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Background Immunosuppressed patients are particularly vulnerable to severe infection from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), risking prolonged viremia and symptom duration. In this study we describe clinical and virological treatment outcomes in a heterogeneous group of patients with severe immunosuppression due to various causes suffering from COVID-19 infection, who were all treated with convalescent plasma (CCP) along with standard treatment. Methods We performed an observational, retrospective case series between May 2020 to March 2021 at three sites in Skåne, Sweden, with a population of nearly 1.4 million people. All patients hospitalized for COVID-19 who received CCP with the indication severe immunosuppression as defined by the treating physician were included in the study (n = 28). Results In total, 28 severely immunocompromised patients, half of which previously had been treated with rituximab, who had received in-hospital convalescent plasma treatment of COVID-19 were identified. One week after CCP treatment, 13 of 28 (46%) patients had improved clinically defined as a decrease of at least one point at the WHO-scale. Three patients had increased score points of whom two had died. For 12 patients, the WHO-scale was unchanged. Conclusion As one of only few studies on CCP treatment of COVID-19 in hospitalized patients with severe immunosuppression, this study adds descriptive data. The study design prohibits conclusions on safety and efficacy, and the results should be interpreted with caution. Prospective, randomized trials are needed to investigate this further.

Along with the current development of molecular diagnostic methods of respiratory viruses, the bedside patient sampling techniques need to be evaluated. We here asked the question whether the addition of an oropharynx swab to the traditional nasopharynx swab might improve the diagnostic yield of multiplex PCR analysis. Ct values from the two sampling sites were compared as well as patient tolerability.In an emergency department in Malmö, Sweden, 98 adult patients with respiratory disease were sampled both from the nasopharynx and oropharynx for virus diagnostics by PCR.Influenza (AH1, AH3, B), human metapneumovirus (hMPV) or respiratory syncytial virus (RSV) were detected by PCR in 58 subjects. The diagnostic yield was improved by combining nasopharyngeal and oropharyngeal sampling - a virus was detected in another 6 patients compared to traditional nasopharyngeal sampling (p = .031, McNemar's test). In 38/55 subjects viral load was higher in the nasopharynx than in the oropharynx. Self-reported discomfort was significantly lower from oropharyngeal sampling than from nasopharyngeal sampling.Adding an oropharynx sample to a nasopharynx sample increased the diagnostic yield of respiratory viruses. Oropharyngeal sampling was well tolerated.

BACKGROUND: Environmental contamination of norovirus (NoV) is believed to be a significant source for further transmission in hospitals.AIM: To investigate the risk of acquiring NoV in a cleaned room previously occupied by a patient with NoV infection. The risk of having a roommate with recent NoV infection was also assessed.METHODS: In a retrospective cohort, comprising 33,788 room stays at five infectious Disease wards in southern Sweden from 2013 to 2018, the risk of acquiring NoV infection after admission to an exposed or non-exposed room was analysed with uni- and multivariable statistical analysis, controlling for age, colonization pressure and any roommate. RNA sequencing of the NoV strains involved in suspected room transmission was also performed.RESULTS: Five of the 1106 patients exposed to a room with a prior occupant with NoV infection and 49 in the non-exposed group acquired NoV infection. An association between NoV acquisition was found in the univariable analysis (odds ratio (OR) 3.3, P=0.01), but not when adjusting for potential confounders (OR 1.9, P=0.2). Sequencing of the NoV samples showed that only two of the five exposed patients with acquired NoV infection were infected by identical strains to the prior room occupant, inferring a room transmission risk of 0.2% (95% confidence interval 0.05-0.78%). None of the 52 patients who shared room with a roommate with NoV symptoms resolved for ≥48 h acquired NoV infection.CONCLUSIONS: In absolute terms, the risk of room transmission of NoV is low. Discontinuation of isolation ≥48 h after resolution of symptoms seems adequate. (Less)

Background Noroviruses are the major cause of viral gastroenteritis. Disease transmission is difficult to prevent and outbreaks in health-care facilities commonly occur. Contact with infected persons and contaminated environments are believed to be the main routes of transmission. However, noroviruses have recently been found in aerosols and airborne transmission has been suggested. The aim of our study was to investigate associations between symptoms of gastroenteritis and the presence of airborne norovirus, and to investigate the size of norovirus-carrying particles. Methods Air sampling was repeatedly performed close to 26 patients with norovirus infections. Samples were analyzed for norovirus RNA by reverse transcription quantitative polymerase chain reaction. The times since each patient’s last episodes of vomiting and diarrhea were recorded. Size-separating aerosol particle collection was performed. Results Norovirus RNA was found in 21 (24%) of 86 air samples from 10 different patients. Only air samples during outbreaks, or before a succeeding outbreak, tested positive for norovirus RNA. Airborne norovirus RNA was also strongly associated with a shorter time period since the last vomiting episode (odds ratio 8.1; P = .04 within 3 hours since the last vomiting episode). The concentrations of airborne norovirus ranged from 5–215 copies/m3, and detectable amounts of norovirus RNA were found in particles 4.51 µm. Conclusions The results suggest that recent vomiting is the major source of airborne norovirus and imply a connection between airborne norovirus and outbreaks. The presence of norovirus RNA in submicrometre particles indicates that airborne transmission can be an important transmission route., Molecular analyses of air collected in the proximity of patients with norovirus gastroenteritis indicate vomiting as a likely source of airborne norovirus and suggest a connection to outbreaks. Norovirus RNA found in submicrometre aerosol particles supports airborne transmission and dissemination.

International migrants could be considered as a risk group for being susceptible to vaccine preventable diseases such as measles and rubella. However, data on immunity in different migrant groups are scarce. Apart from asylum seekers and refugees, other immigrant groups might also be at risk. We have examined measles and rubella specific IgG antibodies among newly arrived adult immigrants in Skåne region in southern Sweden. In contrast to children, adult immigrants are not offered catch-up vaccinations after arrival.Stored serum samples from 989 asylum seekers and 984 pregnant women from the antenatal screening program, who had recently settled in Sweden, were analyzed for specific measles and rubella IgG-antibodies. Sex, age, reason for screening and geographic origin were variables entered into a multivariate regression model.There were considerable differences in seroimmunity to measles with regard to geographic origin (44-97%). Measles seroimmunity gaps were most prominent in immigrants from some European regions such as the Baltic countries, the former Yugoslavia and the Newly Independent States and Russia. Seroprotection for rubella varied less between geographic regions (90-99%).Susceptibility to measles among adult immigrants arriving in Sweden varies considerably depending on their geographic origin. Vaccinations against measles and rubella should be offered to groups of immigrants who might be incompletely immunized.

In January 2019, a human seasonal reassortant influenza A(H1N2) virus with a novel 7:1 genetic constellation was identified in a 68-year-old female patient with suspected pneumonia. The virus harboured A(H3N2) neuraminidase and remaining genes from A(H1N1)pdm09. The patient recovered after severe illness. No additional cases have been detected. This is the second identified A(H1N2) seasonal reassortant in a human in Europe within 1 year; a previous case was detected in the Netherlands in March 2018.

OBJECTIVETo evaluate 2 different methods of surveillance and to estimate the incidence of norovirus (NoV) outbreaks in hospitals.DESIGNProspective observational study.SETTINGAll 194 hospital wards in southern Sweden during 2 winter seasons (2010–2012).METHODSClinical surveillance based on outbreak reports of 2 or more clinical cases, with symptom onset within 5 days, was compared with laboratory surveillance based on positive NoV results among inpatients. At least 2 NoV positive patients sampled within 5 days at a ward defined a cluster. Outbreak reports including at least 1 NoV positive case and clusters including at least 1 NoV positive patient with 5 or more days from ward admission to sampling were defined as NoV outbreaks.RESULTSDuring the study periods 135 NoV outbreaks were identified; 74 were identified by both clinical and laboratory surveillance, 18 were identified only by outbreak reports, and 43 were identified only by laboratory surveillance. The outbreak incidence was 1.0 (95% CI, 0.8–1.2) and 0.5 (95% CI, 0.3–0.6) per 1,000 admissions for the 2 different seasons, respectively. To correctly identify NoV outbreaks, the sensitivity and positive predictive value of the clinical surveillance were 68% and 88% and of the laboratory surveillance were 86% and 81%, respectively.CONCLUSIONThe addition of laboratory surveillance significantly improves outbreak surveillance and provides a more complete estimate of NoV outbreaks in hospitals. Laboratory surveillance can be recommended for evaluation of clinical surveillance.Infect Control Hosp Epidemiol 2016;1–7

SUMMARYRotavirus (RV) infections affect young children, but can also occur in adults. We sought to identify risk factors for RV infections in adults aged ⩾18 years in Denmark, and to describe illness and genotyping characteristics. From March 2005 to February 2009, we recruited consecutive cases of laboratory-confirmed RV infection and compared them with healthy controls matched by age, gender and municipality of residence. We collected information on illness characteristics and exposures using postal questionnaires. We calculated univariable and multivariable matched odds ratios (mOR) with conditional logistic regression. The study comprised 65 cases and 246 controls. Illness exceeded 10 days in 31% of cases; 22% were hospitalized. Cases were more likely than controls to suffer serious underlying health conditions [mOR 5·6, 95% confidence interval (CI) 1·7–18], and to report having had close contact with persons with gastrointestinal symptoms (mOR 9·4, 95% CI 3·6–24), in particular young children aged 18 years. Close contact with young children or adults with gastrointestinal symptoms is the main risk factor for RV infection in adults in Denmark. RV vaccination assessments should consider that RV vaccination in children may indirectly reduce the burden of disease in adults.

Background. Norovirus (NoV) is a major cause of gastroenteritis and hospital outbreaks, leading to substantial morbidity and direct healthcare expenses as well as indirect societal costs. The aim of the study was to estimate the proportion of nosocomial NoV infections among inpatients testing positive for NoV in Denmark, 2002-2010, and to study the distribution of NoV genotypes among inpatients with nosocomial and community-acquired NoV infections, respectively. Methods. Admission and stool sampling dates from 3656 NoV-infected patients were used to estimate the proportion of nosocomial infections. The associations between nosocomial infection and patient age, sex, and NoV genotype GII.4 were examined. Results. Of the 3656 inpatients, 63% were classified as having nosocomial infections. Among these, 9 capsid and 8 polymerase NoV genotypes were detected, whereas in the smaller group of inpatients with community-acquired infections, 12 capsid and 9 polymerase genotypes were detected. Nosocomial NoV infections were associated with age ≥60 years and infections with genotype GII.4. Conclusions. The majority of NoV infections in hospitalized patients were nosocomial. Nosocomial infection was mainly associated with older age but also with the specific genotype GII.4. The genotypes in community-acquired NoV infections were more heterogeneous than in nosocomial infections.

Background: Norovirus is frequently introduced to the hospital and is a frequent cause of hospital outbreaks. Recognition of the factors that facilitate or impede norovirus transmission is an important step to effectively prevent hospital outbreaks. Aim: To investigate risk factors for norovirus outbreaks in hospital settings. Methods: Clinical data, ward setting, and norovirus genotype were collected from all 65 norovirus-positive index cases in outbreaks and all 186 sporadic norovirus cases at 192 wards in southern Sweden during 2010–2012 in a nested case–control study. Uni- and multivariate statistical analyses were conducted. Findings: Outbreak was independently associated with the number of patients sharing a room with the norovirus case (odds ratio (OR): 1.9 per additional patient in the room; P 80 years (OR: 3.2; P < 0.01), comorbidity (OR: 2.3; P = 0.05), and onset of symptoms after admission to the ward (OR: 3.5; P < 0.01) in the multivariate analysis. Infection with genotype GII.4 was found to be strongly associated with outbreak in the univariate analysis (OR: 5.7; P < 0.01). Moreover, associations between GII.4 and vomiting (OR: 2.5; P = 0.01) and old age (OR: 4.3: P < 0.01) were found. Conclusion: This is the first study to investigate clinical, ward and genotype risk factors for norovirus hospital outbreaks. Recognition of these factors may help direct and prioritize infection control actions based on the outbreak risk. The results also suggest that the outbreak association with GII.4 partly may be explained by an enhanced ability to induce vomiting. (Less)

Norovirus GII.4 predominated in patients ≥60 years of age and in health care settings., Norovirus (NoV) is a major cause of gastroenteritis. NoV genotype II.4 (GII.4) is the predominant genotype in health care settings but the reason for this finding is unknown. Stool samples containing isolates with a known NoV genotype from 2,109 patients in Denmark (patients consulting a general practitioner or outpatient clinic, inpatients, and patients from foodborne outbreaks) were used to determine genotype distribution in relation to age and setting. NoV GII.4 was more prevalent among inpatients than among patients in community settings or those who became infected during foodborne outbreaks. In community and health care settings, we found an association between infection with GII.4 and increasing age. Norovirus GII.4 predominated in patients ≥60 years of age and in health care settings. A larger proportion of children than adults were infected with NoV GII.3 or GII.P21. Susceptibility to NoV infection might depend on patient age and infecting NoV genotype. Cohort studies are warranted to test this hypothesis.

The aim of this study was to gain insights into the tempo and mode of the evolutionary processes that sustain genetic diversity in coxsackievirus B5 (CVB5) and into the interplay with virus transmission. We estimated phylodynamic patterns with a large sample of virus strains collected in Europe by Bayesian statistical methods, reconstructed the ancestral states of genealogical nodes, and tested for selection. The genealogies estimated with the structural one-dimensional gene encoding the VP1 protein and nonstructural 3CD locus allowed the precise description of lineages over time and cocirculating virus populations within the two CVB5 clades, genogroups A and B. Strong negative selection shaped the evolution of both loci, but compelling phylogenetic data suggested that immune selection pressure resulted in the emergence of the two genogroups with opposed evolutionary pathways. The genogroups also differed in the temporal occurrence of the amino acid changes. The virus strains of genogroup A were characterized by sequential acquisition of nonsynonymous changes in residues exposed at the virus 5-fold axis. The genogroup B viruses were marked by selection of three changes in a different domain (VP1 C terminus) during its early emergence. These external changes resulted in a selective sweep, which was followed by an evolutionary stasis that is still ongoing after 50 years. The inferred population history of CVB5 showed an alternation of the prevailing genogroup during meningitis epidemics across Europe and is interpreted to be a consequence of partial cross-immunity.

BACKGROUND: Because parvovirus B19 infection in pregnancy has been associated with infant morbidity and mortality in case reports and after intrauterine transfusion, we tested the population-based association using serum and hospital data of high quality.METHODS: We established a cohort of 113 228 children born to women tested for parvovirus B19 infection during pregnancy in a major diagnostic laboratory in Denmark, from 1994 to 2009. Information on 20 selected morbidity diagnoses and on mortality was obtained from the Danish National Patient Register, the Danish Cancer Register and the Danish Civil Registration System. Incidence rate ratios (IRR) were estimated by log-linear Poisson regression with adjustment for age and sex of the child, maternal age and year of maternal parvovirus B19 test.RESULTS: A total of 1095 (1.0%) children were born to mothers who were infected with parvovirus B19 during pregnancy. During 1 million person-years of follow-up, 10 856 children experienced morbidity and 590 children died. Overall, maternal infection status was neither associated with morbidity during infancy (IRR 0.64; 95% CI: 0.40 to 1.02) or childhood (IRR 0.93; 95% CI: 0.77 to 1.14), nor with infant mortality (IRR 0.98; 95% CI: 0.44 to 2.20). Specifically, there was no association with 19 of 20 morbidities. An excess risk of cancer in the central nervous system was observed (IRR 5.88; 95% CI: 1.41 to 24.6); however, the number of exposed cases was very small (n = 2).CONCLUSIONS: Parvovirus B19 infection during pregnancy was not associated with overall morbidity or mortality in infancy and childhood. (Less)

Background: During the last few years many new human picornaviruses have been discovered due to advances in metagenomics and other molecular biological approaches. The clinical significance and the occurrence are only sparsely described. Objectives: To determine the epidemiology and clinical significance of infections with the novel human picornaviruses, aichi virus, cosavirus, salivirus, and saffold virus in infants in Denmark. Study design: We tested 1393 stool samples from a birth cohort of 454 children for these viruses. Samples were collected at ages 6, 10 and 15 months, and at episodes of gastroenteritis. Samples were tested by real-time reverse-transcriptase polymerase chain reaction assays. Each study participant had a diary, where the parents reported episodes of disease, including gastroenteritis. Results: Aichi virus, salivirus and saffold virus were detected in 6, 9 and 38 of the children, respectively, but cosavirus was not detected in any of the children. There was a clear seasonal variation with most infections occurring in autumn and winter. A statistically significant association between the findings of salivirus and gastrointestinal disease was demonstrated. There was no association between gastrointestinal disease and the presence of aichi virus or saffold virus. Conclusions: The newly discovered human picornaviruses aichi virus, saffold virus, and salivirus are circulating in Danish children, with the most common being saffold virus. Saffold virus was seen almost exclusively in the autumn and winter period. Salivirus was the only virus, which was significantly associated with gastroenteritis, although the number of positive samples was rather low. (C) 2013 Elsevier B. V. All rights reserved.

SUMMARYGroup A rotaviruses infect humans and a variety of animals. In July 2006 a rare rotavirus strain with G8P[14] specificity was identified in the stool samples of two adult patients with diarrheoa, who lived in the same geographical area in Denmark. Nucleotide sequences of the VP7, VP4, VP6, and NSP4 genes of the identified strains were identical. Phylogenetic analyses showed that both Danish G8P[14] strains clustered with rotaviruses of animal, mainly, bovine and caprine, origin. The high genetic relatedness to animal rotaviruses and the atypical epidemiological features suggest that these human G8P[14] strains were acquired through direct zoonotic transmission events.

Since the late 1990s enterovirus 71 (EV71) has caused epidemics of hand, foot and mouth disease with fatal cases especially in the Asian Pacific region. The objective of this study was to describe the clinical and virological features of EV71 infections in Denmark.All enterovirus-positive samples in Denmark are submitted to the National Poliovirus Laboratory for typing, and the EV71-positive samples are characterized by sequencing and phylogenetic analysis. Clinical information was gathered for the EV71-positive patients.During 2005-2008, EV71 was demonstrated in 29 patients. In 2007 EV71 was the second most common enterovirus type detected in Denmark. Twenty-one of the 29 patients were children aged ≤1 y, 24 were hospitalized, and meningitis was the most common diagnosis. Gastroenteritis and hand, foot and mouth disease were other common clinical manifestations, but no fatal cases or cases of pulmonary oedema were seen. A novel subgenotype in Europe, B5, dominated the 2007 outbreak, but co-circulated with subgenotypes C1 and C2.In conclusion EV71 was among the common enterovirus types in Denmark, and in 2007 a novel subgenotype, B5, was observed. EV71 was mainly diagnosed in infants, and the majority of patients were hospitalized with meningitis.

Background Sapoviruses are known to cause gastroenteritis mainly in young children. Objectives To establish a collection of sapoviruses and to gain knowledge about the genetic diversity and epidemiology of sapoviruses circulating in children in Denmark. Study design During a 24-month period in 2005–2007 samples from 1104 children, aged 0–3 years, submitted for acute gastroenteritis diagnostics, were analysed for sapoviruses by real-time PCR. Genotyping of positive findings was carried out by sequencing part of the capsid gene, and in several cases also part of the polymerase gene. Results Sapoviruses were detected in stool samples from 97 children (9%), with the highest prevalence in the 7–18 months age group. Viruses from three genogroups and seven genotypes were found. Genotype I.1 was demonstrated in half of the positive samples and was observed throughout the study period. The less common types seemed to appear during shorter periods, often in succession of each other. Positive samples were detected throughout the study period. The only months, in both years studied, with high proportions of positive samples were September, November and February. Conclusions Sapoviruses were commonly found in children with gastroenteritis in Denmark. No clear seasonal pattern could be seen. Genotype I.1 was clearly the most common genotype found, but several other genotypes circulated during shorter periods.

Background The food-borne viruses in Europe (FBVE) network database was established in 1999 to monitor trends in outbreaks of gastroenteritisdue to noroviruses (NoVs), to identify major transmission routes of NoV infections within and between participating countries and to detectdiffuse international food-borne outbreaks.Methods We reviewed the total of 9430 NoVoutbreak reports from 13 countries with date of onset between 1 January 2002 and 1 January2007 for representativeness, completeness and timeliness against these objectives.Results Rates of reporting ranged from a yearly average of 1.8 in 2003 to 11.6 in 2006. Completeness of reporting of an agreed minimumdataset improved over the years, both for epidemiological and virological data. For the 10 countries that provided integrated (epidemiological ANDvirological) reporting over the 5-year period, the completeness of the minimum dataset rose from 15% in 2003 to 48% in 2006. Two countrieshave not been able to combine both data types due to the structure of the national surveillance system (England and Wales and Germany).Timeliness of reporting (median days between the onset of an outbreak and the date of reporting to the FBVE database) differed greatly betweencountries, but gradually improved to 47 days in 2006.Conclusion The outbreaks reported to the FBVE reflect the lack of standardization of surveillance systems across Europe, making directcomparison of data between countries difficult. However, trends in reported outbreaks per country, distribution of NoV genotypes, and detectionof diffuse international outbreaks were used as background data in acute questions about NoV illness and the changing genotype distributionduring the 5-year period, shown to be of added value. Integrated reporting is essential for these objectives, but could be limited to sentinelcountries with surveillance systems that allow this integration. For successful intervention in case of diffuse international outbreaks, completenessand timeliness of reporting would need to be improved and expanded to countries that presently do not participate.Keywords Epidemiology, Food safety, Public health

BACKGROUND: Norovirus (NoV) is the predominant cause of foodborne disease outbreaks. Virus contamination may occur during all steps of food processing, from production to preparation and serving. The relative importance of these different routes of contamination is unknown.METHODS: The purpose of this study was to estimate the proportions of outbreaks caused by asymptomatic and symptomatic food handlers (FHs). Reports of foodborne NoV and sapovirus outbreaks (n = 191) that occurred over a 7-year period were extracted, reviewed, and categorized according to the available evidence for source of contamination.RESULTS: In 64 (34%) of the outbreaks, contamination from FHs took place during preparation or serving of food. In the majority of these outbreaks (n = 41; 64%), the FHs were asymptomatic during food handling. Some had been in contact with ill household members before handling the food and remained asymptomatic; others developed symptoms shortly after or were post-symptomatic. In 51 (27%) of the outbreaks, contamination occurred during production of the food, and in 55 (29%) of the outbreaks, contamination had supposedly occurred after serving a guest at a self-serve buffet.CONCLUSIONS: Guidelines regarding exclusion of FHs where household members suffer from gastroenteritis could limit the number of outbreaks.

Norovirus (NoV) is a leading cause of gastroenteritis and genotype II.4 (GII.4) is responsible for the majority of nosocomial NoV infections. Our objective was to examine whether sequencing of the capsid gene might be a useful tool for the hospital outbreak investigation to define possible transmission routes. All NoV positive samples submitted from one university hospital during the 2007/8 season were selected. Genotyping of selected samples by partial polymerase gene sequencing had shown that the majority belonged to the GII.4 variant Den Haag 2006b and had identical polymerase sequences. Sequences of the capsid gene (1412 nucleotides) were obtained from the first available sample from 55 patients. From six immunocompromised patients with persistent infections a second sample was also included. As a control for a point-source outbreak, five samples from a foodborne outbreak caused by the same GII.4 variant were analyzed. Forty-seven of the inpatients (85%) were infected with the GII.4 variant Den Haag 2006b. Phylogenetic analysis of the Den Haag 2006b sequences identified four distinct outbreaks in different departments and a fifth outbreak with possible inter-department spread. In addition, a more heterogeneous cluster with evidence of repeated introductions from the community, but also possible inter-department spread was observed. In all six patients with paired sequences, evidence for in vivo evolution of the virus was found. Capsid gene sequencing showed substantial sequence variation among NoV GII.4 variant Den Haag 2006b strains from one single institution during a nine months' period. This method proved useful to understand the local epidemiology and, when used promptly, has the potential to make infection control measures more targeted.

It is possible to visualize rapidly viral particles by electron microscopy (EM) in patient samples and in cell cultures, and characterize the particles on the basis of their size and morphology. In many instances, EM has contributed to the diagnosis of specific infectious agents. Four different types of viruses with different characteristics of particle size, capsid structure, the presence or absence of an envelope, genomic content and stability outside the host were screened and diagnosed by EM at the level of family/genus. The results were confirmed at the species level by elution of the sample material from the grids used for EM examination and nucleic acid amplification. This approach could be valuable in situations where the immediate diagnosis is unclear, or when new infectious agents appear.

BACKGROUND: Risk factors for childhood diarrhea in industrialized countries are not well characterized, although diarrhea remains an important cause of morbidity.METHODS: We conducted a case-control study of 422 cases and 866 controls over 22 months in Denmark. We selected cases among children under 5 years of age with diarrhea. Age-matched healthy controls were selected from the background population using a population register. Parents were interviewed about possible exposures and underlying conditions. In addition, stool samples from both cases and controls were analyzed for viruses, parasites, and bacteria. We analyzed risk factors for diarrhea in general and for diarrhea of a viral, bacterial, or "unknown" etiology using logistic regression.RESULTS: The following factors were independently associated with an increased risk of diarrhea: recent foreign travel, contact with symptomatic persons (particularly in daycare centers), hospitalization, contact with a dog with diarrhea, private daycare, consumption of products containing formula milk, unemployment and low educational status of parents, and prior diagnosis of several types of atopic diseases. In a pathogenic-specific analysis of diarrhea of bacterial (73 patients), viral (88), or "unknown" (222) etiology, the major risk factor for viral diarrhea was contact with symptomatic persons. For bacterial diarrhea, foreign travel and socioeconomic factors were the main risk factors.CONCLUSIONS: Viral diarrhea appears to be transmitted predominantly from person to person, whereas bacterial diarrhea appears to be primarily foodborne. A substantial portion of the diarrheal episodes may be of noninfectious etiology. Limiting child-to-child transmission of disease in daycare centers may substantially reduce the disease burden. (Less)

Infectious gastroenteritis is one of the most common diseases in young children. To clarify the infectious etiology of diarrhea in Danish children less than 5 years of age, we conducted a 2-year prospective case-control study. Stools from 424 children with diarrhea and 870 asymptomatic age-matched controls were examined, and their parents were interviewed concerning symptoms. Rotavirus, adenovirus, and astrovirus were detected by enzyme-linked immunosorbent assay, and norovirus and sapovirus were detected by PCR. Salmonella , thermotolerant Campylobacter , Yersinia , Shigella , and Vibrio spp. were detected by standard methods. Shiga toxin-producing (STEC), attaching-and-effacing (A/EEC), enteropathogenic (EPEC), enterotoxigenic, enteroinvasive, and enteroaggregative Escherichia coli were detected by using colony hybridization with virulence gene probes and serotyping. Parasites were detected by microscopy. Overall, a potential pathogen was found in 54% of cases. More cases than controls were infected with rotavirus, Salmonella , norovirus, adenovirus, Campylobacter , sapovirus, STEC, classical EPEC, Yersinia , and Cryptosporidium strains, whereas A/EEC, although common, was not associated with illness. The single most important cause of diarrhea was rotavirus, which points toward the need for a childhood vaccine for this pathogen, but norovirus, adenovirus, and sapovirus were also major etiologies. Salmonella sp. was the most common bacterial pathogen, followed by Campylobacter , STEC, Yersinia , and classical EPEC strains. A/EEC not belonging to the classical EPEC serotypes was not associated with diarrhea, underscoring the importance of serotyping for the definition of EPEC.

BACKGROUND AND OBJECTIVES: Sexually transmitted infections (STIs) in Madagascar have primarily been monitored in selected groups of patients attending STI clinics in major cities as part of the HIV surveillance program in Madagascar.GOAL OF THE STUDY: The aim of the study was to provide complementary data related to STI prevalence in a general rural population.STUDY DESIGN: STIs were investigated in 643 subjects aged 15 to 49 years as part of a cross-sectional morbidity study of urogenital schistosomiasis. Infection rates were reassessed 3 weeks and 6 months after systematic STI treatment at baseline.RESULTS: Neisseria gonorrhoeae (Ng), Chlamydia trachomatis (Ct), Mycoplasma genitalium (Mg), Trichomonas vaginalis (Tv), and/or antibodies to Treponema pallidum (Tp) were diagnosed in 125 (37.5%) of 333 women and in 83 (26.8%) of 310 men. In addition, 49% of the women and 28% of the men were infected with herpes simplex virus-2. Six (0.9%) subjects were found HIV-antibody positive. Between the 3-week and 6-month follow-up surveys Ng, Ct, and/or Mg prevalence increased most prominently in women aged 15 to 24 years.CONCLUSION: Study findings suggest that rural areas in Madagascar should be as closely monitored and assisted in STI and HIV control as their urban counterparts. Following the current consensus, young adults should constitute a priority target group in the control programs. (Less)

We characterized the G and P types from 162 rotavirus-positive stool specimens collected from 162 persons in Denmark (134 children and 28 adults) with acute diarrhea in 1998, 2000, and 2002. Samples were obtained during outpatient consultations (73%) and from hospitalized patients (27%). Although more than 20 different G-P combinations were identified, only 52% represented the globally most common types G1P[8], G2P[4], and G4P[8]. The G9 genotype, which is emerging worldwide, was identified in 12% of all samples. Twenty-one percent of the samples were of mixed genotypic origin, which is the highest frequency reported in any European population. The standard reverse transcription-PCR methods initially failed to identify a considerable fraction of the rotavirus P strains due to mutations at the VP4 primer-binding sites of P[8] strains. The application of a degenerate P[8] primer resulted in typing of most VP4 strains. There was considerable year-to-year variation among the circulating G-P types, and whereas G1P[8] was predominant in 1998 (42% of samples) and 2002 (26%), G2P[4] was the strain that was most frequently detected in 2000 (26% of samples). Our findings might implicate challenges for rotavirus vaccine implementation in a European population and underscore the importance of extensive strain surveillance prior to, during, and after introduction of any vaccine candidate.

SUMMARYNorovirus outbreaks occur frequently in Denmark and it can be difficult to establish whether apparently independent outbreaks have the same origin. Here we report on six outbreaks linked to frozen raspberries, investigated separately over a period of 3 months. Norovirus from stools were sequence-typed; including extended sequencing of 1138 bp encompassing the hypervariable P2 region of the capsid gene. Norovirus was detected in 27 stool samples. Genotyping showed genotype GI.Pb_GI.6 (polymerase/capsid) with 100% identical sequences. Samples from five outbreaks were furthermore identical over the variable capsid P2 region. In one outbreak at a hospital canteen, frozen raspberries was associated with illness by cohort investigation (relative risk 6·1, 95% confidence interval 3·2–11). Bags of raspberries suspected to be the source were positive for genogroup I and II noroviruses, one typable virus was genotype GI.6 (capsid). These molecular investigations showed that the apparently independent outbreaks were the result of one contamination event of frozen raspberries. The contaminated raspberries originated from a single producer in Serbia and were originally not considered to belong to the same batch. The outbreaks led to consultations and mutual visits between producers, investigators and authorities. Further, Danish legislation was changed to make heat-treatment of frozen raspberries compulsory in professional catering establishments.

One of the leading causes of severe childhood gastroenteritis are group A rotaviruses, and they have been found to be associated with similar to 40% of the annual gastroenteritis-associated hospitalizations in young Danish children One of the leading causes of severe childhood gastroenteritis are group A rotaviruses, and they have been found to be associated with ~40% of the annual gastroenteritis-associated hospitalizations in young Danish children

Clostridium difficile infection (CDI) is gradually being recognised as a cause of morbidity in the community. We investigated the incidence and clinical characteristics of CDI in a community setting and characterised the C. difficile strains by toxin gene profiling and polymerase chain reaction (PCR) ribotyping. Patients included in the study had attended general practice, primarily because of diarrhoea; CDI patients (259 patients; 1212 years of age) had positive cultures for toxigenic C. difficile and non-CDI patients (455 patients) were culture-negative. Outcome variables included the frequency and duration of diarrhoea, vomiting, stomach ache, fever38 °C, weight loss and sick leave. Data were analysed by logistic regression. CDI patients2 and ≥2 years of age with C. difficile as the only enteropathogen in the faecal sample reported slimy stools (65% vs. 62%), stomach ache (60% vs. 75%), weight loss (50% vs. 76%) and duration of diarrhoea15 days (59% vs. 73%) as the predominant symptoms. CDI patients ≥2 years old reported duration of diarrhoea15 days more often compared to non-CDI patients (73% vs. 27 %, p 0.0001). The annual incidence of CDI was 518 and 23/100,000 for patients2 and ≥2 years of age, respectively, and 46/100,000 in the subgroup of patients ≥60 years of age. CDI was characterised by stomach ache and persistent diarrhoea, often leading to weight loss. This emphasises the importance of diagnosing CDI not only in hospitalised patients, but also in individuals ≥2 years of age attending general practice because of gastrointestinal symptoms, especially in the elderly, where the incidence of CDI is high.

SummaryA 53-year-old woman presented with a spontaneous splenic rupture. The splenic rupture was considered a complication of a primary cytomegalovirus (CMV) infection as were multiple pulmonary embolisms. CMV infections are common but are most often asymptomatic, and to our knowledge only 15 cases complicated with splenic rupture have been published.

SUMMARYTo identify risk factors forClostridium difficileinfection (CDI) in Danish patients consulting general practice with gastrointestinal symptoms, a prospective matched case-control study was performed; cases (N = 259) had positive cultures for toxigenicC. difficileand controls (N = 455) negative cultures. Data were analysed by conditional logistic regression. In patients aged ⩾2 years (138 cases), hospitalization [odds ratio (OR) 8·4, 95% confidence interval (CI) 3·1–23], consumption of beef (OR 5·5, 95% CI 2·0–15), phenoxymethylpenicillin (OR 15, 95% CI 2·7–82), dicloxacillin (OR 27, 95% CI 3·6–211), and extended spectrum penicillins (OR 9·2, 95% CI 1·9–45) were associated with CDI. In patients aged

Highlights • A novel enterovirus and parechovirus multiplex assay. • Extensive validation and implementation data. • Documentation of the assays performance during the first 15 months of routine testing., As the number of new enteroviruses and human parechoviruses seems ever growing, the necessity for updated diagnostics is relevant. We have updated an enterovirus assay and combined it with a previously published assay for human parechovirus resulting in a multiplex one-step RT-PCR assay. The multiplex assay was validated by analysing the sensitivity and specificity of the assay compared to the respective monoplex assays, and a good concordance was found. Furthermore, the enterovirus assay was able to detect 42 reference strains from all 4 species, and an additional 9 genotypes during panel testing and routine usage. During 15 months of routine use, from October 2008 to December 2009, we received and analysed 2187 samples (stool samples, cerebrospinal fluids, blood samples, respiratory samples and autopsy samples) were tested, from 1546 patients and detected enteroviruses and parechoviruses in 171 (8%) and 66 (3%) of the samples, respectively. 180 of the positive samples could be genotyped by PCR and sequencing and the most common genotypes found were human parechovirus type 3, echovirus 9, enterovirus 71, Coxsackievirus A16, and echovirus 25. During 2009 in Denmark, both enterovirus and human parechovirus type 3 had a similar seasonal pattern with a peak during the summer and autumn. Human parechovirus type 3 was almost invariably found in children less than 4 months of age. In conclusion, a multiplex assay was developed allowing simultaneous detection of 2 viruses, which can cause similar clinical symptoms.

The proportion and absolute numbers of CD4+ and CD8+ lymphocytes in peripheral blood were determined using a new manual method, the cytosphere assay (CA). This method uses small latex beads coated with monoclonal antibodies directed against the CD4 and CD8 receptors, respectively. The CA was compared with two other methods for determination of T lymphocyte subsets, flow cytometry (FC) and the immunoalkaline phosphatase (IA) method, by testing HIV-seropositive and HIV-seronegative samples from Denmark (44) and Ivory Coast (79). For HIV-seropositive samples, both the proportion and the absolute number of CD4+ lymphocytes determined by CA showed a good correlation with results obtained by FC (correlation coefficients were 0.92 and 0.74 in Denmark and The Ivory Coast, respectively) and IA (correlation coefficients were 0.94 and 0.66 in Denmark and The Ivory Coast, respectively). However, for HIV-seronegative samples the corresponding correlation coefficients were low. CD4% determinations deviated more from FC counts at higher CD4 counts than at lower levels for both seronegative and seropositive individuals. In conclusion, the CA performed best for samples from HIV-infected individuals. Before a more general utilization of the method, it is necessary to improve its repeatability and standardize its performance at all levels of CD4+ T cells.

This virus might have caused previously unexplained cerebral infections and deaths in children., The first human virus in the genus Cardiovirus was described in 2007 and named Saffold virus (SAFV). Cardioviruses can cause severe infections of the myocardium and central nervous system in animals, but SAFV has not yet been convincingly associated with disease in humans. To study a possible association between SAFV and infections in the human central nervous system, we designed a real-time PCR for SAFV and tested cerebrospinal fluid (CSF) samples from children

Group A rotaviruses can infect both humans and animals. Individual rotavirus strains can occasionally cross species barriers and might hereby contribute to the emergence of new genotypes in heterologous hosts. The incidence and impact of zoonotic rotavirus are not well defined, and one reason for this is a lack of data about strains circulating in suspected reservoir animal hosts. In this study we report the incidence, genetic diversity, and molecular epidemiology of rotaviruses detected in domestic cattle and swine in 6 European countries. From 2003 to 2007, 1101 and more than 2000 faecal specimens were collected from swine and cattle, both healthy and diarrhoeic, and tested for rotaviruses. Viruses from positive stools were genotyped and a subset of strains was characterized by nucleotide sequencing and phylogenetic analysis of the VP7 (G) and VP4 (P) genes. Rotaviruses were detected in 43% of bovine samples and in 14% of porcine samples. In cattle, 10 different combinations of G and P types were identified and the most common strains were G6P[11] and G6P[5]. In swine, the number of identified G-P combinations was higher (n=21), however, no single combination was predominant across Europe. Newly described genotype specificities, P[27] and P[32], were identified in swine. When compared at the nucleotide sequence level, the identified porcine rotavirus strains and contemporary human strains grouped together phylogenetically, whereas bovine rotavirus strains formed separate clades. These data demonstrate large genetic diversity of porcine and bovine rotavirus strains across Europe, and suggest that livestock herds may serve as potential reservoirs for human infections.

A 64-year-old male was ortotopic heart-transplanted in 2006 ue to fulminant heart failure from acute myocarditis of unknown etiology three weeks earlier. Except for postoperative chronic enal insufficiency the patient recovered well, and was conrolled on a routine basis at the outpatient department at the eart transplant centre. The medical record included ciclosporin, ycophenolatmofetil, pravastatin, labetalol and candesartancilextil. In January 2009, the patient was admitted to the hospital with history of watery, unbloody diarrhoea 10–15 times a day for our days without vomiting or abdominal pain. The patient was ubfebrile, 37 ◦C,6 and dehydrated. Clinical examination of the bdomen was normal. His wife experienced similar but milder, elf-limiting symptoms. The patient was treated with five days of eroral ciprofloxacin and intravenous fluid therapy. Labetolol was aused for four days, ciclosporin for two days and candesartanilexetil was discontinued.

Porcine sapovirus is an enteric calicivirus in domestic pigs that belongs to the family Caliciviridae . Some porcine sapoviruses are genetically related to human caliciviruses, which has raised public health concerns over animal reservoirs and the potential cross-species transmission of sapoviruses. We report on the incidence, genetic diversity, and molecular epidemiology of sapoviruses detected in domestic pigs in a comprehensive study conducted in six European countries (Denmark, Finland, Hungary, Italy, Slovenia, and Spain) between 2004 and 2007. A total of 1,050 swine fecal samples from 88 pig farms were collected and tested by reverse transcription-PCR for sapoviruses, and positive findings were confirmed by sequencing. Sapoviruses were detected in 80 (7.6%) samples collected on 39 (44.3%) farms and in every country. The highest prevalence was seen among piglets aged 2 to 8 weeks, and there was no significant difference in the proportion of sapovirus-positive findings for healthy animals and animals with diarrhea in Spain and Denmark (the only countries where both healthy animals and animals with diarrhea were tested). On the basis of the sequence of the RNA polymerase region, highly heterogeneous populations of viruses representing six different genogroups (genogroups III, VI, VII, and VIII, including potential new genogroups IX and X) were identified, with a predominance of genogroup GIII (50.6%). Genogroup VIII, found in five of the six countries, had the highest degree of homology (up to 66% at the amino acid level) to human sapovirus strains. Sapoviruses are commonly circulating and endemic agents in swine herds throughout Europe. Highly heterogeneous and potential new genogroups of sapoviruses were found in pigs; however, no “human-like” sapoviruses were detected.

International audience; BACKGROUND: The first European rotavirus surveillance network, EuroRotaNet, comprising 16 laboratories in 15 European countries, has been established. METHODS: Fecal samples from gastroenteritis cases positive for group A rotavirus antigen were collected from multiple European countries from 2005 to mid-2008 and were subjected to G and P genotyping. Epidemiological data collected included age, sex, geographical location, setting, dates of onset and sample collection, and clinical symptoms. RESULTS: A total of 8879 rotavirus-positive samples were characterized: 2129 cases were from the 2005-2006 season, 4030 from the 2006-2007 season, and 2720 from the ongoing 2007-2008 season. A total of 30 different G and P type combinations of strains circulated in the region from 2005 through 2008. Of these strains, 90% had genotypes commonly associated with human infections-G1P[8], G2P[4], G3P[8], G4P[8], and G9P[8]-and 1.37% represented potential zoonotic introductions. G1P[8] remained the most prevalent genotype in Europe as a whole, but the incidence of infection with G1P[8] rotavirus strains was

A case of acute hepatitis due to hepatitis E virus genotype 3 was diagnosed by serology and genomic sequencing. Phylogenetic analysis demonstrated a strain identical to one isolated from a Swedish pig, which supports the hypothesis that swine serves as reservoirs for HEV infection. The patient did not have any recent travel history, had experienced no contact with animals and the origin of the infection remained unknown. We emphasize that health personnel should be aware of acute hepatitis E even among patients without a travel history.

A cluster of six confirmed cases with identical measles virus genotype was reported in Denmark between December 2008 and January 2009. Transmission occurred among unvaccinated children aged 15-23 months admitted to the same hospital as a 36-month-old unvaccinated girl diagnosed with measles following travel. The findings highlight the importance of vaccination before travelling and adherence to the routine vaccination schedule.

A cohort of 115 asymptomatic gay men, all seropositive for HIV, was recruited in a health screening project in Stockholm, Sweden, between Nov. 1982 and Dec. 1983 and subsequently followed and clinically evaluated after a mean observation time of 63 months. AIDS in accordance with the surveillance definition (CDC group IV C-1 and D) developed in 34 (29.6%) of the men, while 1 (0.9%) additional man died of multiple myeloma classified as CDC group IV E. Constitutional symptoms (CDC group IV A) developed in 13 (11.3%) men, while symptoms from the central nervous system classified as CDC group IV B occurred in 1 (0.9%) additional man. Minor opportunistic infections included in the definition for CDC group IV C-2 developed in 12 (10.4%) men, while 48 (41.7%) men remained asymptomatic, with or without persistent generalized lymphadenopathy (PGL). One man who died of AIDS had been treated for malignant melanoma (MM) and one who did not fulfill the criteria for CDC group IV died of MM during the observation period. The 5-year actuarial progression rate to surveillance defined AIDS was 31.5% and to CDC group IV 53.6%. No statistically significant association was found between disease progression and a number of recorded epidemiological variables, most previous and present sexually transmitted diseases (STD) (except gonorrhoea) and the presence of PGL at entry. On the other hand, reduced delayed cutaneous hypersensitivity, in particular to tuberculin, as well as the presence of a high IgG titer against cytomegalovirus (CMV), were correlated to disease progression.

The Foodborne Viruses in Europe network has developed integrated epidemiological and virological outbreak reporting with aggregation and sharing of data through a joint database. We analyzed data from reported outbreaks of norovirus (NoV)-caused gastroenteritis from 13 European countries (July 2001 to July 2006) for trends in time and indications of different epidemiology of genotypes and variants. Of the 13 countries participating in this surveillance network, 11 were capable of collecting integrated epidemiological and virological surveillance data and 10 countries reported outbreaks throughout the entire period. Large differences in the numbers and rates of reported outbreaks per country were observed, reflecting the differences in the focus and coverage of national surveillance systems. GII.4 strains predominated throughout the 5-year surveillance period, but the proportion of outbreaks associated with GII.4 rose remarkably during years in which NoV activity was particularly high. Spring and summer peaks indicated the emergence of genetically distinct variants within GII.4 across Europe and were followed by increased NoV activity during the 2002-2003 and 2004-2005 winter seasons. GII.4 viruses predominated in health care settings and in person-to-person transmission. The consecutive emergence of new GII.4 variants is highly indicative of immune-driven selection. Their predominance in health care settings suggests properties that facilitate transmission in settings with a high concentration of people such as higher virus loads in excreta or a higher incidence of vomiting. Understanding the mechanisms driving the changes in epidemiology and clinical impact of these rapidly evolving RNA viruses is essential to design effective intervention and prevention measures.

Mycoplasma (M.) pneumoniae has been associated with exacerbation of symptoms in asthmatic school children and adults; and an etiological role in asthma has been suggested. The purpose of this study was to investigate whether infection with M. pneumoniae in early childhood has a long-term influence on lung function and bronchial responsiveness. In a retrospective, clinical cohort-study children younger than 5 years-of-age when PCR-tested for M. pneumoniae were enrolled. Sixty-five children with clinical symptoms suggesting infection with M. pneumoniae during an epidemic season completed a clinical follow-up examination including lung function testing (28 PCR-positive and 37 PCR-negative). In addition to the PCR-test for M. pneumoniae all respiratory tract specimens were additionally tested for other atypical bacteria and for viruses by PCR. Lung function was measured as specific airway resistance by whole-body plethysmography and bronchial hyperresponsiveness was assessed by cold, dry air hyperventilation. Neither baseline lung function nor bronchial response to cold dry air hyperventilation differed between M. pneumoniae-positive and -negative children: mean baseline lung function were 1.17 versus 1.21 (kPa sec), P = 0.45; and mean change in specific resistance was 13% versus 9%, P = 0.42. In conclusion, M. pneumoniae infection in early childhood was not associated with long-term effects on lung function and bronchial hyperresponsiveness 2 years after infection.

Homosexual men with symptomatic primary HIV-1 infection displayed a pronounced lymphopaenia with significantly depressed numbers of CD3+, CD4+ and CD8+ cells and B cells during the first week of illness. Subsequently, the CD8+ cell counts rose in parallel with numbers of CD3+ cells, atypical lymphocytes and activated (CD38+ and HLA-Dr+) cells to attain maximal levels about a month following onset of illness. In contrast CD4+ and B cell numbers remained low for an extended period of time. Early signs of a host response included a transient appearance of interferon-alpha in the blood and raised levels of neopterin and beta 2-microglobulin (beta 2-M). Neither CD4+/CD8+ cell ratio nor beta 2-M resumed completely normal values during a follow-up period of 2 years. These findings shed some light on pathogenetic events during early HIV-1 infection and suggest that the infection, following the acute symptomatic stage, usually enters a stage of chronic active rather than latent infection.

A total of 61 individuals involved in five norovirus outbreaks in Denmark were genotyped at nucleotides 428 and 571 of the FUT2 gene, determining secretor status, i.e., the presence of ABH antigens in secretions and on mucosa. A strong correlation ( P = 0.003) was found between the secretor phenotype and symptomatic disease, extending previous knowledge and confirming that nonsense mutations in the FUT2 gene provide protection against symptomatic norovirus (GGII.4) infections.