
Surveillance Centre in London, are available to other national centres on request.

References:

1.   Blystad H, Nilsen Ø, Aavitsland P. An outbreak of syphilis among homosexual men in Oslo, Norway. Eurosurveillance Weekly
     1999; 3: 991118. (http://www.eurosurv.org/1999/991118.html)
2.   CDSC. Increased transmission of syphilis in men who have sex with men reported from Brighton and Hove. Commun Dis
     Report CDR Wkly 2000; 10: 177, 180. (http://www.phls.co.uk/publications/CDR00/cdr2000.pdf)
3.   CDSC. Increased transmission of syphilis in Manchester. Commun Dis Report CDR Wkly 2000; 10: 89.
     (http://www.phls.co.uk/publications/CDR00/cdr1000.pdf)
4.   CDSC. Outbreak of heterosexually acquired syphilis in Cambridgeshire. Commun Dis Report CDR Wkly 2000; 10: 401,4.
     (http://www.phls.co.uk/publications/CDR00/cdr4500.pdf)


Reported by Lorraine Doherty (ldoherty@phls.org.uk), Kevin Fenton (kfenton@phls.org.uk), Public Health
Laboratory Service Communicable Disease Surveillance Centre, London, England, Darina O’Flanagan
(darina.oflanagan@ndsc.ie), National Disease Surveillance Centre, Dublin, Republic of Ireland, and
Elisabeth Couturier (ecouturier@invs.sante.fr), Institut de Veille Sanitaire, Paris, France.



Rapid reporting system for meningitis W135: 2a: P1.2, 5: update
A month ago, Eurosurveillance Weekly reported on a rapid reporting system for meningitis W135: 2a:
P1.2, 5, set up by the European Commission and covering France, Germany, Ireland, the Netherlands,
Spain, and the United Kingdom (UK) (1). Seven cases of infection with Neisseria meningitidis of serogroup
W135: 2a: P1.2, 5 or compatible strains were reported between 28 October 2000 and 24 November. Of
the countries contributing to this surveillance, Ireland and Spain have yet to report cases.

Two cases of W135 N. meningitidis infection were reported from France. N. meningitidis W135: 2a: P1.2,
5 was isolated from a 6 month old boy who had died of meningococcal meningitis, and multilocus DNA
fingerprinting (using five genes) showed markers of electrophoretic type (ET)-37 complex. The blood of a
man aged 52 years yielded N. meningitidis W135: 2a: NST on which multilocus DNA fingerprinting also
showed markers of ET-37 complex.

Two cases were reported from Germany, both of whom recovered. Isolates of W135: NT: P1.2 were
found in an aspirate from the hip of a child aged 1 year with hip pain but no known septicaemia or
meningitis. W135: 2a: P1.2, 5 meningitis was reported in a Muslim boy aged 1 year. At the moment it is
not clear if these cases are connected to Mecca.

One case of N. meningitidis W135: 2a: P1.2, 5 was identified by the Netherlands Reference Laboratory for
Bacterial Meningitis in the week ending 24 November.

Two cases were reported from the UK. A 5 year old boy was admitted to a hospital in the north of England
(week ending 3 November) and died. Blood cultures grew W135: 2a:P1.2, 5. The boy was from a strict
Muslim Bangladeshi community and was not known to have travelled to Saudi Arabia recently, although
the possibility cannot be ruled out. A specimen from a 1 year old child (sex not reported) was identified as
W135: 2a:P1.2, 5. There is no known haj contact in the family.

Reference:

1.   Henderson S, Handford S, Ramsay M. Rapid reporting system for meningitis W135: 2a:P1.2, 5 prompted by haj outbreak.
     Eurosurveillance Weekly 2000; 4: 001116. (http://www.eurosurv.org/2000/001116.htm)


Reported by Sarah Handford (shandford@phls.org.uk), Brian Henderson (bhenderson@phls.org.uk), and
Mary Ramsay (mramsay@phls.org.uk), Public Health Laboratory Service Communicable Disease
Surveillance Centre, London, England.



Hepatitis A in tourists returning from Spain
Three German tourists were diagnosed with hepatitis A after they returned from Ibiza, Spain. The cases
stayed in the same resort but at (mostly) different times in September 2000.
The Robert Koch-Institute is looking for further cases living in Germany, defined as having hepatitis A with
a date of onset since 1 August 2000 who visited Ibiza before becoming ill. A further search is being
conducted for secondary infections connected to a case.

Until now, the search of further cases has revealed a total of nine cases from five states in Germany.
Seven of these nine cases stayed at the same resort. No reports about cases in tourists from other
European countries have reached the Robert Koch-Institute after other European countries were informed
through the early warning system of the European Commission. Further investigations are currently being
conducted.

Reference:

1.   Robert Koch-Institut. Erkrankungen an Hepatitis A nach Spanienaufenthalt – Mitteilung erbeten. Epidemiologisches Bulletin
     2000; 46: 369. (http://www.rki.de/INFEKT/EPIBULL/EPI.HTM)

Reported by Wolfgang Kiehl (kiehlw@rki.de) and Walter Haas (haasw@rki.de), Infection Epidemiology
Unit, Robert Koch-Institute, Berlin, Germany.



Tuberculosis in Austria, 1999
A total of 1288 cases of tuberculosis were identified in Austria in 1999, 1203 of which were notified and
fulfilled the case definition (positive culture or positive spontaneous sputum smear; or full course of
treatment initiated in the absence of laboratory confirmation), an overall incidence of 14.9 cases per 100
000 population (1). The remaining 85 (6.2%) were identified only through laboratory reporting. Ninety-one
per cent (1082) of the 1203 cases were new cases (incidence 13.4/100 000) and 9% (121) relapses
(1.5/100 000). Eight hundred and ninety-three cases were Austrian (incidence 12.2/100 000) and 310
were immigrants (41.4/100 000).

Higher incidences were associated with increasing age (20.8/100 000 in those aged 45 to 54 years and
25.4/100 000 in those aged 65 or over; p<0.001).Males accounted for two thirds of cases (777) in 1999
(incidence 19.8/100 000, compared with 10.2/100 000 in women). The incidence rose with increasing age
in men, but had two peaks in women (at 25 to 44 and >64 years). Among immigrants the sex specific
incidences were highest in younger cases (men: 15 to 24 years and 45 to 64 years; women 25 to 44
years).

Eight hundred and sixty-one cases had pulmonary TB only, 216 had extrapulmonary TB, and 126 had TB
that affected the lungs and other organs. In all three types the incidence increased with age. Pulmonary
TB accounted for 75% of male cases (585) and 65% of female cases (276); extrapulmonary TB
accounted for 24% of female cases (103) and 15% of male cases (113). Twenty-four of the 28 children
aged <5 years had isolated pulmonary TB, one an isolated extrapulmonary TB (TB meningitis), and in
three the lungs and another organ were affected.

A total of 144 patients died (12%) – 92 men (64%) and 52 women (36%). Ninety-two per cent of those
who died (133) were over 44 years of age. Death was attributed to TB in 35% (51), 53% (77) died from
another cause, the cause of death for 16 was unknown. Calculations of case fatality rates considered only
the 51 cases whose deaths were attributed to TB: 24 of these had isolated pulmonary TB, six isolated
extrapulmonary TB, and 21 combined TB. Thirty-two (63%) of those who died were male and 19 (37%)
female. Ninety per cent of the dead cases were aged >44 years. None of the seven cases diagnosed with
tuberculous meningitis died. The overall case fatality rate of TB was 4% (4% in men and 5% in women).
The rate was highest in the group with pulmonary and extrapulmonary TB (17%; men 15%, women 19%).

Comment
The average delay in notification is about six months. This annual report was compiled in August 2000,
and it is therefore likely that all notified cases diagnosed in 1999 were included. This does not mean,
however, that all actual cases were notified, as the parallel laboratory reporting system for 1999 registered
85 cases that had not been notified by a doctor. Since 2000, laboratory data and notifications from doctors
have been integrated in the reference centre for TB, which should improve the quality of data in the future.

The number of cases among children aged <5 years was comparatively high in the years 1995 to 1998
(27) and 1999 (28). The incidence in men was almost twice that in women – as has been seen before
(27). The overall incidence is continuously decreasing (1995: 1454 cases, incidence 18.1/100.000; 1999:
1203 cases, incidence 14.9/100 000).

Deaths fell between 1995 (181 of 1454 cases; case fatality rate 12.5%) and 1999 (144/1203; case fatality
rate 11.9%), but the TB specific case fatality rates based on 58 cases in 1995 and 51 in 1999 were similar
(4% in both years).

The high incidence among immigrants has been noted in many European countries (2,3); in Denmark –
reported recently in Eurosurveillance Weekly – the differential is even higher and immigrant cases exceed
native-born cases (4).

Reference:

1.   Strauss R, Pfeifer C, Löffler M, Hain C, Klein JP, Halbich-Zankl H. Tuberkulose in Österreich 1999. Mitteilungen der
     Sanitätsverwaltung 2000; 10: 28-34.
2.   EuroTB (CESES/KNCV) and the national coordinators for tuberculosis surveillance in the WHO European Region.
     Surveillance of tuberculosis in Europe: report on tuberculosis cases notified in 1997. St Maurice, France: EuroTB, 1999.
     (http://www.ceses.org/eurotb)
3.   White C. Rates of tuberculosis continue to rise in eastern Europe. Eurosurveillance Weekly 2000; 4: 000316.
     (http://www.eurosurv.org/2000/000316.html)
4.   Twisselmann B. Tuberculosis in Denmark. Eurosurveillance Weekly 2000; 4: 001130
     (http://www.eurosurv.org/2000/001130.htm)

Translated and adapted from reference 1 by Birte Twisselmann (btwisselmann@phls.org.uk),
Eurosurveillance editorial office.

								
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