Magid Herida

Introduction of SARS in France, March–April, 2003

We describe severe acute respiratory syndrome (SARS) in France. Patients meeting the World Health Organization definition of a suspected case underwent a clinical, radiologic, and biologic assessment at the closest university-affiliated infectious disease ward. Suspected cases were immediately reported to the Institut de Veille Sanitaire. Probable case-patients were isolated, their contacts quarantined at home, and were followed for 10 days after exposure. Five probable cases occurred from March through April 2003; four were confirmed as SARS coronavirus by reverse transcription–polymerase chain reaction, serologic testing, or both. The index case-patient (patient A), who had worked in the French hospital of Hanoi, Vietnam, was the most probable source of transmission for the three other confirmed cases; two had been exposed to patient A while on the Hanoi-Paris flight of March 22–23. Timely detection, isolation of probable cases, and quarantine of their contacts appear to have been effective in preventing the secondary spread of SARS in France.

Rectal lymphogranuloma venereum surveillance in France 2004-2005

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by Chlamydia trachomatis strains belonging to the L1, L2 or L3 genotype. An alert about an outbreak of LGV among MSM in the Netherlands was published in January 2004. The first cases of rectal LGV in France were retrospectively diagnosed in March 2004 and sentinel surveillance for LGV was implemented in April 2004. Most of the participating centres were located in the cities of Paris and Bordeaux. Only confirmed rectal LGV cases were included in the surveillance. Rectal specimens from men that were found to be positive for C trachomatis by PCR were sent to the National Reference Centre for Chlamydia infection for genotyping. Simple epidemiological data provided by clinicians and genotyping results were sent to the Institut de Veille Sanitaire (InVS) where data were anonymously recorded. A total of 328 C. trachomatis rectal strains isolated in men were genotyped by the end of December 2005. Of these, 244 (74%) were LGV strains belonging to the L2 genotype. No L1 or L3 C. trachomatis genotype was found. Diagnosis was made retrospectively for 46 cases. The median age of patients with LGV was 39 years. HIV status was known for 96 patients: 82/96 (85%) were HIV-infected. Most LGV cases were diagnosed in the Paris area (92%). Among the remaining 26% C. trachomatis strains, genotypes Da and G were the most frequent. As with syphilis in recent years, the emergence of LGV in Europe is mainly affecting HIV-infected MSM. The screening and treatment of STIs should be included in the clinical follow-up of all HIV-infected MSM.

Rectal lymphogranuloma venereum, France.

To the Editor: Lymphogranuloma venereum (LGV), a sexually transmitted disease (STD) caused by Chlamydia trachomatis serovars L1, L2, or L3, is prevalent in tropical areas but occurs sporadically in the western world, where most cases are imported (1). LVG commonly causes inflammation and swelling of the inguinal lymph nodes, but it can also involve the rectum and cause acute proctitis, particularly among men who have sex with men. However, LGV serovars of C. trachomatis remain a rare cause of acute proctitis, which is most frequently caused by Neisseria gonorrhoeae or by non-LGV C. trachomatis (2). In 1981, in a group of 96 men who have sex with men with symptoms suggestive of proctitis in the United States, Quinn et al. found that 3 of 14 C. trachomatis infections were caused by LGV serovar L2 (3). In France, 2 cases of rectal LGV were reported in an STD clinic in Paris from 1981 to 1986 (4). In 2003, an outbreak of 15 rectal LGV cases was reported among men who have sex with men in Rotterdam; 13 were HIV-infected, and all reported unprotected sex in neighboring countries, including Belgium, France, and the United Kingdom (5). At the same time, a rise in C. trachomatis proctitis (diagnosed by using polymerase chain reaction [PCR]; [Cobas Amplicor Roche Diagnostic System, Meylan, France]) was detected in 3 laboratories in Paris and in the C. trachomatis national reference center located in Bordeaux. To identify the serovars of these C. trachomatis spp., all stored rectal specimens were analyzed by using a nested omp1 PCR-restriction fragment length polymorphism assay. The amplified DNA product was digested by restriction enzymes. Analysis of digested DNA was performed by electrophoresis. Patterns were compared visually with reference patterns (6). From January 1, 2003, to March 31, 2004, a total of 44 of 124 male rectal swabs were positive for C. trachomatis. Of those, 38 were identified as belonging to the L2 serotype, which confirms the diagnosis of rectal LGV. Epidemiologic information was retrospectively obtained by clinicians through review of medical records, telephone interview, or both. A complete history was available for 14 of the 38 cases. All 14 men reported unprotected anal sex with anonymous male sex partners in France, and none reported a stay in an LGV-endemic area. Their mean age was 40 years (31–50); 8 were HIV-infected, and 9 had another concomitant STD. The mean duration of symptoms before LGV diagnosis was 50 days (range 11–120 days). All 14 patients had symptoms of acute proctitis, including rectal pain, discharge, and tenesmus, and 3 (all HIV-infected) had fever. Deep, extended rectal ulcerations were reported in 8 patients, 3 of whom were HIV-infected and had lesions suggestive of rectal carcinoma. In 1 patient in whom a late diagnosis was made 4 months after the onset of symptoms, a rectal tumorlike stricture was observed. All 14 patients were treated with tetracycline for a mean duration of 16 days (range 10–60 days). An information campaign among microbiologists and clinicians and a sentinel LGV surveillance system were launched in April 2004. Subsequently, LGV was diagnosed in 65 additional male patients, some retrospectively. In total, rectal LGV was diagnosed in 103 patients from July 2002 to August 2004 (Figure). Figure Number of rectal lymphogranuloma venereum cases diagnosed in men in France, July 2002–August 2004. Prompt diagnosis and treatment is indeed paramount to prevention and control. Diagnosis may be further hampered because rectal LGV may mimic other conditions such as rectal carcinoma or Crohn disease. Treatment duration should be no shorter than 21 days, and follow-up examinations should be conducted until all signs and symptoms have resolved (7,8). If left untreated, rectal LGV could lead to serious complications such as rectal stricture (1). If recently exposed to infection, sexual contacts should receive prophylactic treatment to prevent reinfection and to eliminate a potential reservoir. The emergence of rectal LGV, characterized by deep mucosal ulcerations and frequently occurring in HIV-infected men who have sex with men, is a serious concern for the gay community in Europe.

Cost-effectiveness of HIV post-exposure prophylaxis in France.

ObjectiveTo assess the cost-effectiveness of HIV post-exposure prophylaxis (PEP) in France. MethodsWe used a decision tree to evaluate, from a societys perspective, the cost of PEP per quality-adjusted life-year (QALY) saved. We used 1999–2003 PEP surveillance data and literature-derived data on per event transmission probabilities, PEP efficacy and quality of life with HIV. HIV prevalence and lifetime cost of HIV/AIDS management in the HAART era were derived from French studies. We assumed that mean life expectancy in full health was 65 years among uninfected individuals and that the mean survival time after HIV infection was 22.5 years. The costs of PEP drugs and follow-up were derived from the French public sector. A 3% annual rate was used to discount future costs and effects. ResultsDuring 1999–2003, PEP was prescribed to 8958 individuals (heterosexual sex: 47.6%; homosexual sex: 28.4%; occupational exposure: 23.4%; drug injection: 0.6%); of those, 2143 were exposed to a known HIV-infected source. PEP was estimated to prevent 7.7 infections and saved 64.5 QALY at a net cost of &U20AC;5.7 million, resulting in an overall cost-effectiveness ratio of &U20AC;88 692 per QALY saved. PEP was cost saving for 4.4% of cases and cost effective (< &U20AC;50 000 per QALY) in a further 11.3% of cases. In contrast, 72 and 52% of prescriptions had a cost-effectiveness ratio exceeding &U20AC;200 000 and &U20AC;2 millions, respectively, per QALY saved. ConclusionOverall, the French PEP programme is only moderately cost effective. PEP guidelines should be revised to target high-risk exposures better.

Increase of Neisseria gonorrhoeae ciprofloxacin resistance in France in 2001-2003.

AFTER THE SPREAD OF PENICILLINand tetracycline-resistant strains in the early 1990s, ciprofloxacin has been widely used as first-line therapy for gonorrhea. Recently, some European countries have reported an increase of Neisseria gonorrhoeae (NG) ciprofloxacin resistance.1–3 In the United States, fluoroquinolones are no longer recommended for gonorrhea acquired in Hawaii and in California, but also for gonococcal infections occurring in male patients who have sex with men.4 In France, NG antimicrobial susceptibility has been monitored through a sentinel laboratory network, RENAGO, since 1986. An average of 230 laboratories (82% private and 18% laboratories attached to a hospital) located in all regions of France (except Corsica) participate each year. NG ciprofloxacin resistance, which was low until 2000,5 has recently sharply increased.

Economic Evaluations of Public Health Surveillance Systems: a Systematic Review

‘Public Health surveillance is the ongoing systematic collection, analysis and interpretation of health data, closely integrated with the timely dissemination of these data both to those providing the data and to those who can apply the data to control and prevention programs’.1 Public health surveillance is therefore, closely linked to action as it provides accurate and validated information to local and national health authorities in order that these same authorities can implement appropriate prevention and control measures and health promotion strategies.2 This definition was set up several decades ago. Since then, the adoption of the revised International Health Regulations in 2005 has implemented new regulations such as national obligations to guarantee a set of core surveillance and response capacities to prevent international spread of disease irrespective of its origin (biological but also chemical or radio-nuclear sources).3 Furthermore, new diseases have emerged (H1N1pdm09, Middle East Coronavirus), some others have spread dramatically such Ebola virus disease in West Africa.4 In the context of globalisation, the concept of public health surveillance has evolved to include public health security.5,6 Politicians and stakeholders rely upon their public health agencies to be informed in a timely fashion and to be able to respond promptly to all potential health treats that may arise as populations need protection whatever the risk. For public health surveillance, this implies the need to monitor a very large spectrum of all hazards health threats. At the same time, as many public agencies are currently facing budgetary constraints, they must allocate theirs resources as efficiently as possible, as surveillance systems cannot be implemented for all known health threats. The priorities for diseases surveillance need to be reviewed regularly in order to guarantee that the most topical public health issues are consistently tackled and to ensure quality …