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There is a significant risk for ongoing and treatment-resistant courses of hepatitis E virus (HEV) infection in patients after solid organ transplantation. The aim of this study was to identify risk factors for the development of hepatitis E, including the dietary habits of patients. We conducted a retrospective single-center study with 59 adult kidney and combined kidney transplant recipients who were diagnosed with HEV infection between 2013 and 2020. The outcomes of HEV infections were analyzed during a median follow-up of 4.3 years. Patients were compared with a control cohort of 251 transplant patients with elevated liver enzymes but without evidence of an HEV infection. Patients’ alimentary exposures during the time before disease onset or diagnosis were assessed. Previous intense immunosuppression, especially treatment with high-dose steroids and rituximab, was a significant risk factor to acquire hepatitis E after solid organ transplantation. Only 11 out of 59 (18.6%) patients reached remission without further ribavirin (RBV) treatment. A total of 48 patients were treated with RBV, of which 19 patients (39.6%) had either viral rebounds after the end of treatment or did not reach viral clearance at all. Higher age (>60 years) and a BMI ≤ 20 kg/m2 were risk factors for RBV treatment failure. Deterioration in kidney function with a drop in eGFR (p = 0.046) and a rise in proteinuria was more common in patients with persistent hepatitis E viremia. HEV infection was associated with the consumption of undercooked pork or pork products prior to infection. Patients also reported processing raw meat with bare hands at home more frequently than the controls. Overall, we showed that the intensity of immunosuppression, higher age, a low BMI and the consumption of undercooked pork meat correlated with the development of hepatitis E.

Was ist neu? Klinik und Therapie Neben den gut bekannten klinischen Symptomen der Hantavirus-Erkrankung (Fieber, Flanken- und abdominelle Schmerzen sowie Arthralgien) geraten zunehmend auch ungewöhnliche neurologische Veränderungen im Rahmen der Infektion in den Fokus. Das Spektrum reicht von passageren Myopien bis zu schweren Paresen im Rahmen eines Guillain-Barré-Syndroms. In Endemiegebieten sind Schnellteste auf IgM-Antikörper zur Ersteinschätzung eine differenzialdiagnostische Hilfe. Therapeutisch stehen weiterhin nur supportive Maßnahmen bis zur passageren Dialyse zur Verfügung. Ausbruchsregionen in Deutschland und regionale Unterscheidung der Virusstämme Durch molekulargenetische Analyse und Vergleich von Hantavirus-Stämmen aus Patienten und Mäusen desselben geografischen Gebietes konnten Viren verschiedener Ausbruchsregionen charakterisiert werden. Inzwischen sind die Puumalaviren der Haupt-Ausbruchsregionen in Deutschland molekular so gut charakterisiert, dass anhand der Nukleotidsequenz des im Patienten nachgewiesenen Virusstammes Rückschlüsse auf die Gegend möglich sind, in der die Infektion des Patienten stattgefunden hat. Nachweis weiterer pathogener Hantaviren in Deutschland Die bislang nachgewiesenen humanpathogenen Hantaviren in Deutschland sind das Puumalavirus (Reservoir: Rötelmaus) und das Dobrava-Belgrad-Virus, Genotyp Kurkino (Reservoir: Brandmaus). Kürzlich gelang der molekulare Nachweis von weiteren Hantaviren in Patienten mit entsprechender klinischer Symptomatik. Man kann davon ausgehen, dass auch das Seoulvirus (Reservoir: Ratten) und das Tulavirus (Reservoir: Feldmaus und verwandte Arten) in Deutschland vereinzelt Hantavirus-Erkrankungen auslösen. Viruseintritt auch über den Darm? Neue Ergebnisse lassen es möglich erscheinen, dass die Infektion des Menschen nicht nur auf dem üblichen Weg der Einatmung virushaltiger Aerosole erfolgen kann, sondern auch durch Ingestion virushaltigen Materials. Zur Frage der Mensch-zu-Mensch-Übertragung von Hantaviren Bei Patienten mit Hantavirus-Infektion bzw. -Erkrankung kann davon ausgegangen werden, dass diese für ihre Umwelt nicht infektiös sind. Ein neues systematisches Review konnte auch die zuvor in Einzelfällen für südamerikanische Hantaviren postulierte Mensch-zu-Mensch-Übertragung nicht bestätigen. Neue Hantaviren in neuen Wirten Während alle bekannten humanpathogenen Hantaviren von Nagetieren übertragen werden, wurden in den letzten Jahren weitere Hantaviren in Spitzmäusen, Maulwürfen und Fledermäusen nachgewiesen. Die klinische Bedeutung dieser neuen Viren ist noch weitgehend unbekannt.

Objectives To describe the characteristics of a large hepatitis A virus (HAV) outbreak among men who have sex with men (MSM) in Berlin and to assess the impact of measures implemented. Methods Cases of laboratory-confirmed, symptomatic HAV infection notified in Berlin, Germany between August 2016 and February 2018 were analysed using routine and enhanced surveillance data including genotyping results. Several studies involving different groups of participants were conducted to further investigate the outbreak, including surveys on knowledge and practices of HAV vaccination among physicians and vaccination coverage and determinants of vaccination status among MSM. The measures implemented were categorized by target group in a Gantt chart. To assess their impact, health insurance data on HAV vaccination uptake were analysed, comparing Berlin and other federal states. Results During the outbreak period, a total of 222 cases were reported (of which 91 were sequence-confirmed), with a peak in case numbers in January 2017. Physicians were aware of the existing vaccination recommendations, but vaccination coverage among 756 MSM was low, with 32.7% being completely vaccinated and 17.3% being incompletely vaccinated before 2017. HAV vaccination before 2017 was associated with being born in Germany (odds ratio 2.36) and HIV-positive (odds ratio 1.80). HAV monovalent vaccination uptake increased by 164% from 2016 to 2017 among males in Berlin, compared to 7% in other federal states. Conclusions Multiple measures targeting the MSM community, physicians, and public health to increase HAV vaccination uptake were successfully implemented. To prevent future HAV outbreaks, we recommend monitoring vaccination coverage among MSM, promoting awareness of existing recommendations among physicians, and ensuring access for foreign-born and young MSM.

In addition to the well-known clinical early symptoms of hantavirus disease (fever, flank and abdominal pain as well as arthralgia), unusual neurological changes in the context of infection come into focus. The spectrum of neurological symptoms ranges from transient myopia to severe pareses in the context of Guillain-Barré syndrome. In endemic areas, rapid IgM tests for initial assessment are of certain value for differential diagnosis. For therapeutic approaches, only supportive measures up to transient dialysis are available.Molecular genetic analysis and comparison of hantavirus strains of patients and mice from the same geographical area allowed molecular characterization of different outbreak regions. In the meantime, the Puumala viruses of the main outbreak regions in Germany are molecularly well characterized; therefore, the nucleotide sequence of the virus strain detected in a patient makes it possible to draw conclusions about the geographic region where the patient's infection took place.The human pathogenic hantaviruses being prevalent in Germany are the Puumala virus (reservoir: bank vole) and the Dobrava-Belgrade virus, genotype Kurkino (reservoir: striped field mouse). Recently, the molecular detection of further hantaviruses in patients with hantavirus disease was achieved. It can be concluded that also the Seoul virus (reservoir: rats) and the Tulavirus (reservoir: field mouse and related species) occasionally cause hantavirus disease in Germany.New results revealed that human infections can occur not only by the generally accepted route of inhalation of virus-containing aerosols, but also by ingestion of virus-containing materials.For patients with hantavirus infection or disease, it can be assumed that they are not infectious for their environment. A new systematic review could not confirm a human-to-human transmission previously postulated for South American hantaviruses.While all known human pathogenic hantaviruses are transmitted by rodents, other hantaviruses have been recently detected in shrews, moles, and bats. The clinical significance of these new viruses is quite unclear as yet. Neben den gut bekannten klinischen Symptomen der Hantavirus-Erkrankung (Fieber, Flanken- und abdominelle Schmerzen sowie Arthralgien) geraten zunehmend auch ungewöhnliche neurologische Veränderungen im Rahmen der Infektion in den Fokus. Das Spektrum reicht von passageren Myopien bis zu schweren Paresen im Rahmen eines Guillain-Barré-Syndroms. In Endemiegebieten sind Schnellteste auf IgM-Antikörper zur Ersteinschätzung eine differenzialdiagnostische Hilfe. Therapeutisch stehen weiterhin nur supportive Maßnahmen bis zur passageren Dialyse zur Verfügung. AUSBRUCHSREGIONEN IN DEUTSCHLAND UND REGIONALE UNTERSCHEIDUNG DER VIRUSSTäMME: Durch molekulargenetische Analyse und Vergleich von Hantavirus-Stämmen aus Patienten und Mäusen desselben geografischen Gebietes konnten Viren verschiedener Ausbruchsregionen charakterisiert werden. Inzwischen sind die Puumalaviren der Haupt-Ausbruchsregionen in Deutschland molekular so gut charakterisiert, dass anhand der Nukleotidsequenz des im Patienten nachgewiesenen Virusstammes Rückschlüsse auf die Gegend möglich sind, in der die Infektion des Patienten stattgefunden hat. Die bislang nachgewiesenen humanpathogenen Hantaviren in Deutschland sind das Puumalavirus (Reservoir: Rötelmaus) und das Dobrava-Belgrad-Virus, Genotyp Kurkino (Reservoir: Brandmaus). Kürzlich gelang der molekulare Nachweis von weiteren Hantaviren in Patienten mit entsprechender klinischer Symptomatik. Man kann davon ausgehen, dass auch das Seoulvirus (Reservoir: Ratten) und das Tulavirus (Reservoir: Feldmaus und verwandte Arten) in Deutschland vereinzelt Hantavirus-Erkrankungen auslösen. VIRUSEINTRITT AUCH üBER DEN DARM?: Neue Ergebnisse lassen es möglich erscheinen, dass die Infektion des Menschen nicht nur auf dem üblichen Weg der Einatmung virushaltiger Aerosole erfolgen kann, sondern auch durch Ingestion virushaltigen Materials. ZUR FRAGE DER MENSCH-ZU-MENSCH-ÜBERTRAGUNG VON HANTAVIREN: Bei Patienten mit Hantavirus-Infektion bzw. -Erkrankung kann davon ausgegangen werden, dass diese für ihre Umwelt nicht infektiös sind. Ein neues systematisches Review konnte auch die zuvor in Einzelfällen für südamerikanische Hantaviren postulierte Mensch-zu-Mensch-Übertragung nicht bestätigen. Während alle bekannten humanpathogenen Hantaviren von Nagetieren übertragen werden, wurden in den letzten Jahren weitere Hantaviren in Spitzmäusen, Maulwürfen und Fledermäusen nachgewiesen. Die klinische Bedeutung dieser neuen Viren ist noch weitgehend unbekannt.

Objective: We describe epidemiological trends of human brucellosis in Germany over a 13 year period based on national surveillance data. Methods: We analyzed demographic, clinical, laboratory and exposure information of symptomatic laboratory-confirmed brucellosis cases notified 2006–18. Using official population data, we calculated incidences and risk ratios (RR). Results: From 2006 to 2018, 408 brucellosis cases were notified in Germany (mean annual incidence: 0.38/1,000,000 population), of which 75% were travel-associated. Yearly notifications peaked in 2014 (n = 47) and remained elevated compared to 2006–2013 (mean: n = 25). Asylum seekers (AS) arriving in Germany accounted for 9/44 (2015) and 15/36 (2016) cases, respectively. RR AS/non-AS 2015–2016: 28, 95% CI: 17–45. Unpasteurized milk products were most frequently notified as source of infection. Imported food and occupational exposure played a role in autochthonous cases. Conclusions: The incidence of human brucellosis has markedly increased in recent years. Most of the observed rise in notifications can be explained by infections in AS. Exposure still predominantly occurs abroad. Risk factors for autochthonous infections need to be investigated further, though imported dairy products seem to play a role. Physicians should consider brucellosis as differential diagnosis in AS and people with travel to endemic regions with compatible symptoms. Keywords: Brucellosis, Surveillance, Zoonosis, Human, Germany, Foodborne diseases, Asylum seekers

Viral hepatitis A to E describes various infectious inflammations of the liver parenchyma that are caused by the hepatitis viruses A to E (HAV, HBV, HCV, HDV, and HEV). Although the clinical pictures are similar, the pathogens belong to different virus families and differ in terms of pathogenesis, transmission routes, clinical course, prevention, and therapy options. In Germany, there is mandatory reporting according to the Infection Protection Act (IfSG) for direct or indirect laboratory evidence and for suspicion, illness, and death of viral hepatitis. The data are transmitted to the Robert Koch Institute.In this article, on the basis of published studies and notification data, we describe the epidemiology of hepatitis A to E as well as current challenges and prevention approaches. In particular, the latter contains the improvement of existing vaccination recommendations (hepatitis A and B); improvement of access to prevention, testing, and care including therapy with antiviral drugs (hepatitis B, C, and D) and the detection and prevention of foodborne infections and outbreaks; and improvements in the field of food safety (hepatitis A and E).Mit Virushepatitis A bis E werden verschiedene infektiöse Entzündungen des Leberparenchyms bezeichnet, die durch die Hepatitisviren A bis E (HAV, HBV, HCV, HDV und HEV) ausgelöst werden. Zwar ähneln sich die Krankheitsbilder, die Erreger gehören jedoch zu verschiedenen Virusfamilien und unterscheiden sich bezüglich der Pathogenese, der Übertragungswege, des klinischen Verlaufs und der Präventions- und Therapiemöglichkeiten. In Deutschland besteht eine namentliche Meldepflicht nach Infektionsschutzgesetz (IfSG) für den direkten oder indirekten Nachweis und für Verdacht, Erkrankung und Tod. Die Daten werden an das Robert Koch-Institut übermittelt.In diesem Beitrag wird die Epidemiologie der Hepatitiden A bis E anhand publizierter Studien und Meldedaten beschrieben und es werden aktuelle Herausforderungen und Präventionsansätze aufgezeigt. Letztere bestehen insbesondere in der verbesserten Umsetzung bereits bestehender Impfempfehlungen (Hepatitis A und B), dem verbesserten Zugang zu Prävention, Testung und Versorgung, einschließlich Therapie mit antiviralen Medikamenten (Hepatitis B, C und D), und der Erkennung und Verhinderung lebensmittelbedingter Infektionen und Ausbrüche und Verbesserungen auf dem Gebiet der Lebensmittelsicherheit (Hepatitis A und E).

Highlights • Experts suggest primary objectives for national HEV surveillance in EU/EEA countries. • to monitor the incidence of acute HEV cases. • to monitor chronic HEV infections. • to describe the epidemiology of acute and chronic HEV infections. • Suggested secondary objectives for national HEV surveillance in EU/EEA countries: • to monitor HEV phylotypes/subtypes. • to identify potential clusters/outbreaks. • to collect information on possible routes of transmission. • Overall, the majority of EU/EEA countries collect the suggested data and meet the outlined requirements to confirm an acute case., Background Hepatitis E virus (HEV) infection is not notifiable at EU/EEA level, therefore surveillance relies on national policies only. Between 2005 and 2015, more than 20,000 cases were reported in EU/EEA countries. HEV testing is established in 26 countries and 19 countries sequence HEV viruses. Objective and study design WHO's European Action plan for viral hepatitis recommends harmonised surveillance objectives and case definitions. ECDC's HEV expert group developed minimal and optimal criteria for national hepatitis E surveillance to support EU/EEA countries in enhancing their capacity and to harmonise methods. Results The experts agreed that the primary objectives of national surveillance for HEV infections should focus on the basic epidemiology of the disease: to monitor the incidence of acute cases and chronic infections. The secondary objectives should be to describe viral phylotypes or subtypes and to identify potential clusters/outbreaks and possible routes of transmission. Seventeen of 20 countries with existing surveillance systems collect the minimal data set required to describe the epidemiology of acute cases. Eleven countries test for chronic infections. Twelve countries collect data to identify potential clusters/outbreaks and information on possible routes of transmission. Discussion Overall, the majority of EU/EEA countries collect the suggested data and meet the outlined requirements to confirm an acute case.

Human norovirus accounts for the majority of viral gastroenteritis cases worldwide. It is a fast evolving virus generating diversity via mutation and recombination. Therefore, new variants and new recombinant strains emerge in the norovirus population. We characterized norovirus positive stool samples from one intensively studied district M&auml, rkisch-Oderland state Brandenburg with the samples from other states of Germany in order to understand the molecular epidemiological dynamics of norovirus outbreaks in Germany 2018. PCR systems, Sanger sequencing, and phylogenetic analyses were used for genotyping. Noroviruses of 250 outbreaks in Germany were genotyped, including 39 outbreaks for the district M&auml, rkisch-Oderland. Viral diversity in M&auml, rkisch-Oderland as compared to Germany was similar, but not identical. The predominant genogroup in Germany was GII with predominate genotype GII.P16-GII.4 Sydney, whereas GII.P31-GII.4 Sydney was the most frequent in M&auml, rkisch-Oderland. Genogroup I viruses were less frequently detected, regional and national. Within the sequences of GII.4 recombinants, two distinct clusters were identified with outbreaks from M&auml, rkisch-Oderland. Further analysis of sequence data and detailed epidemiological data are needed in order to understand the link between outbreaks in such clusters. Molecular surveillance should be based on samples collected nationally in order to trace comprehensive virus distribution and recombination events in virus population.

Hepatitis E virus (HEV) infection is a major public health concern in low-income countries, yet incidence and prevalence estimates are often lacking. Serum (n = 653) and faecal (n = 150) samples were collected from apparently healthy individuals using convenience sampling technique in six communities (Ore, Oke-Osun, Osogbo, Ede, Esa-Odo, and Iperindo) from Osun State, Nigeria. Serum samples were analysed for total anti-HEV IgG/IgM and anti-HEV IgM using commercially available HEV ELISA kits. Total anti-HEV positive serum and all stool samples were analysed for HEV RNA by RT-PCR. Overall, 15.0% (n = 98/653) and 3.8% (n = 25/653) of the serum samples were positive for anti-HEV total and IgM antibodies, respectively. Total anti-HEV and IgM in Ore, Oke-Osun, Osogbo, Ede, Esa-Odo, and Iperindo was 21.0% (n = 13/62) and 3.2% (n = 2/62), 19.4% (n = 20/103) and 6.8% (n = 7/103), 11.4% (n = 12/105) and 2.9% (n = 3/105), 8.0% (n = 16/199) and 1.5% (n = 3/199), 22.0% (n = 22/100) and 10.0% (n = 10/100), and 17.9% (n = 15/84) and 0.0% (n = 0/84), respectively. All samples (stool and serum) were HEV RNA negative. Anti-HEV seroprevalence was associated with rural location, increasing age, alcohol consumption, and rearing of animals. This study demonstrated a high anti-HEV seroprevalence in Osun State, indicating the need to implement surveillance and asses the hepatitis E burden in Nigeria.

A steep rise in Hepatitis E diagnoses is currently being observed in Germany and other European countries. The objective of this study was (i) to assess whether this trend mirrors an increase in infection pressure or is caused by increased attention and testing and (ii) estimate individual and population-based Hepatitis E Virus (HEV) seroconversion and seroreversion rates for Germany. We measured anti-HEV IgG prevalence in 10 407 adults participating in two linked, population-representative serosurveys (total n = 12 971) conducted in 1998 and 2010. In this period, we found a moderate but statistically significant decline of overall anti-HEV IgG prevalence from 18.6% to 15.3%. At both time points, seroprevalence increased with age and peaked in persons born between 1935 and 1959 suggesting a past period of increased infection pressure. Paired samples of individuals participating in 1998 and 2010 (n = 2564) revealed respective seroconversion and seroreversion rates of 6.2% and 22.6% among seronegative and seropositive individuals during 12 years, or 5.2 and 2.9 per 1000 inhabitants per year. This corresponds to a total of 417 242 [95%CI: 344 363-495 971] new seroconversions per year in the German population. While anti-HEV seroprevalence has decreased in the last decade, infection pressure and seroincidence remains high in Germany. Continuously rising numbers of Hepatitis E diagnoses in Europe are likely due to an increased awareness of clinicians and indicate that still there is a gap between incident and diagnosed cases. Studies on the true burden of the disease, specific risk factors and sources of autochthonous infections as well as targeted prevention measures are urgently needed.

Introduction Two hantavirus species, Puumala (PUUV) and Dobrava-Belgrade (DOBV) virus (genotype Kurkino), are endemic in Germany. Recent PUUV outbreaks raised questions concerning increasing frequency of outbreaks and expansion of PUUV endemic areas. Aims To describe the epidemiology of human PUUV and DOBV infections in Germany. Methods We conducted an observational retrospective study analysing national hantavirus surveillance data notified to the national public health institute and hantavirus nucleotide sequences from patients collected at the national consultation laboratory between 2001 and 2017. Matching molecular sequences with surveillance data, we conducted epidemiological, phylogenetic and phylogeographic analyses. Results In total, 12,148 cases of symptomatic hantavirus infection were notified 2001–17 (mean annual incidence: 0.87/100,000; range: 0.09–3.51). PUUV infections showed a highly variable space-time disease incidence pattern, causing large outbreaks every 2–3 years with peaks in early summer and up to 3,000 annually reported cases. Sex-specific differences in disease presentation were observed. Of 202 PUUV nucleotide sequences obtained from cases, 189 (93.6%) fall into well-supported phylogenetic clusters corresponding to different endemic areas in Germany. DOBV infections caused few, mostly sporadic cases in autumn and winter in the north and east of Germany. Conclusions The frequency of PUUV outbreaks increased between 2001 and 2017 but our data does not support the suggested expansion of endemic areas. The epidemiology of PUUV and DOBV-Kurkino infections differs in several aspects. Moreover, the latter are relatively rare and combining efforts and data of several countries to identify risk factors and develop specific recommendations for prevention could be worthwhile.

Introduction Sequence-based typing of hepatitis A virus (HAV) is important for outbreak detection, investigation and surveillance. In 2013, sequencing was central to resolving a large European Union (EU)-wide outbreak related to frozen berries. However, as the sequenced HAV genome regions were only partly comparable between countries, results were not always conclusive. Aim The objective was to gather information on HAV surveillance and sequencing in EU/European Economic Area (EEA) countries to find ways to harmonise their procedures, for improvement of cross-border outbreak responses. Methods In 2014, the European Centre for Disease Prevention and Control (ECDC) conducted a survey on HAV surveillance practices in EU/EEA countries. The survey enquired whether a referral system for confirming primary diagnostics of hepatitis A existed as well as a central collection/storage of hepatitis A cases’ samples for typing. Questions on HAV sequencing procedures were also asked. Based on the results, an expert consultation proposed harmonised procedures for cross-border outbreak response, in particular regarding sequencing. In 2016, a follow-up survey assessed uptake of suggested methods. Results Of 31 EU/EEA countries, 23 (2014) and 27 (2016) participated. Numbers of countries with central collection and storage of HAV positive samples and of those performing sequencing increased from 12 to 15 and 12 to 14 respectively in 2016, with all countries typing an overlapping fragment of 218 nt. However, variation existed in the sequenced genomic regions and their lengths. Conclusions While HAV sequences in EU/EEA countries are comparable for surveillance, collaboration in sharing and comparing these can be further strengthened.

Hepatitis A is a vaccine-preventable disease with a global distribution. It predominantly occurs in regions with inadequate living conditions, but also affects populations in industrialised countries. Children are frequently involved in the transmission of hepatitis A virus (HAV) and thus play a central role in the epidemiology of hepatitis A. Here, we investigated HAV infections, immunisations, and associated demographic determinants in a nationwide, population-based, cross-sectional survey conducted in Germany from 2003–2006. Out of 17,640 children and adolescents, complete data sets (HAV serology, demographic information and vaccination card) were available for 12,249 (69%), all aged 3–17 years. We found protective antibody levels (>=20 IU/L) in 1,755 (14%) individuals, 1,395 (11%) were vaccinated against hepatitis A, 360 (3%) individuals were HAV seropositive without prior hepatitis A vaccination, thus indicating a previous HAV infection. Antibody prevalence (attributable to vaccination or infection) increased significantly with age. Multivariate logistic regression revealed that predominantly children and adolescents with migration background–even if they were born in Germany–are affected by HAV infections. Our results provide a rationale to emphasise existing vaccination recommendations and, moreover, to consider additional groups with a higher risk of infection for targeted vaccination, especially children with a migration background.

Background Giardia duodenalis is a leading cause of gastroenteritis worldwide. Humans are mainly infected by two different subtypes, i.e., assemblage A and B. Genotyping is hampered by allelic sequence heterozygosity (ASH) mainly in assemblage B, and by occurrence of mixed infections. Here we assessed the suitability of current genotyping protocols of G. duodenalis for epidemiological applications such as molecular tracing of transmission chains. Methodology/Principal findings Two G. duodenalis isolate collections, from an outpatient tropical medicine clinic and from several primary care laboratories, were characterized by assemblage-specific qPCR (TIF, CATH gene loci) and a common multi locus sequence typing (MLST; TPI, BG, GDH gene loci). Assemblage A isolates were further typed at additional loci (HCMP22547, CID1, RHP26, HCMP6372, DIS3, NEK15411). Of 175/202 (86.6%) patients the G. duodenalis assemblage could be identified: Assemblages A 25/175 (14.3%), B 115/175 (65.7%) and A+B mixed 35/175 (20.0%). By incorporating allelic sequence heterozygosity in the analysis, the three marker MLST correctly identified 6/9 (66,7%) and 4/5 (80.0%) consecutive samples from chronic assemblage B infections in the two collections, respectively, and identified a cluster of five independent patients carrying assemblage B parasites of identical MLST type. Extended MLST for assemblage A altogether identified 5/6 (83,3%) consecutive samples from chronic assemblage A infections and 15 novel genotypes. Based on the observed A+B mixed infections it is estimated that only 75% and 50% of assemblage A or B only cases represent single strain infections, respectively. We demonstrate that typing results are consistent with this prediction. Conclusions/Significance Typing of assemblage A and B isolates with resolution for epidemiological applications is possible but requires separate genotyping protocols. The high frequency of multiple infections and their impact on typing results are findings with immediate consequences for result interpretation in this field., Author summary Giardia duodenalis is a leading cause of gastroenteritis worldwide. Humans are mainly infected by the two different genetic subtypes, assemblage A and B. Molecular typing tools for epidemiological applications such as tracking transmission, attribution to a source and outbreak investigations have been developed and are highly desirable. However, to what degree the tetraploid genome with allelic sequence heterogeneity (ASH), and the frequent occurrence of mixed, assemblage A and B infections hamper performance is unclear. Here, we assessed the suitability of current genotyping protocols for deciphering the molecular epidemiology of G. duodenalis. Against a common reporting bias, we incorporated ASH in the analysis and we show that typing with resolution for epidemiological applications is possible for both, assemblage A and B isolates, but requires separate protocols. We also demonstrate how the high frequency of multiple infections overall impacts on typing results, which has immediate consequences for result interpretation in this field.

Background Hepatitis E virus (HEV) is endemic in EU/EEA countries, but the understanding of the burden of the infection in humans is inconsistent as the disease is not under EU surveillance but subject to national policies. Study Countries were asked to nominate experts and to complete a standardised questionnaire about the epidemiological situation and surveillance of HEV in their respective EU/EEA country. This study reviewed surveillance systems for human cases of HEV in EU/EEA countries and nominated experts assessed the epidemiology in particular examining the recent increase in the number of autochthonous cases. Results Surveillance systems and case definitions across EU/EEA countries were shown to be highly variable and testing algorithms were unreliable. Large increases of autochthonous cases were reported from Western EU/EEA countries with lower case numbers seen in Northern and Southern European countries. Lack of clinical awareness and variability in testing strategies might account for the observed differences in hepatitis E incidence across EU/EEA countries. Infections were predominantly caused by HEV genotype 3, the most prevalent virus type in the animal reservoirs. Conclusion Discussions from the expert group supported joint working across countries to better monitor the epidemiology and possible changes in risk of virus acquisition at a European level. There was agreement to share surveillance strategies and algorithms but also importantly the collation of HEV data from human and animal populations. These data collected at a European level would serve the ‘One Health’ approach to better informing on human exposure to HEV.

Free PMC Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205254/ Between 1 June 2016 and 31 May 2017, 17 European Union (EU) and European Economic Area countries reported 4,096 cases associated with a multi-country hepatitis A (HA) outbreak. Molecular analysis identified three co-circulating hepatitis A virus (HAV) strains of genotype IA: VRD_521_2016, V16-25801 and RIVM-HAV16-090. We categorised cases as confirmed, probable or possible, according to the EU outbreak case definitions. Confirmed cases were infected with one of the three outbreak strains. We investigated case characteristics and strain-specific risk factors for transmission. A total of 1,400 (34%) cases were confirmed; VRD_521_2016 and RIVM-HAV16-090 accounted for 92% of these. Among confirmed cases with available epidemiological data, 92% (361/393) were unvaccinated, 43% (83/195) travelled to Spain during the incubation period and 84% (565/676) identified as men who have sex with men (MSM). Results depict an HA outbreak of multiple HAV strains, within a cross-European population, that was particularly driven by transmission between non-immune MSM engaging in high-risk sexual behaviour. The most effective preventive measure to curb this outbreak is HAV vaccination of MSM, supplemented by primary prevention campaigns that target the MSM population and promote protective sexual behaviour. info:eu-repo/semantics/publishedVersion

The intensity and extent of transmission of arboviruses such as dengue, chikungunya, and Zika virus have increased markedly over the last decades. Autochthonous transmission of dengue and chikungunya by Aedes albopictus has been recorded in Southern Europe where the invasive mosquito was already established and viraemic travelers had imported the virus. Ae. albopictus populations are spreading northward into Germany. Here, we model the current and future climatically suitable regions for Ae. albopictus establishment in Germany, using climate data of spatially high resolution. To highlight areas where vectors and viraemic travellers are most likely to come into contact, reported dengue and chikungunya incidences are integrated at the county level. German cities with the highest likelihood of autochthonous transmission of Aedes albopictus-borne arboviruses are currently located in the western parts of the country: Freiburg im Breisgau, Speyer, and Karlsruhe, affecting about 0.5 million people. In addition, 8.8 million people live in regions considered to show elevated hazard potential assuming further spread of the mosquito: Baden-W&uuml, rttemberg (Upper Rhine, Lake Constance regions), southern parts of Hesse, and North Rhine-Westphalia (Lower Rhine). Overall, a more targeted and thus cost-efficient implementation of vector control measures and health surveillance will be supported by the detailed maps provided here.

Background Travel to countries with high or intermediate hepatitis A virus (HAV) endemicity is a risk factor for infection in residents of countries with low HAV endemicity. Aim: The objective of this study was to estimate the risk for hepatitis A among European travellers using surveillance and travel denominator data. Methods: We retrieved hepatitis A surveillance data from 13 European Union (EU)/ European Economic Area (EEA) countries with comprehensive surveillance systems and travel denominator data from the Statistical Office of the European Union. A travel-associated case of hepatitis A was defined as any case reported as imported. Results: From 2009 to 2015, the 13 countries reported 18,839 confirmed cases of hepatitis A, of which 5,233 (27.8%) were travel-associated. Of these, 39.8% were among children younger than 15 years. The overall risk associated with travel abroad decreased over the period at an annual rate of 3.7% (95% confidence interval (CI): 0.7–2.7) from 0.70 cases per million nights in 2009 to 0.51 in 2015. The highest risk was observed in travellers to Africa (2.11 cases per million nights). Cases more likely to be reported as travel-associated were male and of younger age (Conclusion: Travel is still a major risk factor for HAV infection in the EU/EEA, although the risk of infection may have slightly decreased in recent years. Children younger than 15 years accounted for a large proportion of cases and should be prioritised for vaccination.

Background Notified cases of hepatitis E have increased 40-fold in the past 10 years in Germany. Food safety is a major concern as hepatitis E virus (HEV) RNA has been detected in ready-to-eat retail-level food products. The objective of this case–control study was to assess risk factors for autochthonous symptomatic hepatitis E and explore reasons for delays in diagnosis. Methods: Demographic, clinical and exposure data from notified hepatitis E cases and individually matched population controls were collected in semi-standardised telephone interviews. Conditional logistic regression analysis was used to calculate matched odds ratios (mOR) and population attributable fractions (PAF). Results: In total, 270 cases and 1,159 controls were included (mean age 53 years, 61% men in both groups). Associated with disease were: consumption of undercooked pork liver, pork, wild boar meat, frankfurters, liver sausage and raw vegetables; contact with waste water (occupational) and various host factors (mORs between 1.9 and 34.1, p value Conclusions: Our study suggests that there are indeed sex-specific differences in disease development and lends important epidemiological evidence to specific ready-to-eat pork products as a major source for autochthonous hepatitis E. A review of existing consumer recommendations and production methods may be indicated.

From January to June 2018, two ongoing hepatitis A outbreaks affected travellers returning from Morocco and cases in Europe without travel history, resulting in 163 patients in eight European countries. Most interviewed travel-related cases were unaware of the hepatitis A risk in Morocco. Molecular analysis revealed two distinct hepatitis A virus (HAV) strains (subgenotype IA DK2018_231; subgenotype IB V18-16428). Vaccination recommendations should be emphasised to increase awareness among non-immune travellers to Morocco and HAV-endemic countries. First, we thank the European Centre for Disease Prevention and Control (ECDC)’s Food- and Waterborne Diseases and Zoonoses team, particularly Ettore Severi and Johanna Takkinen for their support of this joint investigation. We also thank Lelia Thornton, HSE - Health Protection Surveillance Centre, Dublin, Ireland for sharing information on the Irish hepatitis A patient. Moreover, we greatly acknowledge the work of local and state health departments for their support of epidemiological investigations and molecular surveillance. Sí

Since 14 November 2016, 38 cases of hepatitis A have been notified in Berlin; of these, 37 were male and 30 reported to have sex with men (MSM). Median age of MSM cases is 31 years (range: 24–52 years). Phylogenetic analysis revealed three distinct sequences, linking cases in Berlin to those in other German cities and to clusters recognised in other European countries in 2016.

Since early November 2016, the number of laboratory-confirmed norovirus infections reported in Germany has been increasing steeply. Here, we report the detection and genetic characterisation of an emerging norovirus recombinant, GII.P16-GII.2. This strain was frequently identified as the cause of sporadic cases as well as outbreaks in nine federal states of Germany. Our findings suggest that the emergence of GII.P16-GII.2 contributed to rising case numbers of norovirus gastroenteritis in Germany.

From September 2015 to March 2016, hepatitis A notifications in Germany increased by 45% to 699 cases compared to 482 cases in the same period of the previous year. Children aged five to nine years were predominantly affected (22% of all cases in this period). We hypothesized that this increase could be explained by the marked influx of asylum seekers in this time period. We analysed national surveillance data and estimated the number of imported and autochthonous hepatitis A cases in asylum seekers. We also investigated molecular signatures of hepatitis A viruses sampled from asylum seekers to identify chains of transmission. We found that 40% (278 cases) of all 699 hepatitis A cases notified between September 2015 and March 2016 in Germany concerned asylum seekers. Most infections were acquired abroad, but at least 24% accounted for autochthonous infections. Among asylum seekers, children aged five to nine years were overrepresented with 97 of 278 (35%) notified cases. The analysed hepatitis A virus sequences were primarily subgenotype IB strains and clustered with previously isolated samples from the Middle East, Turkey, Pakistan and East Africa. Except one transmission from an asymptomatic child to a nursery nurse working in a mass accommodation, we are not aware of infection chains involving asylum seekers and German residents. We conclude that asylum-seeking children and adolescents are susceptible to hepatitis A virus infections, particularly children aged five to nine years. Measures to prevent secondary infections in asylum seekers such as extended hygiene measures and post-exposure prophylaxis seem advisable.

We report an ongoing, protracted and geographically dispersed outbreak of haemolytic uraemic syndrome (HUS) and gastroenteritis in Germany, involving 30 cases since December 2016. The outbreak was caused by the sorbitol-fermenting immotile variant of Shiga toxin-producing (STEC) Escherichia coli O157. Molecular typing revealed close relatedness between isolates from 14 cases. One HUS patient died. Results of a case–control study suggest packaged minced meat as the most likely food vehicle. Food safety investigations are ongoing.

In 2010, the highest annual number of human Puumala virus (PUUV) infections was reported in Germany since hantavirus surveillance started in 2001. The increase in annual case numbers was especially marked in western Thuringia. We combined results of case-based hantavirus surveillance in humans and serological and molecular investigations in the rodent reservoir to describe the epidemiological situation and to identify the putative outbreak strain. A 5-fold increase in notified hantavirus cases compared to the previous annual maximum was observed in western Thuringia in 2010. Disease incidence varied tremendously within a small geographical area with case patients' places of residence clustering around beech-dominated broad leaf forest patches. Investigations in the rodent reservoir revealed a novel Puumala virus (PUUV) subtype, which is clearly distinct from strains collected in other PUUV endemic regions of Germany. It can be assumed that in regions in western Thuringia where hantavirus cases occurred in 2010 or previous outbreak years, PUUV has been present in the environment for a long time. Further studies are needed to elucidate the population dynamics and hantavirus prevalence of the rodent reservoir and driving ecological factors.

After the emergence of unusual clusters of microcephaly among babies born in the fall of 2015 in Brazil—and, retrospectively, in French Polynesia—WHO declared a Public Health Emergency of International Concern in January 2016 (http://www.who.int/mediacentre/news/statements/2016/1st-emergency-committee-zika/en/). Based on the spatial and temporal correlation of these clusters with outbreaks of Zika virus infections a few months before, a causal link is suspected. Whether the observed link between infection and microcephaly is indeed causal needs careful assessment—not the least because we might fall into the trap of ecological fallacy, inferring a causal association on the individual level from an association on the aggregate or population level. Here, we organize the currently available data into Austin Bradford Hill's aspects of evidence for the consideration of causality (Hill, 1965). Although it is no longer considered a litmus test in itself, Hill's recipe for careful and multifaceted contemplation of the available evidence is still a rigorous method for separating what is known from what is not known. For each aspect, we first consider individual‐level evidence, but supplement it with likely more readily observable effects on the population level. Studies to characterize the strength of this association in terms of odds ratios from case–control studies or (preferable) relative risks from cohort studies are already underway. These should be able to answer how much more likely a mother infected with Zika virus any time during pregnancy, or in a specific time window, will be giving birth to a child with microcephaly compared to mothers who were not infected. On the ecological level, a strong increase in microcephaly cases is not by itself evidence for a strong causal association because there might be confounding or biases. Nevertheless, if there were a strong causal association, we would expect to see a large increase in cases of microcephaly in a population with …

Background We describe an outbreak of gastroenteritis and the hemolytic–uremic syndrome caused by Shiga-toxin–producing Escherichia coli in Germany in May, June, and July, 2011. The consumption of sprouts was identified as the most likely vehicle of infection. Methods We analyzed data from reports in Germany of Shiga-toxin–producing E. coli gastro enteritis and the hemolytic–uremic syndrome and clinical information on patients presenting to Hamburg University Medical Center (HUMC). An outbreak case was defined as a reported case of the hemolytic–uremic syndrome or of gastroenteritis in a patient infected by Shiga-toxin–producing E. coli, serogroup O104 or serogroup unknown, with an onset of disease during the period from May 1 through July 4, 2011, in Germany. Results A total of 3816 cases (including 54 deaths) were reported in Germany, 845 of which (22%) involved the hemolytic–uremic syndrome. The outbreak was centered in northern Germany and peaked around May 21 to 22. Most of the patients in whom the hemolytic–uremic syndrome developed were adults (88%; median age, 42 years), and women were overrepresented (68%). The estimated median incubation period was 8 days, with a median of 5 days from the onset of diarrhea to the development of the hemolytic–uremic syndrome. Among 59 patients prospectively followed at HUMC, the hemolytic–uremic syndrome developed in 12 (20%), with no significant differences according to sex or reported initial symptoms and signs. The outbreak strain was typed as an enteroaggregative Shiga-toxin–producing E. coli O104:H4, producing extended-spectrum beta-lactamase. Conclusions In this outbreak, caused by an unusual E. coli strain, cases of the hemolytic–uremic syndrome occurred predominantly in adults, with a preponderance of cases occur ring in women. The hemolytic–uremic syndrome developed in more than 20% of the identified cases.

Von Mai bis Juli 2011 ereignete sich vor allem in Norddeutschland der bisher groste Ausbruch von Infektionen durch enterohamorrhagische Escherichia coli (EHEC) O104:H4 und von hamolytisch-uramischem Syndrom (HUS) mit insgesamt uber 3.800 Erkrankten und 53 Todesfallen. Bei den Erkrankten handelte es sich uberwiegend um Erwachsene. Dies steht im Gegensatz zu den in den Meldedaten der letzten Jahre beobachteten Erkrankungsfallen an EHEC-Gastroenteritis und HUS, als vor allem Kinder betroffen waren. Der Ausbruch begann, bezogen auf den Erkrankungsbeginn (Durchfallsymptomatik) der ubermittelten Falle, am 08. Mai 2011, gipfelte am 22. Mai und klang danach ab. Am 26. Juli 2011 wurde der Ausbruch vom Robert Koch-Institut (RKI) fur beendet erklart, da zu diesem Zeitpunkt drei Wochen lang keine neuen, offensichtlich dem Ausbruch zugehorigen Erkrankungsfalle ubermittelt worden waren, die nach dem 4. Juli erkrankt waren. Epidemiologische Studien des RKI in Kooperation mit dem Offentlichen Gesundheitsdienst von Landern und Kommunen und Kliniken sowie Ermittlungen der Lebensmitteluberwachungsbehorden identifizierten mit groser Wahrscheinlichkeit kontaminierte Sprossen aus einem Gartenbaubetrieb in Niedersachsen bzw. importierte Bockshornkleesamen als Infektionsvehikel im Ausbruchsgeschehen. Die enge Kooperation der Gesundheits- und Lebensmitteluberwachungsbehorden ermoglichte die zeitnahe Aufklarung des Ausbruchsgeschehens.

Introduction: On May 3, 2009, a first case of influenza A/H1N1 infection occurred in the federal state of Saxony-Anhalt, Germany. In order to stop the possible spread of the virus and to study the epidemiological and clinical characteristics of the infection, an investigation was launched by the local health authorities and the RKI. Methods: Standardised questionnaires were used to assess demographic and clinical data. Specimens were collected from case patients and close contacts and were analysed for influenza A/H1N1 using real-time PCR. Results: The index patient showed fever and coughing 3.5 days after returning from a holiday in Mexico. The local health authorities were informed on May 3, and measures were rapidly implemented. These measures included a trace-back of possible contact persons, isolation of the case and close contacts, prophylactic treatment with Oseltamivir. Virological investigations showed that the case shedded viral genome up until the last day of antiviral therapy. Viral genome was also detected in the spouse and the son of the patient. Both showed no symptoms under a prophylactic treatment with antiviral medication. No viral genome was detected in three other family members, and in six other contact persons outside of the family. Discussion: The spread of the virus was contained due to the fast response of the local health authorities. Two secondary cases occurred in the family. These cases remained asymptomatic, possibly due to antiviral prophylaxis. Epidemiological and virological results suggest that the influenza A/H1N1 virus has a longer incubation period and that viral shedding may probably be prolonged when compared with seasonal influenza.

Background In Germany, 17 % of the general human population have antibodies to hepatitis E virus (HEV) (recomLine HEV-IgG/IgM immunoassay [Mikrogen GmbH]). Wild boars represent an animal reservoir for HEV genotype 3, which is the common genotype in Germany. We estimated the seroprevalence among hunters with contact to wild boars to identify factors that may be associated with past or present HEV infection. Methods In 2013, the local veterinarian authority in a district in Central Germany attended meetings of hunters who provided blood specimens and completed a questionnaire collecting information on age, sex, hunting-related activities and consumption of wild boar meat. Specimens of wild boars were taken during drive hunts in this district during the season 2012/2013. All specimens were tested for HEV RNA and anti-HEV IgM and IgG antibodies. Log-binomial regression was used to estimate prevalence ratios (PR) for the hunters. Results Of 126 hunters (median age 55; 94 % male) 21 % tested positive for anti-HEV IgG antibodies (95 % confidence interval [CI] 13–28 %) (recomWell HEV IgG assay [Mikrogen GmbH]). Anti-HEV prevalence was highest in the age group of the 70–79-year-olds (67 %; 95 % CI 39–95 %). Wild boars showed an average anti-HEV prevalence of 41 %. HEV RNA was detected in 4/22 (18 %) liver specimens and in 1/22 (4.5 %) muscle specimens. Most wild boars were tested positive for HEV RNA (3/10; 30 %) and HEV-specific antibodies (7/15; 47 %) in the southwestern part of the district. Hunters preferring this hunting ground had a lower anti-HEV prevalence when gloves were frequently used during disembowelling of wild boars compared to hunters using gloves never or infrequently (age-adjusted PR 0.12; 95 % CI 0.02–0.86). Conclusions Hunters may benefit from wearing gloves when in contact with blood or body fluids of HEV animal reservoirs. Anti-HEV prevalence among the hunters of this study did not significantly differ from that of the general population suggesting that other factors play a major role in the epidemiology of HEV in Germany. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1199-y) contains supplementary material, which is available to authorized users.

In May 2013, Italy declared a national outbreak of hepatitis A, which also affected several foreign tourists who had recently visited the country. Molecular investigations identified some cases as infected with an identical strain of hepatitis A virus subgenotype IA. After additional European Union/European Economic Area (EU/EEA) countries reported locally acquired and travel-related cases associated with the same outbreak, an international outbreak investigation team was convened, a European outbreak case definition was issued and harmonisation of the national epidemiological and microbiological investigations was encouraged. From January 2013 to August 2014, 1,589 hepatitis A cases were reported associated with the multistate outbreak; 1,102 (70%) of the cases were hospitalised for a median time of six days; two related deaths were reported. Epidemiological and microbiological investigations implicated mixed frozen berries as the vehicle of infection of the outbreak. In order to control the spread of the outbreak, suspected or contaminated food batches were recalled, the public was recommended to heat-treat berries, and post-exposure prophylaxis of contacts was performed. The outbreak highlighted how large food-borne hepatitis A outbreaks may affect the increasingly susceptible EU/EEA general population and how, with the growing international food trade, frozen berries are a potential high-risk food.

BACKGROUND Food safety authorities discovered that wild boar meat products contaminated with Trichinella spiralis had entered the food chain in Germany in March 2013. Public health authorities issued guidelines for health professionals including post-exposure prophylaxis (PEP) using mebendazole and advised the public to seek medical advice if exposed. Our objective was to identify factors associated with the development of trichinellosis and to evaluate post exposure prophylaxis. METHODS Persons who reported to local public health departments as exposed were interviewed concerning exposure, symptoms, and medication. Serum samples were tested by an in-house Trichinella-specific enzyme-linked innunosorbent assay. Cases were defined as persons presenting with myalgia and/or periorbital edema and Trichinella-specific immunoglobulin M and immunoglobulin G antibodies after exposure to implicated products. RESULTS Of 101 persons interviewed, 71 were exposed and serologically tested. Antibodies were detected in 21/71 (30%) and 14/71 (20%) met the case definition. Attack rates were positively correlated to the amount of implicated product consumed. Among n = 37 persons who received anthelmintics as PEP, 6 persons developed trichinellosis. These cases exclusively occurred among persons starting PEP 6 days or later post-exposure. Exposure to implicated products and delaying PEP were also significantly associated with developing trichinellosis (P < .01) in a multivariable analysis. CONCLUSIONS Concerted efforts by food safety and public health authorities lead to timely outbreak control and facilitated the provision of early PEP. PEP appears to be effective in preventing trichinellosis when given early, preferably within 6 days. We therefore recommend initiating PEP without delay in similar settings and encourage public health professionals to fast-track this intervention.

Background and objective Cytochrome P450 (CYP) 1A2 activity is induced by cigarette smoking. Thus smoking cessation in patients while they are undergoing therapy with a CYP1A2 substrate such as theophylline or clozapine increases its concentrations and may cause adverse effects. Our objective was to determine the time course of CYP1A2 activity changes after smoking cessation in heavy smokers as the basis for dosing adaptation schemes. Methods The study was conducted in 8 men and 4 women (all white) who smoked 20 cigarettes or more per day. Sudden smoking cessation was carried out after a 14-day run-in period. Subjects were phenotyped for CYP1A2 activity at 6, 4, and 1 day before smoking cessation and at 0, 1, 2, 3, 6, 8, 10, and 13 days thereafter by use of the paraxanthine-to-caffeine ratio in plasma 6 hours after a 148-mg caffeine test dose. A monoexponential decay of CYP1A2 activity to a residual value was fitted to the data by nonlinear regression analysis. Results On cessation of smoking, initial caffeine clearance (estimated geometric means and 95% confidence intervals) decreased significantly (P < .01), by 36.1% (30.9%-42.2%), from 2.47 mL · min−1 · kg−1 body weight (2.03–3.00 mL · min−1 · kg−1 body weight) to a new steady state of 1.53 mL · min−1 · kg−1 body weight (1.24–1.89 mL · min−1 · kg−1 body weight). The apparent half-life of CYP1A2 activity decrease was 38.6 hours (27.4–54.4 hours). Conclusion Doses of CYP1A2 substrates with a narrow therapeutic range should be decreased immediately on cessation of heavy smoking. As a rule of thumb, a stepwise daily dose reduction of approximately 10% until the fourth day after smoking cessation is proposed, which should be accompanied by therapeutic drug monitoring. Clinical Pharmacology & Therapeutics (2004) 76, 178–184; doi: 10.1016/j.clpt.2004.04.003

Humanpathogene, vektorubertragene Infektionserreger spielen fur Deutschland eine bedeutende Rolle. Die endemischen, zoonotischen Infektionserreger sind entweder bundesweit verbreitet (Borrelia burgdorferi sensu latu) oder kommen in bestimmten geografischen Regionen vor (FSME-Viren, Hantaviren). Sie verursachen eine erhebliche Krankheitslast. Ihre Pravention und Kontrolle beruhen im Wesentlichen auf Aufklarung und personlichen Schutzmasnahmen (FSME-Impfung, Schutz vor Vektoren). Eine gute Surveillance, erganzt um gezielte epidemiologische Studien, ist Voraussetzung zur Bewertung der raumlich-zeitlichen Infektionsrisiken und der Wirksamkeit von Praventionsmasnahmen. Neben den endemischen Erregern mussen die importierten, durch Vektoren – zumeist Mucken – ubertragenen Erreger im Rahmen der Surveillance-Aktivitaten ebenfalls systematisch und intensiv beobachtet werden, zum einen, um das Risiko fur Reisende aus Deutschland einschatzen zu konnen, zum anderen, um das Risiko einer moglichen autochthonen Ubertragung adaquat bewerten zu konnen. Hierbei sind weitere Faktoren zu berucksichtigen (Etablierung von invasiven Muckenarten in Deutschland, zunehmende Erwarmung). Unter diesen Erregern sind vor allem das West-Nil-Virus, das Denguevirus, das Chikungunyavirus und der Malariaerreger (Plasmodien) zu nennen. Im vorliegenden Beitrag geben wir einen Uberblick uber die epidemiologische Situation bei ausgewahlten, fur Deutschland besonders relevanten, durch Vektor-ubertragene Erreger ausgelosten Infektionskrankheiten.