Irene Schöneberg

Leptospirosis in Germany, 1962–2003

Epidemiologic trends of human leptospirosis in Germany were investigated by analyzing national surveillance data from 1962 to 2003 and by conducting a questionnaire-based survey from 1997 to 2000. After a steady decrease of leptospirosis incidence from 1962 to 1997, surveillance data indicate an increase in disease incidence to 0.06 per 100,000 (1998–2003). Of 102 laboratory-confirmed cases in humans from 1997 to 2000, 30% were related to occupational exposures. Recreational exposures were reported in 30% (including traveling abroad in 16%), whereas residential exposure accounted for 37% of the cases. Direct contact with animals, mostly rats and dogs, was observed in 31% of the cases. We conclude that recent changes in transmission patterns of leptospirosis, partially caused by an expanding rat population and the resurgence of canine leptospirosis, may facilitate the spread of the disease in temperate countries like Germany. Preventive measures should be adapted to the changing epidemiology of leptospirosis.

Changing Epidemiology of Human Brucellosis, Germany, 1962-2005

This endemic occupational disease has become a foodborne and travel-associated zoonosis primarily affecting Turkish immigrants.

Sex Differences in Clinical Leptospirosis in Germany: 1997–2005

BACKGROUND Although the majority of patients with reported leptospirosis are male, several seroepidemiologic studies demonstrated that leptospirosis seroprevalences are at least identical between both sexes. To study the effect of sex on the severity--and possibly, recognition--of leptospirosis, we conducted a sex-specific analysis of the clinical manifestations of the disease among patients with reported leptospirosis in Germany during 1997-2005. METHODS Data on demographic characteristics, symptoms, place of infection and place of residence when infection occurred, possible exposure risks, infecting serovars, and mortality were evaluated for patients with laboratory-confirmed leptospirosis reported in Germany during 1997-2005. Mantel-Haenszel odds ratios (OR(MH)), adjusted for age, were used to determine the association between sex and the frequency of reported symptoms. RESULTS Among 338 patients with leptospirosis (263 male patients and 75 female patients) reported in Germany during 1997-2005, male patients were more likely than female patients to be hospitalized (OR, 2.6; P<.01) and to exhibit symptoms of severe leptospirosis with jaundice (OR(MH), 3.7; P<.01), renal impairment (OR(MH), 3.4; P<.01), and hemorrhage (OR(MH), 7.8; P<.05). These sex-related differences were not associated with differences in exposure risks, presumptive infecting serogroups, or health-seeking behavior. CONCLUSIONS Our results indicate that male sex is associated with a higher severity of clinical leptospirosis. Reports on male predominance in leptospirosis may thus reflect sex-related variability in the incidence of severe disease, rather than different infection rates. In clinical practice, sex differences in the manifestation of leptospirosis may cause systematic underinvestigation and undertreatment of the disease in female patients.

Underreporting of Human Alveolar Echinococcosis, Germany

Underreporting of Human Alveolar Echinococcosis, Germany

Chemoprophylaxis and Malaria Death Rates

Malaria chemoprophylaxis increases the survival of nonimmune travelers.

Increase in Imported Dengue, Germany, 2001–2002

Dengue fever is a reportable disease in Germany. Surveillance data from 2001 and 2002 were analyzed and compared to travel patterns. Imported dengue fever increased strongly in this time. Most infections were acquired in Southeast Asia, specifically Thailand. The 2002 epidemic in Brazil was also reflected in these data.

Autochthonous dengue virus infection in Japan imported into Germany, September 2013.

In September 2013, dengue virus (DENV) infection was diagnosed in a German traveller returning from Japan. DENV-specific IgM and IgG and DENV NS1 antigen were detected in the patient’s blood, as were DENV serotype 2-specific antibodies. Public health authorities should be aware that autochthonous transmission of this emerging virus may occur in Japan. Our findings also highlight the importance of taking a full travel history, even from travellers not returning from tropical countries, to assess potential infection risks of patients.

The Risk of Malaria in Travelers to India

BACKGROUND Several countries have reported a decline in malaria cases imported by travelers returning from India. METHODS We collected data on imported malaria for the period 1992 to 2005 from nine countries. Traveler statistics denominator data were obtained from the Indian Ministry of Tourism. RESULTS The malaria case numbers declined from 93 cases per 100,000 travelers in 1992 to 19 cases per 100,000 travelers in 2005. The proportion of Plasmodium falciparum decreased steadily throughout the years. The proportion of Plasmodium vivax accounts for more than 80% of all cases of malaria in travelers to India. Deaths due to malaria were rare; only the UK and the United States reported deaths, a total of 16, between 1992 and 2005. The high-risk areas for malaria in India can be clearly identified using endemic malaria data. High-risk states are Chhattisgarh, Orissa, Jharkhand, West Bengal, Goa (mainly P vivax), and the states east of Bangladesh. CONCLUSIONS The decreasing incidence of malaria in travelers to India and the high proportion of P vivax support the current change in guidelines in some European countries advocating the use of the standby emergency self-treatment strategy or bite precautions plus awareness of risk instead of chemoprophylaxis. Otherwise in high-risk states, chemoprophylaxis should still be considered particularly in high-transmission seasons.

Epidemiology of Trichinellosis in Germany, 1996–2006

The epidemiology of trichinellosis in Germany was investigated by analyzing national surveillance data from 1996-2006. During this period, 95 laboratory-confirmed infections and 12 outbreaks were reported. The highest mean annual incidence was found in immigrants from southeast European countries (0.3 cases/100,000 vs. 0.01 cases/100,000 in the German population) with an incidence rate ratio of 26.0 (95% confidence interval 11.6-51.8). The predominant clinical symptom was muscle pain in 79 patients (83%). Mean diagnostic delay was 49 days. Among patients with reported source of infection (85%; n = 81), the consumption of pork (mostly originating from endemic countries) represented the most frequent exposure (93%; n = 75). In addition, trichinellosis cases were associated with both indigenous (n = 1) and imported (n = 5) wild boar meat. Although domestic pigs in Germany are practically free from Trichinella spp., the parasite was found in German wild animals such as wild boars, foxes, and racoon dogs. We conclude that trichinellosis still remains a public health issue in Germany, especially among individuals with a migrational background. Immigrants from endemic countries need to be educated about the risks of consuming raw or inadequately cooked pork and wild boar products from their homeland. In addition, German healthcare providers need to be aware of trichinellosis, especially in areas with a large immigrant population.

Trends in Imported Chikungunya Virus Infections in Germany, 2006–2009

Chikungunya virus (CHIKV) has been previously reported in many African and Asian areas, but it recently reemerged strongly in countries bordering the Indian Ocean as well as caused an outbreak in northern Italy. In Germany, where potential CHIKV vectors are not yet established, CHIKV infection is mandatorily notifiable. Cases reported from 2006 through 2009 were analyzed for travel characteristics and demographic factors. 152 cases of symptomatic CHIKV infection were notified. Both sexes were affected, with a median age of 46 years. Over the years, countries of infection largely followed the outbreaks reported from various travel destinations. India and the Maldives were the countries of infection most frequently named. In Sri Lanka, India, and Thailand, which are also frequently named countries of infection for dengue virus, the median age of CHIKV-affected patients was higher than that of dengue fever patients. Taking traveler numbers into consideration, risk of CHIKV infection was higher in the Seychelles and Mauritius than in Thailand and India. Even though substantial underdiagnosis is suspected, this assessment of CHIKV importation to Germany offers valuable information about the details of travel-associated cases. Between 17 and 53 notified cases per year signify that CHIKV would be occasionally available for local transmission in Germany once a vector becomes present. Although CHIKV most often causes a comparatively mild disease, the high median age of notified cases and the higher age than dengue patients support more severe disease courses in older adults. Travelers to all CHIKV endemic areas should protect against mosquito bites. In Germany, CHIKV surveillance will be continued to monitor ongoing importation of the virus and to detect early potential autochthonous cases.