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The global prevalence of intestinal extended spectrum beta-lactamases producing Enterobacterales (ESBL-PE) is about 17% in communities, with significant variations between regions. This longitudinal study aimed to assess the impact of antibiotic intake on incidence of intestinal ESBL-PE in Ghanaian pharmacy costumers outside of hospitals.Screening for ESBL-PE was performed in four independent pharmacies in Kumasi, Ghana, by using rectal swabs and ESBL-PE-selective medium. Pharmacy customers purchasing antibiotics were recruited, those buying non-antibiotic drugs served as controls. Participants who were negative for ESBL-PE provided follow-up swabs for up to 28 days.At baseline, 302 of 404 participants (75%) were colonized with ESBL-PE. Sixty-three participants negative for ESBL-PE at baseline received per-protocol follow-up, including 28 individuals who took antibiotics and 35 controls. The cumulative proportion of ESBL-PE in the antibiotics and control group was 71% (20/28) vs. 54% (19/35) at the first follow-up (p=0.258), 86% (24/28) vs. 80% (28/35) at the second follow-up (p=0.741) and 86% (24/28) vs. 94% (33/35) at the third follow-up (p=0.393), respectively.The rate of intestinal ESBL-PE carriage among pharmacy costumers outside of hospitals was higher than expected at baseline and further increased during the 28 days of follow-up - irrespective of antibiotic intake. This alarming finding needs to be considered in antibiotic treatment of outpatients and emphasizes the urgent need of improved prevention strategies,development of new antibiotic drugs and potential future elimination strategies. Further longitudinal studies on ESBL-PE in African communities, also outside of pharmacy settings, are required.

BackgroundCoagulopathy is common in acute symptomatic Plasmodium falciparum malaria, and the degree of coagulation abnormality correlates with parasitemia and disease severity. Chronic asymptomatic malaria has been associated with increased morbidity. However, the role of coagulation activation in asymptomatic, semi-immune individuals remains unclear. This study investigates the potential effect of asymptomatic P falciparum infection on coagulation activation in semi-immune Ghanaian adults.MethodsBlood from asymptomatic Ghanaian adults with P falciparum blood stage infection detectable by polymerase chain reaction (PCR) or by both PCR and rapid diagnostic test and from noninfected individuals, was investigated. Markers of coagulation activation including global coagulation tests, D-dimer, antithrombin III, fibrinogen, and von Willebrand factor antigen were tested. Furthermore, blood count, inflammation markers, and liver and kidney function tests were assessed.ResultsAcquired coagulopathy was not found in asymptomatic P falciparum infection. Asymptomatic malaria was associated with significantly lower platelet counts. Systemic inflammation markers and liver and kidney function tests were not altered compared to noninfected controls.ConclusionsThere is no laboratory evidence for acquired coagulopathy in adults with asymptomatic P falciparum malaria in highly endemic regions. Lack of laboratory evidence for systemic inflammation and liver and kidney dysfunction indicates that asymptomatic malaria may not be associated with significant morbidity.

International travel has been identified as a major contributing factor to the global spread of MRSA. We examined the incidence of MRSA-colonization in a cohort of 196 travellers. We observed a low rate of only one case of MRSA, indicating a low risk of acquisition of MRSA-colonization in travel.

Objectives This longitudinal case–control study aimed to determine the frequency of polymicrobial enteric detections in Ghanaian infants with and without diarrhoea. Methods Infants aged 1–12 months with and without diarrhoea attending the outpatient department of a peri-urban Ghanaian hospital were prospectively assessed and stool samples were collected on days 0, 6 and 28 and analysed for 18 enteric pathogens with PCR. Results At least one enteric pathogen was detected in 100 of 107 cases with diarrhoea (93%) and in 82 of 97 controls (85%). The number of pathogens was higher in cases than in controls (median three versus two pathogens, p 0.001). The adjusted attributable fraction (AF) for diarrhoea was highest for enterotoxigenic Escherichia coli (7.2%, 95% CI –2.0% to 16.3%), rotavirus (4.1%, 95% CI 0.6%–7.5%), Giardia lamblia (2.3%, 95% CI –0.7 to 5.3%) and astrovirus (2.3%, 95% CI –2.9 to 7.5%). In cases, a higher pathogen number was significantly associated with watery stool consistency (median 3, interquartile range (IQR) 2–5 versus median 2.5, IQR 1–4, p 0.014), stool frequency five or more per day (median 4, IQR 3–5 versus median 3, IQR 2–4, p 0.048) and vomiting (median 4, IQR 3–5 versus median 3, IQR 2–4, p 0.025). During follow-up, 94% (78/83) of cases and 85% (67/79) of controls had acquired at least one new pathogen without developing a new episode of diarrhoea. Conclusion Enteric pathogens could be identified in the stool of the vast majority of Ghanaian infants, whereby pathogens were very frequently acquired without resulting in new episodes of diarrhoea during follow-up. A higher number of co-occurring pathogens may increase the risk of diarrhoea and disease severity.

Was ist neu? Epidemiologie Weltweit sind die Malaria-Inzidenzen rückläufig. Die Zahl der nach Deutschland importierten Fälle blieb zuletzt auf hohem Niveau stabil. Von größter Bedeutung ist es gut bekannte Risikogruppen mit Beratungsangeboten zu erreichen, z. B. Reisende auf Verwandtenbesuch in Endemiegebieten. Prophylaxe Mefloquin steht seit 2013 in Deutschland nur noch als Einzelimport zur Verfügung, bleibt jedoch für bestimmte Personengruppen weiter ein wichtiges Prophylaktikum. Die notfallmäßige Selbsttherapie der Malaria, die gängige Praxis für Reisende in Länder mit niedrigem und mittlerem Übertragungsrisiko ist, wird in der Reisemedizin zunehmend kritisiert und sollte zielgerichteter eingesetzt werden. Therapie der Malaria tropica Patienten mit einem höheren Körpergewicht müssen nach einer Therapie engmaschig nachbeobachtet werden, da sie ein höheres Risiko einer Rekrudeszenz haben. Artesunat ist Mittel der Wahl zur Therapie der komplizierten Malaria tropica. Auch hier ist eine konsequente Kontrolle nach Therapieende notwendig, um eine mit Artesunat assoziierte hämolytische Anämie frühzeitig zu erfassen. Malaria tertiana Seit 2014 gab es in Deutschland eine Zunahme von Patienten mit einer Malaria tertiana, insbesondere bei Migranten aus Eritrea. Aufgrund der unzureichenden Gesundheitsversorgung der Flüchtenden haben nicht alle Patienten die bei Plasmodium vivax notwendige Rezidivprophylaxe mit Primaquin erhalten.

Objectives Eosinophilia in travelers and migrants returning from the tropics is often associated with invasive helminthic infections. Total IgE is considered a useful additional diagnostic parameter; however, both parameters are also increased in various other non-helminthic diseases. Methods We retrospectively evaluated travelers and migrants seen at our department between September 2007 and May 2014. Patients with an absolute eosinophil count ≥500 cells/μl were considered for further analyses. Results Among 6618 returned travelers and migrants, 154 (2.3%) had a total eosinophil count ≥500 cells/μL. Of these, 71 patients (46%) were diagnosed with helminthic infection. In an additional 62 patients (40%) with eosinophilia a final diagnosis was found, including non-helminthic infections in 34 patients and non-infectious causes in 28 patients, while in 21 patients (14%) no diagnosis was made. Patients with helminthic infections had higher eosinophil counts than travelers and migrants with other diagnoses (median 981 vs. 710 cells/μl; p = 0.001), while total IgE levels (n = 70; 172 vs. 152 kU/l; p = 0.731) were similar in both groups. Conclusion Eosinophil count but not total IgE levels are associated with helminthic infections in returning travelers and migrants with eosinophilia. Our results do not support the use of total IgE to differentiate helminthic infections from other causes of eosinophilia in this population.

The pathophysiology of malarial anemia is multifactorial and incompletely understood. We assessed mechanistic and risk factors for post-malarial anemia in Ghanaian and Gabonese children with severe P. falciparum malaria treated with parenteral artesunate followed by an oral artemisinin-combination therapy. We analyzed data from two independent studies in which children were followed on Days 7,14, and 28 after treatment with artesunate. Specific hematological parameters included the presence of hemoglobinopathies and erythropoietin. Presence of once-infected erythrocytes was assessed by flow cytometry in a sub-population. Of 143 children with a geometric mean parasitemia of 116,294/µL (95% CI: 95,574–141,505), 91 (88%) had anemia (Hb

Background Travelers’ diarrhea (TD) is the most common illness experienced by travelers to developing regions of the world and may be caused by bacterial, parasitic or viral pathogens. The available diagnostic tests include stool microscopy for parasitic infections, culture-dependent methods for bacterial infections and molecular methods for bacterial, parasitic and viral infections. Method We retrospectively evaluated demographic, clinical and microbiological data of patients presenting with TD at our travel clinic between 2009 and 2017. Results Among 676 patients with TD included in our study, at least one etiologic agent was found in 21% (n = 145) of cases. In total, 195 enteropathogens were detected of which 110 were bacteria, 70 protozoa and 15 helminths. Bacterial infections were significantly more common when symptoms were present less than 14 days and travel duration did not exceed 29 days. Protozoa and helminths were predominantly detected in patients with longer lasting complaints. After stool culture was replaced by a multiplex-PCR gastrointestinal pathogen panel (GPP) at our center, significantly more intestinal bacterial pathogens were detected. Conclusions Our results support an individualized approach in the diagnostic workup of patients with TD taking host and travel characteristics into account to avoid unnecessary diagnostic testing. Molecular culture-independent diagnostic stool tests provide better coverage of the variety of etiological agents than traditional stool culture and have the benefit of rapid detection. However, the high sensitivity bears challenges differentiating colonization from infection.

Summary Background Health threats during mass gatherings, such as the FIFA world cup 2014 differ from traditional health risks. The influence of event type, demographics of attendees and environmental conditions are still not fully understood. Methods An observational, prospective case–control survey conducted at the Frankfurt international airport in Germany on 544 travelers to the FIFA world cup 2014 and 432 regular travelers to Brazil departing after the end of the world cup. Results Travelers to the FIFA world cup 2014 were predominantly male whereas the gender distribution in the control group was more balanced. The majority in both groups obtained insect bites and sunburns as environmental risk factors. Every third traveler suffered from diarrheal complaints in both groups, whereas the proportion of travelers with flu-like symptoms was higher in the case group. Travelers to the FIFA world cup 2014 indicated alcohol intake and sexual contacts outside of a relationship more frequently than travelers in the control group. Conclusions The additional health risks of travelers to sporting events as the FIFA world cup 2014 should be addressed in addition to traditional health threats in pre-travel counseling for the Summer Olympic Games 2016 in Brazil.

ZusammenfassungLeitlinien in mehreren europäischen Ländern empfehlen die notfallmäßige Selbstbehandlung einer Malaria (SBET) für Reisende in Malariagebiete mit geringem Transmissionsrisiko. Dabei sollen die mitgeführten Medikamente eingenommen werden, falls eine Malaria möglich und sofortige medizinische Hilfe nicht verfügbar ist. Über die Praktikabilität der SBET wurde innerhalb der Reisemedizin in der Vergangenheit vermehrt spekuliert. Neuere Daten stellen das Konzept der SBET für alle in Regionen mit niedrigem oder mittlerem Transmissionsrisiko Reisende infrage.

Malaria incidence is decreasing on a global scale, while the number of imported cases has remained at a high level in Germany. To decrease this number, counselling of travellers to malaria-endemic regions is important. Patients to high risk countries need regular chemoprophylaxis. The alternative of stand-by emergency treatment for travellers to regions with low or medium risk has been met with growing criticism. For the treatment of all malaria cases, artemisinins are a mainstay of treatment. Regular follow-up is warranted to prevent relapses. After treatment with intravenous artesunate for complicated malaria, delayed haemolysis must be kept in mind. A special situation has risen in Germany since 2014 with a growing number of Eritrean migrants presenting with Plasmodium vivax malaria. These patients need an additional course of primaquine to prevent relapses. Weltweit sind die Malaria-Inzidenzen rückläufig. Die Zahl der nach Deutschland importierten Fälle blieb zuletzt auf hohem Niveau stabil. Von größter Bedeutung ist es gut bekannte Risikogruppen mit Beratungsangeboten zu erreichen, z. B. Reisende auf Verwandtenbesuch in Endemiegebieten. Mefloquin steht seit 2013 in Deutschland nur noch als Einzelimport zur Verfügung, bleibt jedoch für bestimmte Personengruppen weiter ein wichtiges Prophylaktikum. Die notfallmäßige Selbsttherapie der Malaria, die gängige Praxis für Reisende in Länder mit niedrigem und mittlerem Übertragungsrisiko ist, wird in der Reisemedizin zunehmend kritisiert und sollte zielgerichteter eingesetzt werden. Patienten mit einem höheren Körpergewicht müssen nach einer Therapie engmaschig nachbeobachtet werden, da sie ein höheres Risiko einer Rekrudeszenz haben. Artesunat ist Mittel der Wahl zur Therapie der komplizierten Malaria tropica. Auch hier ist eine konsequente Kontrolle nach Therapieende notwendig, um eine mit Artesunat assoziierte hämolytische Anämie frühzeitig zu erfassen. Seit 2014 gab es in Deutschland eine Zunahme von Patienten mit einer Malaria tertiana, insbesondere bei Migranten aus Eritrea. Aufgrund der unzureichenden Gesundheitsversorgung der Flüchtenden haben nicht alle Patienten die bei Plasmodium vivax notwendige Rezidivprophylaxe mit Primaquin erhalten.

Objective Group B streptococcal (GBS) colonization of pregnant women can lead to subsequent infection of the new-born and potentially fatal invasive disease. Data on GBS colonization prevalence and serotype distribution from Africa are scarce, although GBS-related infections are estimated to contribute substantially to infant mortality. In recent years, GBS vaccine candidates provided promising results in phase I and II clinical trials. We aimed to assess the prevalence and serotype distribution of GBS in Ghana since this knowledge is a prerequisite for future evaluation of vaccine trials. Methods This double-centre study was conducted in one rural and one urban hospital in central Ghana, West Africa. Women in late pregnancy (≥35 weeks of gestation) attending the antenatal care clinic (ANC) provided recto-vaginal swabs for GBS testing. GBS isolates were analysed for serotype and antibiotic susceptibility. GBS-positive women were treated with intrapartum antibiotic prophylaxis (IAP) according to current guidelines of the Center for Disease Control and Prevention (CDC). Results In total, 519 women were recruited at both study sites, recto-vaginal swabs were taken from 509. The overall prevalence of GBS was 19.1% (18.1% in rural Pramso and 23.1% in urban Kumasi, restrospectively). Capsular polysaccharide serotype (CPS) Ia accounted for the most frequent serotype beyond all isolates (28.1%), followed by serotype V (27.1%) and III (21.9%). No resistance to Penicillin was found, resistances to second line antibiotics clindamycin and erythromycin were 3.1% and 1%, respectively. Discussion Group B Streptococcus serotype distribution in Ghana is similar to that worldwide, but variations in prevalence of certain serotypes between the urban and rural study site were high. Antibiotic resistance of GBS strains was surprisingly low in this study. Objectif Evaluer la distribution de la prevalence et du serotype du Streptococcus du groupe B (SGB) au Ghana car la colonisation des femmes enceintes peut entrainer une infection subsequente du nouveau-ne et potentiellement la maladie invasive mortelle. Cette connaissance est aussi un prerequis pour l’evaluation de futurs essais vaccinaux. Methodes Etude bi-centrique realisee dans un hopital rural et un hopital urbain dans le centre du Ghana, en Afrique de l'ouest. Les femmes en fin de grossesse (≥35 semaines de gestation) se presentant a la clinique des soins prenatals (ANC) ont fourni des prelevements recto-vaginaux par ecouvillon pour la recherche du SGB. Les isolats SGB ont ete analyses pour le serotype et la sensibilite aux antibiotiques. Les femmes positives pour le SGB ont ete traitees avec une antibio-prophylaxie intra-partum (IAP), conformement aux directives actuelles du Center for Disease Control and Prevention (CDC). Resultats 519 femmes ont ete recrutees dans les deux sites de l’etude, les prelevements recto-vaginaux ont ete effectues chez 509 d'entre elles. La prevalence globale du SGB etait de 19,1% (18,1% a Pramso, zone rurale et 23,1% a Kumasi, zone urbaine). Le serotype polysaccharide capsulaire (CPS) I.a etait plus frequent (28,1%), suivi du serotype V (27,1%) et III (21,9%). Aucune resistance a la penicilline n'a ete detectee; mais il y avait une resistance aux antibiotiques de deuxieme ligne, la clindamycine (3,1%) et l’erythromycine (1%). Discussion La distribution des serotypes de SGB au Ghana est similaire a celle dans le monde entier, mais les variations de la prevalence de certains serotypes entre l’etude urbaine et l’etude rurale etaient elevees. La resistance aux antibiotiques des souches de SGB etait etonnamment faible dans cette etude. Objetivo Evaluar la prevalencia y distribucion de serotipos del Estreptococo del Grupo B (EGB) en Ghana, ya que la colonizacion de mujeres embarazadas puede conllevar a la infeccion del recien nacido y a una enfermedad invasiva potencialmente letal, y este conocimiento es un prerequisito para la evaluacion futura de ensayos de vacunas. Metodos Estudio doble centrico realizado en un hospital rural y un hospital urbano en Ghana central, Africa Occidental. Las mujeres atendidas en una maternidad durante las ultimas semanas de embarazo (≥35 semanas de gestacion) proveyeron dos frotis recto-vaginales para realizar la prueba EGB. Los aislados de EGB obtenidos fueron analizados para determinar el serotipo y la susceptibilidad a antibioticos. Las mujeres positivas para EGB recibieron profilaxis antibiotica intraparto (PAI) siguiendo las guias actuales del Centro para el Control y la Prevencion de Enfermedades (CDC). Resultados Se reclutaron 519 mujeres en ambos centros de estudios, y se tomaron frotis recto-vaginales de 509 de ellas. La prevalencia general de EGB era del 19.1% (18.1% en la zona rural de Pramso y del 23.1% en la zona urbana de Kumasi). El serotipo Ia con polisacarido capsular (PSC) era el mas frecuente (28.1%), seguido por el serotipo V (27.1%) y el III (21.9%). No se detecto resistencia a la penicilina; pero habia resistencia a antibioticos de segunda linea como la clindamicina (3.1%) y la eritromicina (1%). Discusion La distribucion de serotipos de EGB en Ghana era similar a la que existe globalmente, pero las variaciones en prevalencia de algunos serotipos entre zonas urbanas y rurales era alta. La resistencia a antibioticos de cepas de EGB era sorprendentemente baja en este estudio.

An injectable Vi-capsular polysaccharide vaccine against typhoid fever is available but vaccine-induced immunity tends to wane over time. The phenomenon of immunotolerance or hyporesponsiveness has earlier been described for polysaccharide vaccines such as pneumococcal capsular polysaccharide vaccine and some publications also suggest a possible immunotolerance after revaccination with Vi-capsular polysaccharide vaccines. In this study, post-immunisation antibody concentrations in adult travellers first vaccinated with a Salmonella typhi Vi-capsular polysaccharide vaccine (primary vaccination group) were compared with those having received one or more vaccinations previously (multiple vaccinations group). Vaccines administered were Typherix® (GlaxoSmithKline), Typhim Vi® (Sanofi Pasteur MSD) or Hepatyrix® (GlaxoSmithKline). Blood samples were obtained prior to vaccination (day 0) and on day 28 (−1/+14) after vaccination. Serum Vi-Antigen IgG concentrations were measured by ELISA. Of the 85 subjects included in the per protocol data set, 45 (53%) belonged to the multiple vaccinations group. In both groups, geometric mean antibody concentrations (GMCs) were significantly higher after vaccination than before vaccination. Pre-vaccination GMCs were lower in the primary vaccination group than in the multiple vaccinations group (3.40 μg/ml versus 6.13 μg/ml, P = 0.005), while there was no significant difference in the post vaccination GMCs between groups (11.34 μg/ml versus 14.58 μg/ml, P = 0.4). In the multiple vaccinations group, vaccination was performed 18 to 57 months after the last vaccination (median 38 months) and there was a negative correlation between time since last vaccination and antibody concentration on day 0. In conclusion, we were not able to demonstrate a relevant immunotolerance after multiple versus primary vaccination with S. typhi Vi-capsular polysaccharide vaccines.

Background Specific travel-related recommendations exist for the prevention or self-treatment of infectious diseases contracted by travellers to the tropics. In the current study, we assessed the medical preparedness per these recommendations, focusing on whether travellers carried antidiarrheal and antimalarial medication with them stratified by type of pre-travel advice. Methods We surveyed travellers departing from Hamburg International Airport to South or Southeast Asia, using a questionnaire on demographic, medical and travel characteristics. Results 975 travellers were analysed – the majority (817, 83%) being tourists. A large proportion packed any antidiarrheal medication (612, 63%) – most frequently loperamide (440, 72%). Only 176 of 928 (19%) travellers to destinations with low-to medium risk for malaria packed a recommended antimalarial medication. The majority (162, 17%) of them carried antimalarials as stand-by emergency treatment (SBET). 468 (48%) travellers had a pre-travel medical consultation. This lead to higher odds of carrying SBET– with the highest odds associated with a consultation at a travel medicine specialist (OR 7.83 compared to no consultation). Conclusions Attending a travel medicine specialist was associated with better adherence to current recommendations concerning the carriage of stand-by emergency treatment of malaria. However, the proportion of travellers seeking pre-travel health advice was overall low in our population. Promoting pre-travel consultations may, therefore, lead to higher adherence to the current recommendations in travel medicine

Bacterial meningitis continues to be one of the most dreaded infections in sub-Saharan Africa and other countries that fall in the "meningitis belt" due to recurrent nature of the infection and the sequel of deliberating effects among survivors even after treatment. Ghana has had recurrent epidemics in the past but has been free from high mortality levels. Whereas reasons for the low reported number of deaths in the past are unclear, we hypothesize that it may be due to increased vaccination from expanded program on immunization (EPI) and consequent herd immunity of the general population. As at the end of February, 2016, 100 individuals were reported to have died out of 500 recorded cases. The infection may cause severe brain damage and kills at least 1 out of 10 individuals if quick interventions are not provided. The Ghana Health Service (GHS) and the Ministry of Health (MoH), together with other local and international stakeholders are working intensely to control the spread of the infection in affected communities with treatment and other health management programmes. This review presents a quick overview of meningitis in Ghana with emphasis on S. pneumoniae (responsible for about 70% of cases in the recent epidemic) together with some recommendations aimed at ensuring a "meningitis-free Ghana".

Background Globally, there are an estimated 22 million cases of Salmonella enterica serovar Typhi infection each year. However, this figure is likely to be an underestimate due to the low sensitivity of blood culture in S. Typhi diagnosis. The aim of this study was to diagnose S. Typhi by conventional polymerase chain reaction (PCR) using patient's blood preserved with ethylenediamine tetraacetic acid (EDTA). Methods From April 2012 to September 2013, typhoid fever surveillance was conducted in Polesgo and Nioko, 2 dry slum areas in Ouagadougou, Burkina Faso. Blood culture was performed for febrile patients using an automated blood culture system. Additional blood was collected in EDTA tubes from those patients and preserved at -80°C. DNA was extracted from EDTA blood and PCR was performed to identify presence of S. Typhi. Randomly selected PCR products were further sequenced to identify S. Typhi-specific amplicons. Results Of 1674 patients, S. Typhi was isolated from 18 (1.1%) individuals by blood culture. EDTA blood was collected from 1578 patients, of which 298 EDTA samples were tested by PCR. Salmonella Typhi-specific DNA was identified in 44 (14.8%) samples. The sensitivity of S. Typhi-specific PCR from EDTA blood was 89% (74%-100%) among the blood culture-positive cases. Sixteen S. Typhi-positive PCR products were sequenced, and 13 retrieved the sequence of a S. Typhi-specific amplicon. Conclusions These findings suggest that blood culture-based diagnoses of S. Typhi underestimate the burden of typhoid fever in Burkina Faso. PCR could be considered as an alternative method for the identification and diagnosis of S. Typhi in blood samples.

Background Malaria is a mosquito-borne parasitic disease that causes severe mortality and morbidity, particularly in Sub-Saharan Africa. As the vectors predominantly bite between dusk and dawn, risk of infection is determined by the abundance of P. falciparum infected mosquitoes in the surroundings of the households. Remote sensing is commonly employed to detect associations between land use/land cover (LULC) and mosquito-borne diseases. Due to challenges in LULC identification and the fact that LULC merely functions as a proxy for mosquito abundance, assuming spatially homogenous relationships may lead to overgeneralized conclusions. Methods Data on incidence of P. falciparum parasitaemia were recorded by active and passive follow-up over two years. Nine LULC types were identified through remote sensing and ground-truthing. Spatial associations of LULC and P. falciparum parasitaemia rate were described in a semi-parametric geographically weighted Poisson regression model. Results Complete data were available for 878 individuals, with an annual P. falciparum rate of 3.2 infections per person-year at risk. The influences of built-up areas (median incidence rate ratio (IRR): 0.94, IQR: 0.46), forest (median IRR: 0.9, IQR: 0.51), swampy areas (median IRR: 1.15, IQR: 0.88), as well as banana (median IRR: 1.02, IQR: 0.25), cacao (median IRR: 1.33, IQR: 0.97) and orange plantations (median IRR: 1.11, IQR: 0.68) on P. falciparum rate show strong spatial variations within the study area. Incorporating spatial variability of LULC variables increased model performance compared to the spatially homogenous model. Conclusions The observed spatial variability of LULC influence in parasitaemia would have been masked by traditional Poisson regression analysis assuming a spatially constant influence of all variables. We conclude that the spatially varying effects of LULC on P. falciparum parasitaemia may in fact be associated with co-factors not captured by remote sensing, and suggest that future studies assess small-scale spatial variation of vegetation to circumvent generalised assumptions on ecological associations that may in fact be artificial. Electronic supplementary material The online version of this article (doi:10.1186/1476-072X-13-35) contains supplementary material, which is available to authorized users.

Background: The present study aimed to evaluate immunogenicity and safety of the 2012/2013 seasonal influenza vaccine (Optaflu®) after the World Health Organization recommended two new strains for the composition. Results: Twenty-one days post-vaccination geometric mean titers (GMTs) against A(H1N1), A(H3N2) and the B strain were 528, 935, and 201 for adults and 272, 681, and 101 for elderly subjects, respectively. The proportion of subjects with a HI titer of ≥ 40 against the three strains A(H1N1), A(H3N2) and B was 98%, 100%, and 98% in adults and 100%, 100%, and 85% in elderly subjects, respectively. Optaflu® met the CHMP criteria of the Committee for Medicinal Products for Human Use (CPMP/BWP/214/96). Pre-vaccination titers indicated seroprotection against the A(H1N1), the A(H3N2) and the B strain in 56%, 86%, and 54% of the adults and in 61%, 85%, and 40% of the elderly with highest titers against the A(H3N2) strain. In the safety analysis injection site pain (37%) and myalgia (31%) were the most common local and systemic reactions. No serious adverse events were recorded. Conclusion: The 2012/2013 seasonal influenza vaccine Optaflu® showed good immunogenicity and an acceptable safety profile in both adults and elderly. Methods: In this trial, 126 subjects (63 adults ≥18 to ≤60 y, 63 elderly ≥61 y) were vaccinated with a single dose Optaflu® containing each of the three virus strains recommended for the 2012/2013 season (A/California/7/2009(H1N1)-like strain, A/Victoria/361/2011(H3N2)-like strain, and B/Wisconsin/1/2010-like strain). Immunogenicity was assessed by hemagglutinin inhibition (HI) and single radial hemolysis (SRH) assays on day 22, the safety profile was investigated throughout the whole study period.

Tropheryma whipplei has been hypothesized to be able to cause diarrhoea, but data from young children are scarce. In this hospital-based case-control study 534 stool samples of children aged between 2 months and 15 years from rural Ghana were analysed for the presence of T. whipplei. Overall stool prevalence of T. whipplei was high (27.5%). Although there was no difference in T. whipplei carriage overall between cases and controls, cases aged between 0 and 12 months carried T. whipplei in their stool twice as often as controls without diarrhoea. The results from this study may support the hypothesis that T. whipplei can cause diarrhoea in first-time infection.

Introduction: Although the incidence of Plasmodium falciparum malaria in some parts of sub-Saharan Africa is reported to decline and other conditions causing similar symptoms as clinical malaria are gaining in relevance presumptive anti-malarial treatment is still common. This study traced for age-dependent signs and symptoms predictive for P. falciparum parasitaemia. Methods: In total 5447 visits of 3641 patients between 2-60 months of age who attended an outpatient department (OPD) of a rural hospital in the Ashanti Region Ghana were analysed. All Children were examined by a paediatrician and a full blood count and thick smear were done. A Classification and Regression Tree (CART) model was used to generate a clinical decision tree to predict malarial parasitaemia a7nd predictive values of all symptoms were calculated. Results: Malarial parasitaemia was detected in children between 2-12 months and between 12-60 months of age with a prevalence of 13.8% and 30.6% respectively. The CART-model revealed age-dependent differences in the ability of the variables to predict parasitaemia. While palmar pallor was the most important symptom in children between 2-12 months a report of fever and an elevated body temperature of greater-than or equal to 37.5°C gained in relevance in children between 12-60 months. The variable palmar pallor was significantly (p

Background Guidelines in several European countries recommend standby emergency treatment (SBET) for travellers to regions with low or medium malaria transmission instead of continuous chemoprophylaxis: travellers are advised to seek medical assistance within 24 h in case of fever and to self-administer SBET only if they are not able to consult a doctor within the time period specified. Data on healthcare-seeking behaviour of febrile travellers and utilization of SBET is however scarce as only two studies were performed in the mid-1990s. Since tourism is constantly increasing and malaria epidemiology has dramatically changed in the meantime more knowledge is urgently needed. Methods Some 876 travellers to destinations in South and Southeast Asia with low or medium malaria transmission were recruited in the travel clinic of the University Medical Center Hamburg-Eppendorf. Demographic and travel-related data were collected by using questionnaires. Pre-travel advice was carried out and SBET was prescribed in accordance to national guidelines. Post-travel phone interviews were performed to assess health incidents during travel and individual responses of travellers to febrile illness. Results Out of 714 patients who were monitored, 130 (18%) reported onset of fever during travel or 14 days after return. Of those travellers who reported fever, 100 (80%) carried SBET during travel. The vast majority of 79 (79%) febrile travellers who carried SBET did not seek medical assistance. Overall, 14 (14%) febrile patients who carried SBET and six (20%) patients who did not carry SBET took the correct measure (doctor visit or timely SBET administration) as a response to febrile illness, respectively. Only two travellers self-administered SBET, but both of them applied the wrong regimen. Conclusions In view of declining malaria transmission and improving medical infrastructure in most countries of Southeast Asia and obvious obstacles concerning SBET as shown in this study the current strategy should be re-evaluated. Pre-travel advice concerning malaria in SEA should focus on appropriate mosquito bite protection and clearly emphasize the need to see a doctor within 24 h after onset of fever.