Low prevalence of active COVID-19 in Slovenia: a nationwide population study of a probability-based sample.

OBJECTIVES: Accurate population-level assessment of the coronavirus disease 2019 (COVID-19) burden is fundamental for navigating the path forward during the ongoing pandemic, but current knowledge is scant. We conducted the first nationwide population study using a probability-based sample to assess active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, combined with a longitudinal follow-up of the entire cohort over the next 6 months. Baseline SARS-CoV-2 RNA testing results and the first 3-week follow-up results are presented. METHODS: A probability-based sample of the Slovenian population comprising data from 2.1 million people was selected from the Central Population Register (n = 3000). SARS-CoV-2 RNA was detected in nasopharyngeal samples using the cobas 6800 SARS-CoV-2 assay. Each participant filled in a detailed baseline questionnaire with basic sociodemographic data and detailed medical history compatible with COVID-19. After 3 weeks, participants were interviewed for the presence of COVID-19-compatible clinical symptoms and signs, including in household members, and offered immediate testing for SARS-CoV-2 RNA if indicated. RESULTS: A total of 1368 individuals (46%) consented to participate and completed the questionnaire. Two of 1366 participants tested positive for SARS-CoV-2 RNA (prevalence 0.15%; posterior mean 0.18%, 95% Bayesian confidence interval 0.03-0.47; 95% highest density region (HDR) 0.01-0.41). No newly diagnosed infections occurred in the cohort during the first 3-week follow-up round. CONCLUSIONS: The low prevalence of active COVID-19 infections found in this study accurately predicted the dynamics of the epidemic in Slovenia over the subsequent month. Properly designed and timely executed studies using probability-based samples combined with routine target-testing figures provide reliable data that can be used to make informed decisions on relaxing or strengthening disease mitigation strategies.

Oseltamivir prophylaxis in controlling influenza outbreak in nursing homes: a comparison between three different approaches.

PURPOSE: To assess influenza outbreaks in nursing homes (NHs) using different pharmacological preventive measures. METHODS: We compared characteristics of influenza A outbreaks that occurred during 2011/2012 influenza season in three NHs of similar size (208, 167, and 164 residents in NH1, NH2, and NH3, respectively) implementing comparable treatment approaches and non-pharmacological outbreak control measures but different prophylactic pharmacological interventions including oseltamivir 75 mg o.d. for 10 days for all residents (NH1), for directly exposed residents (NH2), and no prophylaxis (NH3). RESULTS: The proportions of residents who developed acute respiratory infection (ARI) in the course of influenza outbreak were 55/208 (26.4 %) in NH1, 64/167 (38.3 %) in NH2, and 31/164 (18.9 %) in NH3; hospital admission was required in 2/55 (3.6 %), 5/64 (7.8 %), and 5/31 (16.1 %) residents of NH1, NH2, and NH3, respectively, while 1/55 (1.8 %), 1/64 (1.6 %), and 3/31 (9.7 %) residents of the corresponding NHs died during influenza outbreak. The duration of the outbreak was shorter in the NH1 where oseltamivir prophylaxis was instituted for all residents (8 days), than in NHs where selective prophylaxis with oseltamivir and no prophylaxis were used (14 and 12 days, respectively). The calculated vaccine effectiveness in residents was 48, 71, and 44 % in NH1, NH2, and NH3, respectively. Staff members had similar ARI attack rate but in comparison to residents were less often vaccinated against influenza and demonstrated higher influenza vaccine effectiveness. CONCLUSIONS: Comparison of influenza outbreaks in three NHs revealed that the duration of the outbreak was the shortest in the NH where prophylaxis with oseltamivir was given to all residents.

High non-specific T lymphocyte response to the adjuvanted H1N1 vaccine in comparison with the H1N1/H3N2/B-Brisbane vaccine without adjuvant.

Shortly after the report of pandemic 2009 influenza A (H1N1), vaccine manufacturers, in conjunction with public agencies, started developing a H1N1 vaccine. In 2009, various approaches were implemented around the globe. The United States and Australia finally approved only non-adjuvanted H1N1 influenza vaccines, whereas Canada and the EU also approved adjuvanted vaccines. In 2010, seasonal influenza vaccine without adjuvant was again widely accepted in both hemispheres. The addition of adjuvant to the vaccine enhances the immunogenity of the vaccine in the presence of a relatively low amount of antigen. However, it might also induce undesirable non-specific immune response. For this reason, we conducted a prospective observational study to monitor T cell absolute count and H1N1-specific immunogenicity after 2009 and 2010 immunization. Fourteen healthy volunteers received the monovalent H1N1 AS03 adjuvanted influenza vaccine (3.5 µg of H1N1 and squalene-based adjuvant) in October 2009. The immunization was associated with a significant increase in T lymphocyte absolute count (P < 0.0001), reaching abnormal values in 57% of subjects. During this period, none of the subject showed any manifestation of severe viral infection or inflammation. Acute infection by CMV or EBV viruses was also excluded. In October 2010, the same subjects received a seasonal non-adjuvanted influenza vaccine (15 µg of each: H1N1, H3N2, and B-Brisbane). However, after 2010 immunization, no change in T lymphocyte absolute count was observed. H1N1-induced immunogenicity was good for both vaccines. Our results suggest a pronounced non-specific T cell response after AS03-adjuvanted 2009 H1N1 vaccination.

Respiratory viruses in patients and employees in an intensive care unit.

PURPOSE: To evaluate the frequency of respiratory viruses in a nonselected population of intensive care unit patients and employees and to investigate the clinical as well as the epidemiological association with virological findings. METHODS: Between 12 January and 5 March 2009, nasopharyngeal swabs were collected from 55 intensive care unit (ICU) patients and 41 medical personnel at 16 different time-points and tested for 11 respiratory viruses by single real-time PCR using TaqMan or MGB probes. RESULTS: Among the 55 ICU patients tested, there were 30 virus-positive respiratory specimens (30/173, 17.3%) and 23 patients who tested positive at least once for respiratory viruses (23/55, 41.8%). Only the time from admission to the ICU was associated with the probability of testing positive, with the probability of testing positive decreasing with increasing length of stay (P < 0.001). Of the 418 respiratory specimens collected from the healthcare personnel, 27 (6.5%) tested positive. Seventeen employees tested positive at least once for respiratory viruses (17/41, 41.5%). Among the employees, calendar time (P = 0.03) and having sick contacts at home (P = 0.006) were significantly associated with swab positivity. Among the study population, patients had a significantly higher probability of having a positive swab result than employees. The distribution of viruses differed between the two groups. CONCLUSIONS: Our results suggest that when hygiene precautions are adopted, the possibility of transmitting selected respiratory viruses between patients and personnel is limited. They also point to a greater importance of the community over the hospital environment for acquisition of viral respiratory infections by ICU patients and employees.

Spotlight on measles 2010: a cluster of measles in a hospital setting in Slovenia, March 2010.

After ten years of being measles free, Slovenia experienced a cluster with secondary transmission in a hospital setting in March 2010. The index case, a resident of Ireland, was hospitalised on the day after his arrival to Slovenia and diagnosed with measles two days later. After his discharge, two cases of measles were notified, a hospital staff member and a visitor to the clinic, suggesting transmission in a hospital setting.

[Prevalence of urinary incontinence and pelviperineal rehabilitation during the postpartum in a cohort of primipara and secondipara patients]. / Prevalenza dell'incontinenza urinaria e della riabilitazione pelvi-perineale nel postpartum in una coorte di pazienti primipare e secondipare.

AIM: Urinary incontinence is a classical sign of childbirth-related perineal trauma, the prevalence of which is estimated, depending on age, at between 10% and 50%. Pelviperineal rehabilitation offers an excellent opportunity to prevent pelviperineal disorders. The aim of the present study was to evaluate the prevalence of urinary incontinence and pelviperineal disorders in the local context, and also that of pelviperineal rehabilitation. METHODS: Of the 1793 women who gave birth in Udine in 2006, 900 primipara and secondipara Caucasians with single term pregnancies dated ultrasonically to be within 20 weeks of gestation, were selected. A total of 602 of them were contacted by telephone and two questionnaires were administered. RESULTS: The prevalence of pelviperineal rehabilitation in our population was 4.49%, while that of pelviperineal disorders was much higher, at around 40.20%. The prevalence of urinary incontinence was due in 27.57% of cases to stress and in 14.45% to urgency, with an overlap in 9.8% of cases and a story of prior incontinence in 9.97%. The prevalence of urinary urgency in women subjected to rehabilitation is significantly lower than in those not treated (P=0.004). Dyspareunia represents 16.11% of cases, coital incontinence 0.33%. One case of gas incontinence emerged but there was no case of faecal incontinence. CONCLUSIONS: Pelviperineal rehabilitation in the observed population has a very low prevalence, especially if compared with the high prevalence of disturbances related to dysfunctions of the pelvic floor during postpartum.

Molecular characterisation of Cryptosporidium isolates from humans in Slovenia.

Twenty-nine faecal specimens from Slovenian patients in which Cryptosporidium oocysts had been identified were studied. A fragment of the Cryptosporidium 18S rRNA gene and a fragment of the Cryptosporidium COWP gene were amplified by PCR and sequenced. Cryptosporidium parvum was identified in 26 of the 29 specimens, Cryptosporidium hominis in two, and Cryptosporidium cervine genotype in one. The fact that C. parvum, which is associated traditionally with animals, was identified in the majority of human faecal specimens suggests that cryptosporidiosis may have primarily a zoonotic origin in Slovenia.

The molecular evidence of Babesia microti infection in small mammals collected in Slovenia.

In Europe, the zoonotic cycle of Babesia microti has not been determined so far. Recently, B. microti was detected in Ixodes ricinus ticks in Slovenia by using molecular methods. In order to investigate the mammalian hosts of B. microti in Slovenia we collected 261 small mammals representing 11 species. They were tested for the presence of babesial parasites with a PCR assay based on the nuclear small subunit rRNA gene (nss-rDNA). The bank vole (Clethrionomys glareolus) and yellow-necked mouse (Apodemus flavicollis) were infected with B. microti. The prevalence rate was 15.9% for C. glareolus and 11.8% for A. flavicollis. Nucleotide sequences of amplified portions of B. microti nss-rDNA from C. glareolus and A. flavicollis were indistinguishable from each other and identical with those previously described in I. ricinus ticks collected in Slovenia. The results of this study represent molecular evidence of B. microti in small mammals in Europe.

First European pediatric case of human granulocytic ehrlichiosis.

Herein we report on the first confirmed pediatric case of acute human granulocytic ehrlichiosis in Europe. Presentation in this 11-year-old girl was comparable to clinical findings seen in adult European patients with human granulocytic ehrlichiosis; i.e., she had self-limited febrile illness with leukopenia, thrombocytopenia, and elevated serum C-reactive protein concentration. It is of interest that the patient not only had a fourfold change in antibody titer to Ehrlichia phagocytophila but also developed antibodies to Ehrlichia chaffeensis and that her PCR test result was positive on the third as well as on the 22nd day after the onset of illness, that is, 16 days after spontaneous defervescence.

Probable atypical cat scratch disease presenting as isolated posterior pancreatic duodenal lymphadenitis and abdominal pain.

We report a case involving a 15-year-old girl with atypical, clinically unsuspected cat scratch disease (CSD) presenting as isolated posterior pancreatic duodenal lymphadenitis, fever, and abdominal pain. The serological, abdominal ultrasonographic, and CT findings, as well as clinical and epidemiological data, indicate that B. henselae was likely an etiologic agent of CSD in our patient.

Clinical and serological follow-up of patients with human granulocytic ehrlichiosis in Slovenia.

An evaluation of the clinical outcome and the duration of the antibody response of patients with human granulocytic ehrlichiosis (HGE) was undertaken in Slovenia. Adult patients with a febrile illness occurring within 6 weeks of a tick bite were classified as having probable or confirmed HGE based on the outcome of serological or PCR testing. Thirty patients (median age, 44 years) were enrolled, and clinical evaluations and serum collection were undertaken at initial presentation and at 14 days, 6 to 8 weeks, and 3 to 4, 6, 12, 18, and 24 months. An indirect immunofluorescence assay (IFA) was performed, and reciprocal titers of > or =128 were interpreted as positive. Patients presented a median of 4 days after the onset of fever and were febrile for a median of 7.5 days; four (13.3%) received doxycycline. Seroconversion was observed in 3 of 30 (10.0%) patients, and 25 (83.3%) showed >4-fold change in antibody titer. PCR results were positive in 2 of 3 (66.7%) seronegative patients but in none of 27 seropositive patients at the first presentation. IFA antibody titers of > or =128 were found in 14 of 29 (48.3%), 17 of 30 (56.7%), 13 of 30 (43.4%), and 12 of 30 (40.0%) patients 6, 12, 18, and 24 months after presentation, respectively. Patients reporting additional tick bites during the study had significantly higher antibody titers at most time points during follow-up. No long-term clinical consequences were found during follow-up.

Diversity of Babesia Infecting European sheep ticks (Ixodes ricinus).

Questing Ixodes ricinus (Acari: Ixodidae) adult and nymphal ticks collected in various parts of Slovenia were tested for the presence of babesial parasites with a PCR assay based on the nuclear small subunit rRNA gene (nss-ribosomal DNA [rDNA]). Thirteen of 135 ticks were found to contain babesial DNA. Sequence determination and analysis of amplified portions of nss-rDNA revealed their identity with Babesia microti and a high degree of homology with Babesia odocoilei and Babesia divergens. The results of this study represent the first genetic evidence of B. microti and B. divergens-like parasites in I. ricinus ticks in Europe.

Prospective assessment of the etiology of acute febrile illness after a tick bite in Slovenia.

A prospective study established the etiology of febrile illnesses in residents of Slovenia that occurred within 6 weeks after a tick bite. A combination of laboratory and clinical criteria identified 64 (49.2%) of 130 patients as having confirmed, probable, or possible cases of tickborne disease during 1995 and 1996. Of the 130 patients, 36 (27.7%) had laboratory evidence of tickborne encephalitis, all of whom had clinically confirmed disease. Evidence of infection with Borrelia burgdorferi sensu lato was identified in 26 patients; 10 (7.7%) had confirmed Lyme borreliosis. Of 22 patients with evidence of Ehrlichia phagocytophila infection, 4 (3.1%) had confirmed ehrlichiosis. Infection by multiple organisms was found in 19 (14.6%) of 130 patients. Patients with meningeal involvement (43 [72.3%] of 59) were more likely to have confirmed tickborne disease than were patients with illness of undefined localization (18 [26.5%] of 68; P<.0001). Tickborne viral and bacterial infections are an important cause of febrile illness in Slovenia.

Seroprevalence of ehrlichiosis, Lyme borreliosis and tick-borne encephalitis infections in children and young adults in Slovenia.

BACKGROUND: Little is known about the seroprevalence of ehrlichiosis in adults and much less about the same in children. METHODS: One hundred and forty-three healthy children and young adults (6-24 years of age, male to female ratio, 1:1) were assessed for the presence of antibodies to the agents of human granulocytic ehrlichiosis (HGE), human monocytic ehrlichiosis (HME), Borrelia burgdorferi sensu stricto (BB), and tick-borne encephalitis (TBE) virus in Slovenia, where tick-related infections are endemic. Antibodies to HGE and HME agents were assayed by indirect immunofluorescence, and antibodies to BB and TBE by enzyme-linked immunosorbent assay. A questionnaire about tick exposure was answered by all subjects. In the event of a positive result, a detailed interview was conducted. RESULTS: Of 143 study subjects, 22 (15.4%) had detectable antibodies to HGE agent, 22 (15.4%) were positive to BB, 18 (12.6%) were positive to TBE virus (12 of these were vaccinated) and 4 (2.8%) were positive to the HME agent. The history of persons seropositive to an HGE agent had been uneventful. CONCLUSIONS: Our study documents a high seroprevalence of HGE in children and young adults in Slovenia, similar to the seroprevalence of LB and higher than that of TBE and HME. Although the majority of these infections are probably asymptomatic or mild, active surveillance for acute HGE infections in children in areas endemic for tick-related infections is necessary.

Sequence analysis of the ank gene of granulocytic ehrlichiae.

The ank gene of the agent of human granulocytic ehrlichiosis (HGE) codes for a protein with a predicted molecular size of 131.2 kDa that is recognized by serum from both dogs and humans infected with granulocytic ehrlichiae. As part of an effort to assess the phylogenetic relatedness of granulocytic ehrlichiae from different geographic regions and in different host species, the ank gene was PCR amplified and sequenced from a variety of sources. These included 10 blood specimens from patients with confirmed human granulocytic ehrlichiosis (three from New York, four from Wisconsin, two from Slovenia, and one from Sweden). Also examined was a canine granulocytic ehrlichia sample obtained from Minnesota, Ehrlichia equi from California, Ehrlichia phagocytophila from Sweden, and the granulocytic ehrlichia isolate USG3. The sequences showed a high level of homology (>95.5% identity), with the lowest homology occurring between a New York HGE agent and the Swedish E. phagocytophila. Several 3-bp deletions and a variable number of 51- and 81-bp direct repeats were noted. Although the North American HGE sequences showed the highest conservation (>98.1% identity), phylogenetic analyses indicated that these samples represent two separate clades, one including the three New York HGE samples and the USG3 strain and another with the Wisconsin HGE and Minnesota canine sequences. Two of the New York samples and the USG3 strain showed 100% identity over the entire 3,696-bp product. Likewise, three of the Wisconsin human samples and the Minnesota dog sample were identical (3,693 bp). Whereas phylogenetic analysis showed that the E. equi sequence was most closely related to the Upper Midwest samples, analysis of the repeat structures showed it to be more similar to the European samples. Overall, the genetic analysis based on the ank gene showed that the granulocytic ehrlichiae are closely related, appear to infect multiple species, and can be grouped into at least three different clades, two North American and one European.

Genetic analysis of wild-type Dobrava hantavirus in Slovenia: co-existence of two distinct genetic lineages within the same natural focus.

Genetic analysis was performed of wild-type (wt) Dobrava hantavirus (DOB) strains from Slovenia, the country where the virus was first discovered and where it was found to cause haemorrhagic fever with renal syndrome (HFRS), with a fatality rate of 12%. Two hundred and sixty mice of the genus APODEMUS:, trapped in five natural foci of DOB-associated HFRS during 1990-1996, were screened for the presence of anti-hantavirus antibodies and 49 APODEMUS: flavicollis and four APODEMUS: agrarius were found to be positive. RT-PCR was used to recover partial sequences of the wt-DOB medium (M) and small (S) genome segments from nine A. flavicollis and one A. agrarius. Sequence comparison and phylogenetic analysis of the Slovenian wt-DOB strains revealed close relatedness of all A. flavicollis-derived virus sequences (nucleotide diversity up to 6% for the M segment and 5% for the S segment) and the geographical clustering of genetic variants. In contrast, the strain harboured by A. agrarius showed a high level of genetic diversity from other Slovenian DOB strains (14%) and clustered together on phylogenetic trees with other DOB strains harboured by A. agrarius from Russia, Estonia and Slovakia. These findings suggest that the DOB variants carried by the two species of APODEMUS: in Europerepresent two distinct genetic lineages.