Download Cutaneous - Eurosurveillance

Eurosurveillance Weekly, funded by Directorate General Health and Consumer Protection of the
European Commission, is also available on the world wide web at <http://www.eurosurveillance.org/>.
If you have any questions, please contact Birte Twisselmann <[email protected]>, +44 (0)208200 6868 extension 4417. Neither the European Commission nor any person acting on its behalf is
liable for any use made of the information published here.
Eurosurveillance Weekly: Thursday 1 November 2001. Volume 5, Issue 44
Contents:
1.
2.
3.
4.
5.
Interim European surveillance case definition for anthrax
Anthrax in the United States – summary of cases confirmed by CDC
Flu season in Europe starts off at very low levels
Severe invasive group A streptococcal disease, Norway, 2000
Adverse effects of antiretroviral treatment for HIV infection
Interim European surveillance case definition for anthrax
The heads of national surveillance and public health centres, at a meeting in Luxembourg on 30
October 2001, agreed an interim surveillance case definition for anthrax for Europe (box). While
anthrax is not formally notifiable internationally at the present time (http://policy.who.int/cgibin/om_isapi.dll?infobase=Ihreg&softpage=Browse_Frame_Pg42), it was agreed that ascertainment
of a single case of confirmed or probable human anthrax should be the subject of an “early warning”
within the European Union under the provision of Decision no. 2119/98/EC of 24 September 1998
(Network Decision).
The interim European case definition for anthrax is closely related to that published on 19 October by
the Centers for Disease Control and Prevention (CDC) in the United States, except that what is called
a “probable case” in the European definition would be termed a “suspect case” in the CDC document
(1). Individual European countries may of course use variations on these case definitions according to
locally available tests.
The case definition requires both the presence of particular clinical features and positive laboratory
results (box). Isolation of Bacillus anthracis from a normally sterile site or body fluid, or from a lesion
provides the confirmatory test result, as does having both a positive result from polymerase chain
reaction and characteristic microscopic findings on immunochemistry staining of a clinical specimen.
Clinical compatibility combined with recent exposure to environmental anthrax confirmed by a
reputable laboratory meets one of the definitions of a probable case. Serological tests are being used
in some countries. Not all of these have, however, been validated and are therefore not part of the
case definition. Further descriptions of the clinical appearance of anthrax and photographs are
available on the websites of the Public Health Laboratory Service in the United Kingdom, at
<www.phls.co.uk/facts/deliberate_releases.htm> and CDC in the United States at <www.bt.cdc.gov>.
Nasal swabbing for anthrax spores is not considered a useful investigation outside epidemiological
investigations once the presence of environmental anthrax has been confirmed (1,2).
Box – Interim European anthrax case definition
Clinical description
Inhalational anthrax: After inhalation of Bacillus anthracis and a brief prodrome, acute febrile respiratory
failure develops with hypoxia, dyspnoea, and radiological evidence of mediastinal widening.
Cutaneous anthrax: A skin lesion developing from a papule through a vesicular stage into a depressed
black eschar with surrounding oedema. The lesion is usually painless, but there may be constitutional
disturbance (fever and malaise).
Gastointestinal anthrax: After consumption of raw contaminated food a syndrome of severe abdominal
pain, diarrhoea, fever, and septicaemia.
Laboratory criteria for diagnosis

isolation and confirmation of B. anthracis from specimens collected from a normally sterile site
(for example, blood or cerebrospinal fluid (CSF)) or lesion of other affected tissue (skin, lung,
or gut).
or

evidence of B. anthracis DNA (for example, by polymerase chain reaction) from specimens
collected from a normally sterile site (such as blood or CSF) or lesion of other affected tissue
(skin, lung, or gut) and demonstration of B. anthracis in a clinical specimen by
immunohistochemical staining of affected tissue (skin, lung, or gut).
Note: A nasal swab without indication of disease does not contribute to diagnosis of a case.
Possible:
Not applicable.
Probable:
A probable case is defined as:
1) a clinically compatible case of illness without isolation of B. anthracis and no alternative diagnosis, but
with laboratory evidence of B. anthracis by one supportive laboratory test, or
2) a clinically compatible case of anthrax epidemiologically linked to a confirmed environmental exposure,
but without corroborative laboratory evidence of B. anthracis infection.
Confirmed:
A clinically compatible case that is laboratory confirmed.
Comments on the case definition should be sent to Dr Franz Karcher ([email protected]) and
Dr Angus Nicoll ([email protected]).
References:
1.
2.
Centers for Disease Control and Prevention (CDC). Investigation of anthrax associated with intentional exposure and
interim public health guidelines, October 19th 2001. Morb Mortal Wkly Rep MMWR 2001; 50: 889-93.
(http://www.cdc.gov/mmwr//preview/mmwrhtml/mm5041a1.htm)
Nicoll A. Interim guidance on deliberate releases of biological agents in the UK and US. Eurosurveillance Weekly
2001; 5: 011025. (http://www.eurosurv.org/2001/011025.htm)
Reported by Angus Nicoll ([email protected]), Public Health Laboratory Service Communicable
Disease Surveillance Centre, London, England.
Anthrax in the United States – summary of cases confirmed by CDC
On the basis of a rigorous case definition
(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a1.htm), the Centers for Disease Control and
Prevention (CDC) in Atlanta has reported 16 confirmed cases of anthrax: two in Florida, four in New
York City, five in New Jersey, and five in Washington DC. CDC is also reporting four suspect cases:
three in New York City and one in New Jersey. The table below summarises the numbers of cases
reported by 30 October 2001 (6pm ET).
Case status
Confirmed
Cutaneous
Inhalational
Florida
2
0
2
Suspect
Cutaneous
Inhalational
New York City
4
3
1
0
0
0
New Jersey
5
3
2
3
3
0
1
1
0
Washington DC
5
0
5
Total
16
0
0
0
4
Updated guidelines for handling suspicious mail are published at
http://www.bt.cdc.gov/DocumentsApp/Anthrax/10302001/10302001PM.asp, and updates on activities
and investigations in connection with anthrax at <www.bt.cdc.gov> and <www.cdc.gov/od/oc/media>.
Flu season in Europe starts off at very low levels
Influenza activity in Europe is very low, according to the first weekly electronic bulletin of the 2001-02
influenza season from the European Influenza Surveillance Scheme (EISS) (1).
Eight networks reported clinical influenza activity to EISS in week 42/2001 (15-21 October 2001).
Seven networks reported no influenza activity (Belgium, Denmark, England, Germany, Ireland, Italy,
and Switzerland), and a local outbreak of influenza was reported in Wales. The intensity of activity in
all networks was low.
There are indications that influenza A and B viruses are circulating in Europe. The surveillance
network in the Czech Republic reported two cases of influenza A in week 40/2001 and one case of
influenza B in week 41/2001 (all reported by sentinel physicians). The GROG
(http://www.grog.org/EuroGROG1.htm) surveillance network in France reported a case of influenza B
(confirmed by immunofluorescence) in week 40/2001, in a baby admitted to hospital, and four cases
of influenza were detected by sentinel physicians in week 42/2001 using a rapid influenza surveillance
test (three cases in the Ile de France (Paris region), two aged 18 and one aged 51, and one case in
Port-de-Bouc (near Marseille) aged 23).
<<INSERT MAP>>
The map presents the geographical spread of influenza as assessed by each of the networks in EISS.
A=dominant virus A; H1=dominant virus A(H1N1); H3=dominant virus A(H3N2); B=dominant virus B.
The levels of influenza activity in European countries reported by EISS members during the 2001-02
influenza season are based on two assessments of influenza activity:
1. an indicator of the geographical spread of influenza in that country; and
2. an indicator of the overall intensity of influenza activity in that country.
Each of these assessments is described below.
1. Indicators of the geographical spread of influenza:
Each network defines the geographical spread of influenza according to the definitions outlined below.
The definitions are based on those used by the WHO global influenza surveillance system – FluNet
(http://oms.b3e.jussieu.fr/flunet/).
ILI: influenza-like illness
ARI: acute respiratory infection
Country: Countries may be made up of one (for example, the Netherlands) or more regions (for
example, France North and France South).
Region: The population under surveillance in a defined geographical sub-division of a country (for
example, France North and France South). A region should not (generally) have a population of less
than five million unless the country is large with geographically distinct regions.
No report: No report received.
No activity: Reports indicate no evidence of influenza virus activity. Cases of ILI/ARI may be reported
in the country but the overall level of clinical activity remains at baseline levels and influenza virus
infections are not being laboratory confirmed. Cases occurring in people recently returned from other
countries are excluded.
Sporadic: Isolated cases of laboratory confirmed influenza infection in a region, or an outbreak in a
single institution (such as a school, nursing home or other institutional setting), with clinical activity
remaining at or below baseline levels. Cases occurring in people recently returned from other
countries are excluded.
Local outbreak: Increased ILI/ARI activity in local areas (such as a city, county or district) within a
region, or outbreaks in two or more institutions within a region, with laboratory confirmed cases of
influenza infection. Levels of activity in the remainder of the region, and other regions of the country,
remain at or below baseline levels.
Regional activity*: ILI/ARI activity above baseline levels in one or more regions with a population
comprising less than 50% of the country’s total population, with laboratory confirmed influenza
infections in the affected region(s). Levels of activity in other regions of the country remain at or below
baseline levels.
* This term is not (generally) to be used in countries with a population of less than five million unless
the country is large with geographically distinct regions.
Widespread activity: ILI/ARI activity above baseline levels in one or more regions with a population
comprising 50% or more of the country’s population, with laboratory confirmed influenza infections.
2. Indicators of the intensity of influenza activity:
The intensity of influenza activity is based on the overall level of influenza activity in the country. Each
network assesses the intensity of activity based on the historical data at its disposal. Some networks
have historical data that date back over 30 years (for example, England and the Netherlands) and
others have data that date back over shorter periods (for example, Belgium).
Some networks can establish numeric thresholds that define the intensity of influenza activity. For
example, if the level of influenza activity rises above 200 cases per 100 000 population in England
(and is below 400 cases per 100 000 population), the intensity of activity is considered to be “high”
(“higher than average season activity”).
EISS uses the following definitions to indicate the intensity of influenza activity in each country:
Low: No influenza activity or influenza activity is at baseline level.
Medium: Level of influenza activity usually seen when influenza virus is circulating in the country
based on historical data.
High: Higher than usual influenza activity compared with historical data.
Very high: Influenza activity is particularly severe compared with historical data.
Reference:
1.
European Influenza Surveillance Scheme. Very low levels of influenza activity in Europe. EISS Weekly Electronic
Bulletin 2001; week 42: issue 38. (http://www.eiss.org/cgi-files/bulletin_v2.cgi?display=1&code=38&bulletin=38)
Reported by John Paget ([email protected]) on behalf of EISS, Netherlands Institute for Health
Services Research (Nivel), Utrecht, Netherlands.
Severe invasive group A streptococcal disease, Norway, 2000
The modernised national notification system for infectious diseases in Norway (Meldingssystem for
smittsomme sykdommer, MSIS) was implemented on a national level in 1975. Cases of systemic
group A streptococcal (GAS) disease (diagnosed by blood culture or cerebrospinal fluid (CSF)
positives, or both) have been notifiable since the beginning. With the introduction of the Infectious
Diseases Control Act in 1995, severe invasive GAS disease (including necrotising fasciitis) with or
without a positive blood culture was included in the MSIS database. After more than two decades of
very low occurrence of systemic GAS disease, a rise was noted in 1985 when the incidence reached
>100 cases per year for the first time – corresponding to an overall rate of systemic disease of 2.4 per
100 000 population (1,2). An outbreak occurred in 1987-8, whereas the other winter seasons of the
1980s and early 1990s were rather calm. A new increase started rather abruptly in early 1993, and
the situation concerning GAS disease in Norway has remained similar ever since (figure 1) (3).
Figure 1. Severe invasive GAS disease (total and systemic cases), Norway, 1977-2000
<<FIGURE 1>>
In 2000, 194 cases of severe GAS disease (updated figures) were notified (4). Ninety-three (48%)
were in male patients, 100 (52%) in female patients, and for one case information on the patient’s sex
was not known. The mean age was 49 years. The median age was 53 years (range 0-96). The age
group 70-79 years was most affected, with 33 cases (17%). There were 147 cases of systemic
disease (76% of the total), resulting in an incidence of 3.3 per 100 000 per year; 145 of these were
blood culture positive, and in only two cases (1%) GAS was grown from the CSF. The remaining 47
cases (24%) spanned diagnoses such as necrotising fasciitis and streptococcal toxic shock
syndrome, some of which were blood culture negative. As reporting of blood culture positive cases
has been shown to be quite efficient in Norway's system it is believed that the number of systemic
cases is realistic and that the degree of underreporting is insignificant. The definition of severe cases,
however, is more difficult due to having to rely on clinical data. This probably renders these data less
complete. Altogether 180 patients (93%) were admitted to hospital. Twenty-three deaths (12%) were
recorded. The mean age of the patients who died was 66 years. The median age was 70 years (range
20-92).
Most cases occurred during the winter, and the highest monthly incidence – 31 cases (16%) –
occurred in January, compared with 20 cases (10%) in February and 24 cases (12%) in March.
Around 50% of the cases since 1993 have been typed as T1 OF- (2), whereas other types have rarely
reached 10%.
Figure 2. Severe invasive group A (GAS) disease by sex and age group (n=194), Norway, 2000
<<FIGURE 2>>
The graph with the distribution of notified cases by sex and age group shows that male patients are
affected at the extremes of life and in the group of young to middle aged adults. Female patients,
however, have another profile. Women of childbearing age (mainly 20-39 years) are most affected.
Twenty-five per cent of the total of female cases were in the gynaecological or obstetric setting.
Among the female cases there have been notifications throughout the 1990s and 2000 of classical
Semmelweissian puerperal fever; some of the patients were only in their early 20s, and some died.
Like other industrialised countries, Norway has experienced an unexpected increase in the incidence
of severe invasive GAS disease since the mid-1980s (1). The reasons for this increase are not
known. In its weekly report and many national and international scientific publications, Norway’s
public health institute has regularly emphasised the importance of early active diagnostic procedures,
early surgical (explorative) intervention when needed, and prompt antibiotic and supportive treatment
to try to shorten patient’s and doctor’s delays. A particularly disturbing finding is the high occurrence
of severe GAS disease in women in their 20s and 30s (figure 2) – this parallels findings from the
preantibiotic era (5). Barber (J Obstet Gynaecol 1960; 67: 727, as discussed by Greenwood (6))
pointed out that penicillin not only lowered the case fatality ratio of cases of puerperal fever – as
sulfonamides also did – but in addition also lowered the occurrence of contagious GAS in the
population, leading to a lower overall incidence of puerperal fever caused by GAS. Could the recent
increased incidence of severe GAS infections in young women in Norway be a consequence of less
active management of non-invasive GAS infections these days?
References:
1.
2.
3.
4.
5.
6.
Martin P, Høiby EA. Streptococcal serogroup A epidemic in Norway 1987-1988. Scand J Infect Dis 1990; 22; 421-9.
Hasseltvedt V. Bakteriemi/sepsis – meldte tilfeller i 1985. De 10 hyppigst forekommende bakterier. MSIS-rapport
1986; 14: 33.
Høiby EA. Systemic group A streptococcal (GAS) infections: continuing outbreak in Norway [abstract 308]. Abstracts
from 39th Interscience Conference on Antimicrobial Agents and Chemotherapy, San Francisco, CA, 26-29
September, 1999. Washington DC: American Society for Microbiology, 1999: 658.
Høiby EA, Hasseltvedt V. Alvorlig gruppe A streptokokksykdom 2000 noe lavere forekomst. MSIS-rapport 2001; 29:
28.
Keefer CS, Ingelfinger FJ, Spink WW. Significance of haemolytic streptococcal bacteremia. Arch Intern Med 1937;
60: 1084-7.
Greenwood D. Historical introduction. In: O'Grady FO, Finch R, Lambert HP, Greenwood D, eds. Antibiotic and
chemotherapy: anti-infective agents and their use in therapy. New York, Edinburgh: Churchill Livingstone 1997: 2-9.
Reported by Viggo Hasseltvedt ([email protected]) and E Arne Høiby, Department of
Bacteriology, Statens institutt for folkehelse, Oslo, Norway.
Adverse effects of antiretroviral treatment for HIV infection
Treatment of HIV-1 infection is known to have adverse effects, but there are few studies of how many
people having treatment are affected by adverse reactions, especially studies of ordinary clinical
practise and not clinical trial situations. The authors of a study conducted in Switzerland among 1160
people receiving antiretroviral treatment, which was published in the Lancet, report a high prevalence
of toxic effects attributed to antiretroviral treatment for HIV-1 (1).
The Swiss HIV Cohort Study is a prospective cohort study of adult patients with HIV-1 infection and
who were followed up in one of seven outpatient clinics in various Swiss cities. The authors
conducted a cross sectional study over four weeks (August-September 1999) that included all
participants in the Swiss HIV Cohort Study receiving potent antiretroviral treatment, which is defined
as a combination that includes at least three drugs from one or more of the following categories – a
protease inhibitor (PI), a non-nucleoside reverse transcriptase inhibitor, or a nucleoside analogue
reverse transcriptase inhibitor. Patients who had started or changed regimens in the previous 30 days
were excluded.
Structured interviews and laboratory analysis were used to identify and describe all potential adverse
events attributed to treatment according to standard definitions (http://www.who-umc.org/defs.html).
Independent associations were then identified by using logistic regression analysis that excluded the
investigator’s assessment.
All patients included in the study received at least three agents. Sixty per cent (698) of patients
received single PI antiretroviral treatment, 15% (172) PI sparing (ie the three drugs did not include a
PI), 15% dual PI treatment, and 10% (116) one drug from each of the three classes listed above. The
latter group tended to have a lower CD4 cell count and more instances of suboptimum viral
suppression than the other three groups. Agents for treatment or prophylaxis of opportunistic
infections were used by 354 (31%) patients, lipid lowering drugs by 36 (3%), and antidiabetic drugs by
12 (1%). Other co-medications were not investigated.
Forty-seven per cent (545 of 1160) of patients presented with clinical and 27% (194 of 712) with
laboratory adverse events probably or definitely attributed to antiretroviral treatment. Among these,
9% (47 of 545) and 16% (30 of 194), respectively, were graded as serious or severe.
Single PI and PI sparing antiretroviral treatment were associated with a comparable prevalence of
adverse events. Compared with single PI treatment, use of dual PI antiretroviral treatment and three
class antiretroviral treatment was associated with a higher prevalence of adverse events (odds ratio
2.0, 95% confidence interval 1.0 to 4.0, and 3.9, 1.2 to 12.9, respectively).
The study is subject to several problems that are explained in detail. The authors conclude that
postmarketing surveillance of drug toxic effects is essential for development of treatment guidelines,
and tolerability of anti-HIV-1 treatment needs to be improved.
Reference:
1.
Fellay J, Boubaker K, Ledergerber B, Bernasconi E, Furrer H, Battegay M, et al. Prevalence of adverse effects
associated with potent antiretroviral treatment: Swiss HIV Cohort Study. Lancet 2001; 358: 1322-7.
(http://www.thelancet.com)
Reported by Birte Twisselmann ([email protected]), Eurosurveillance editorial office.