[Taking Care of Asylum Seekers: Occupational Health Aspects with a Special Focus on Vaccination]. / Arbeitsmedizinische Aspekte und Impfschutz beim Umgang mit Asylbewerbern.

Employees and volunteers often feel insecure about the potential transmission of infectious diseases when taking care of asylum seekers. It could be shown that overall only a minor risk of infection emanates from asylum seekers. However, aspects of occupational health and vaccination should be kept in mind.Besides the standard vaccination the Standing Committee on Vaccination (STIKO) recommends for occupational indication, which is given for employees and volunteers in asylum facilities, vaccination against hepatitis A, hepatitis B, polio (if the last vaccination was more than 10 years before) as well as influenza (seasonal).According to the German Occupational Safety and Health Act taking care of the employer has to determine which exposures might occur at the workplace (risk assessment) and define necessary protection measures. Depending on task and exposure when taking care of asylum seekers different acts (e. g. biological agents regulation) and technical guidelines for the handling biological agents (e. g. TRBA 250 or TRBA 500) have to be applied.The Bavarian Health and Food Safety Authority (LGL) has published several information sheets regarding "asylum seekers and health management" for employees and volunteers from the non-medical as well as the medical area (www.lgl.bayern.de search term "Asylbewerber"). With theses publications insecurities in taking care of asylum seekers should be prevented. Furthermore the employer gets support in the implementation of legal obligations to ensure occupational safety for the employees.

Fate of Clostridium botulinum and incidence of pathogenic clostridia in biogas processes.

AIMS: This study aimed to assess the sanitary situation in agricultural biogas plants (BP) regarding pathogenic Clostridium spp. METHODS AND RESULTS: The incidence of Clostridium botulinum, Clostridium difficile, Clostridium novyi, Clostridium haemolyticum, Clostridium septicum and Clostridium chauvoei was investigated in 154 plant and animal substrates, digester sludges and digestates from full-scale BP using a method combining microbial enrichment with Real-Time PCR. The investigated clostridia were absent in the samples, except for Cl. novyi that was barely present (3·9%) and Cl. difficile that was more frequently detected (44·8%). Clostridium botulinum exposed to lab-scale digesters in sentinel chambers was reduced with D-values of 34·6 ± 11·2 days at 38°C and 1·0 ± 0·2 days at 55°C. CONCLUSIONS: These findings indicate minor relevance of clostridial pathogens in BP and an improved sanitary quality of the digestion product compared to untreated substrates concerning Cl. botulinum. However, the frequent detection of Cl. difficile opens questions on the durability of this organism in manure digestion lines. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first study providing data on the reduction of Cl. botulinum during biogas processes that scientifically invalidate contrary claims by some media in the public. Furthermore, the results improve the fragmentary knowledge on the prevalence of several clostridial pathogens in agricultural biogas production.

[Preoperational study for the improvement of hygiene conditions in long-term care facilities]. / Modellprojekt zur Verbesserung der Hygiene in stationären Pflegeeinrichtungen.

Hygiene is becoming more and more important in long-term care facilities. Long-term care facilities are subject to monitoring by the Public Health Service (PHS) and other authorities. For the PHS in Bavaria the Bavarian Health and Food Safety Authority (Landesamt für Gesundheit und Lebensmittelsicherheit, LGL) published a hygiene monitoring concept and there exists an inspection guide developed by a specialist department for nursing homes and institutions for the handicapped (Fachstelle für Pflege und Behinderteneinrichtungen, FQA). Because inspections are performed in multiprofessional teams, it makes sense to use a coordinated inspection catalog. The aim was to integrate hygienic requirements specified in the Bavarian guidelines for hygiene by the LGL into the inspection guide published by the FQA to obtain a quality assured surveillance. The involved parties were questioned about the inspection guide and their hygiene management and then the hygiene criteria of the LGL were implemented into the inspection guide. Questions dealing with hygiene requirements concerning intensive care, management of multidrug resistant bacteria and interviews with the person responsible for infection control in the facility itself were developed for the first time and were integrated into the inspection guide. The revised inspection guide was tested for its applicability. With the revised inspection guide there now exists a tool which allows not only comprehensive inspections of the facilities including hygiene issues but also a good cooperation of the various parties involved. There are many actions which have to be conveyed into the future, especially programs to train staff to apply the inspection guide and to enhance the ability of all participants to act in cooperation. The guide will also allow the facilities to cooperate more easily and more closely, as the guide takes the respective problems and challenges of the different facilities into consideration. Additionally the development of legal guidelines regarding hygiene can support general healthcare of residents.

[Infection control management and practice in home care - analysis of structure quality]. / Infektionshygiene in der ambulanten Pflege - Eine Untersuchung zur Strukturqualität.

BACKGROUND: Surveillance of infection control management and practices in home care is an important task of the public health service. While infection control aspects in residential homes for the aged and nursing are increasingly being discussed this subject has been poorly recognised in home care. AIM: The aim of this study was to identify problems in hygiene regarding the transmission of infectious diseases as well as quality assessment in home care. Based on the results of this study implications for infection control in home care facilities for public health services should be developed. METHOD: Statistical analyses were performed on the primary quality assessment data of home care facilities collected by the medical service of health insurances via computer-assisted personal interviews between March 2006 and March 2009. Structure quality in 194 home care facilities was analysed as well as human resources and organisational conditions. Analyses were also done in the context of the clients' risk factor load. All analyses were performed by stratifying for the size of the home care services. To assess how the involved characteristics vary according to the size of the home care services chi-square tests and non-parametric tests were calculated. RESULTS: About 80% of the assessed home care services disposed of an infection control management plan. Compared to larger services smaller home care services, especially services with less than 10 clients had a poor structure in infection control management and practice. They also carried a higher load of risk factors in clients. The larger services had significantly less human resources. CONCLUSIONS: Surveillance of infection control management and practices by the public health services should focus on the structure of the smaller home care services. At the same time smaller home care services should be supported by offering training for the staff or counselling regarding hygiene-related aspects. Furthermore, the outcome quality of the larger home care services with poorer human resources (one full-time nurse cares for more than 10 dependants) should also be assessed in the frame of infection surveillance.

[Methicillin-resistant Staphylococcus aureus (MRSA) in medical rehabilitation. Draft of a model hygiene plan]. / Methicillin-resistente Staphylococcus aureus (MRSA) in der medizinischen Rehabilitation. Entwurf eines Rahmenhygieneplans

Rehabilitation facilities often apply the same standards for management of methicillin-resistant Staphylococcus aureus (MRSA) carriers as acute care hospitals. This makes it difficult to ensure access to the facilities and adequate rehabilitation for carriers. A working group of the Bavarian state committee for multiresistant pathogens addressed these problems by a systematic review of literature, expert group meetings and evaluation of existing hygiene plans. Thereby a model hygiene plan for rehabilitation facilities concerning management of MRSA carriers was derived. The management is based on physician risk assessment blending standards applied in acute and long-term care facilities. For rehabilitation typical risk scenario examples of risk analyses are given. The preventive measures are based on the respective objectives of protection. The risk analysis which gives the basis for the model hygiene plan described in this paper gives equal weight to two main objectives of protection: infection control and medical rehabilitation.

[Strategies to prevent the transmission of multidrug-resistant pathogens and their practical implementation in oupatient care]. / Präventionsstrategien zur Vermeidung der Übertragung multiresistenter Erreger und praktische Umsetzung in der ambulanten Pflege.

BACKGROUND: Multidrugresistant pathogens which are highly relevant for infection control in hospitals and other health-care facilities are a serious public health problem and a big challenge for all players in the health sector. In order to prevent the spread of multi-resistant pathogens the Commission for Hospital Hygiene of the Robert Koch-Institute (RKI) has published guidelines. These recommendations refer to the consequent implementation of an infection control management in all health care settings, including outpatient care. In Germany there are only few data available concerning infection control management and the implementation of preventive strategies in outpatient care. SUBJECT: To what extent are national guidelines concerning infection control of multidrugresistant pathogens (i.e. methicillin-resistant Staphylococcus aureus, MRSA) feasible and practicable in outpatient care? And what are the reasons not to practice these strategies. METHOD: In outpatient care the status of the infection control management and the implementation of prevention strategies was surveyed and assessed. Data were collected by structured interviews - a face to face method. RESULT: Guidelines concerning infection control management are not always sufficiently implemented in outpatient care. There are multiple reasons for this, such as, e.g., lack of compliance with the recommendations as well as structural problems in the health-care system, and special challenges of outpatient care. CONCLUSION: Implementation of an infection control management concerning multidrug-resistant pathogens in outpatient care is problematic. Prevention strategies are commonly not known or not adequately implemented into daily practice. Actions to improve the situation should focus at the individual level (e.g., trainings in the context of the initiative "clean hands" ), the institutional level (improving networking, bonus schemes) and the social level (financial and legal support for outpatient care centres to bear the expenses of infection control management, "search and destroy").

Culture and molecular method for detection of Mycobacterium tuberculosis complex and Mycobacterium avium subsp. paratuberculosis in milk and dairy products.

A combined molecular and cultural method for the detection of the Mycobacterium tuberculosis complex (MTBC) and Mycobacterium avium subsp. paratuberculosis was developed and tested with artificially contaminated milk and dairy products. Results indicate that the method can be used for a reliable detection as a basis for first risk assessments.

[Interdisciplinary management of a large Legionella outbreak in Germany]. / Interdisziplinäres Management eines länderübergreifenden Legionellenausbruchs.

Between December 2009 and the end of January 2010, the largest hitherto known outbreak of Legionella in Germany took place in the cities of Ulm and Neu-Ulm. Of a total of 64 patients involved, 60 patients had to be hospitalized, and 5 patients died from the infection. This event was caused by a wet cooling tower of a large air conditioning system in the city center of Ulm. The search for the source of the Legionella emission was extremely difficult, since these plants are neither notifiable nor subject to authorization in Germany. We report about the search for the source and the measures to control the outbreak. We also discuss communication and coordination during these investigations. Regulatory measures as proposed by the World Health Organization (WHO) and the European Network for Legionellosis (EWGLI) and already implemented in numerous other European countries would be desirable to prevent such outbreaks in the future.

Development of CLL in the TCL1 transgenic mouse model is associated with severe skewing of the T-cell compartment homologous to human CLL.

Chronic lymphocytic leukemia (CLL) cells require complex microenvironmental and immunologic interactions to survive and proliferate. Such interactions might be best recreated in animal models; however, this needs extensive verification. We therefore investigated the composition of the T-cell compartment in the Eµ-TCL1 transgenic mouse, currently the most widely used murine model for CLL. Immunophenotyping and transplant approaches were used to define T-cell subsets at various stages of CLL. Analogous to human CLL, we observed a skewing of T-cell subsets from naive to antigen-experienced memory T cells that was more pronounced in lymph nodes than in blood. Transplantation of CLL into non-transgenic recipients was feasible without immunosuppression in a pure C57BL/6 background and resulted in the prominent skewing of the T cells of the recipient mice. Both in spontaneously developed CLL and in the transplantation setting, a loss in T-cell receptor diversity was observed, with a relevant number of clonal T-cell populations arising. This suggests that antigen-dependent differentiation toward the T memory pool is initiated by murine CLL cells. In summary, we validate the TCL1 transgenic mouse model for analysis of T-cell phenotypes and suggest a CLL-dependent antigen-driven skewing of T cells in these mice.

Occurrence of thermotolerant Campylobacter spp. on eggshells: a missing link for food-borne infections?

We analyzed the prevalence of thermotolerant Campylobacter spp. compared that of to Salmonella spp. in raw yolk and on eggshells. A total of 2,710 eggs were investigated for each bacterium. Viable bacteria were found in 4.1% (Campylobacter spp.) and 1.1% (Salmonella spp.) of the eggshell samples, whereas the egg yolk samples were negative for both bacteria.

Detection and differentiation of Vibrio spp. in seafood and fish samples with cultural and molecular methods.

Vibrio spp. as natural inhabitants of sea- and brackwater of both tropical and temperate regions of the world are commonly found in different kinds of seafood. Even among the three main human pathogenic species Vibrio parahaemolyticus, Vibrio cholerae and Vibrio vulnificus most of the isolates from seafood do not carry the different virulence factors responsible for foodborne infections. Therefore, the risk assessment of Vibrio spp. in seafood is currently based mainly on the knowledge of the genetic setting of foodborne strains. For the detection and differentiation of Vibrio spp. (V. parahaemolyticus, V. cholerae and V. vulnificus) three probe-based multiplex real-time PCR systems were developed and validated. One real-time PCR system simultaneously detects V. parahaemolyticus, V. cholerae and V. vulnificus on genus level combined with an Internal Amplification Control. The detection limit for the system was between 1cfu/mL and 10cfu/mL in pure culture and in different artificially contaminated sample material, e. g. prawns or Alaska Pollock. The other two PCR systems were implemented for the detection of different virulence genes of V. parahaemolyticus and V. cholerae isolates. The molecular detection systems were applied for the investigation of 338 raw and cooked seafood and fish samples for the presence of the different Vibrio spp. The collected data indicate that the PCR systems can be useful for rapid detection and differentiation of Vibrio spp. in different food matrices as basis for a preventive consumer protection policy.

Prevalence of emetic Bacillus cereus in different ice creams in Bavaria.

In this study, 809 samples of ice cream from different sources were investigated by using cultural methods for the presence of presumptive Bacillus cereus. Isolates from culture-positive samples were examined with a real-time PCR assay targeting a region of the cereulide synthetase gene (ces) that is highly specific for emetic B. cereus strains. The samples were collected from ice cream parlors and restaurants that produced their own ice cream and from international commercial ice cream companies in different regions of Bavaria during the summer of 2008. Presumptive B. cereus was found in 508 (62.7%) ice cream samples investigated, and 24 (4.7%) of the isolates had the genetic background for cereulide toxin production. The level of emetic B. cereus in the positive samples ranged from 0.1 to 20 CFU/g of ice cream.

[Management of antibiotic-resistant pathogens in Bavarian hospitals: results of a systematic survey and prospects to establish a statewide network "multidrug-resistant pathogens"]. / Management von Antibiotika-resistenten Erregern in bayerischen Kliniken: Ergebnisse einer systematischen Erhebung und Perspektiven zur Bildung eines landesweiten Netzwerks "multiresistente Erreger"

BACKGROUND: Infections caused by multidrug-resistant pathogens are a serious infection control problem with considerable public-health relevance. Regional networks coordinated by local public health departments are to be originated to establish a broader implementation of currently available official guidelines on infection prevention and control which consider the nosocomial transmission of MRSA. This is also due to the raise of awareness for the need of infection control implications to fight other multidrug-resistant pathogens. METHOD: A standardised guidance and survey in Bavarian hospitals on the basis of a checklist concerning structure, process and outcome quality parameters was done by the local public health departments. The data analysis was carried out by the Bavarian Health and Food Safety Authority. OUTCOMES: Checklists from 130 hospitals spread on 92% of the local districts of Bavaria were analysed. The results point out the need for improvements considering working time and duties of infection control professionals, especially infection control nurses, screening concepts and the compliance with legal regulations on the surveillance of nosocomial infections. On the other hand, the available guidelines for the management of patients carrying MRSA seem to be held serious.

Management of a large healthcare-associated outbreak of Panton-Valentine leucocidin-positive meticillin-resistant Staphylococcus aureus in Germany.

We report the largest documented healthcare-associated outbreak of Panton-Valentine leucocidin-positive meticillin-resistant Staphylococcus aureus (PVL(+) MRSA) in Europe. Six index patients from three long-term care facilities (LTCFs) were screened positive for PVL(+) MRSA in 2004 on admission to a community hospital in Germany. The purpose of this prospective study was to describe the prevalence of PVL(+) MRSA in the LTCFs before and after infection control interventions. Screening for MRSA with or without PVL was performed in all three LTCFs in 2004 [453 residents, 240 healthcare workers (HCWs)] and 2005 (440 residents, 192 HCWs). Swabs from anterior nares and wounds, if applicable, were collected. Colonised residents and staff were treated with mupirocin nasal ointment and topical antiseptics, and staff were provided with hygiene education. Total MRSA carrier rate of residents and HCWs in 2004 was 11.3% (PVL(+) MRSA 9.1%, PVL(-) MRSA 2.2%). There were comparable carrier rates between residents and HCWs in each LTCF. All PVL(+) MRSA isolates were of clonal origin (MLST 22) representing a novel spa sequence type t310. A decrease in total MRSA prevalence (from 11.3 to 5.5%) and PVL(+) MRSA (from 9.1 to 3.3%) was observed in 2005. The rate of PVL(-) MRSA remained unaffected. No symptomatic skin infections were noted among residents or HCWs. In this outbreak incomplete control of PVL(+) MRSA presumably resulted from difficult and delayed detection and decolonisation of carriers, incomplete compliance with control measures and lack of enforcement by public health authorities.

Fatal relapse of a purulent pleurisy caused by Campylobacter fetus subsp. fetus.

Campylobacter fetus is associated with invasive disease, while other Campylobacter species, such as C. coli and C. jejuni, are a common cause of bacterial diarrhea. Bacteremia has been well described, but pleurisy remains very uncommon. We report the recurrent isolation of a C. fetus subsp. fetus strain during two episodes of pleural effusion with a fatal outcome.

Campylobacter spp., Enterococcus spp., Escherichia coli, Salmonella spp., Yersinia spp., and Cryptosporidium oocysts in semi-domesticated reindeer (Rangifer tarandus tarandus) in Northern Finland and Norway.

The specific aim of this study was to assess the faecal shedding of zoonotic enteropathogens by semi-domesticated reindeer (Rangifer tarandus tarandus) to deduce the potential risk to human health through modern reindeer herding. In total, 2,243 faecal samples of reindeer from northern regions of Finland and Norway were examined for potentially enteropathogenic bacteria (Campylobacter species, Enterococcus species, Escherichia coli, Salmonella species and Yersinia species) and parasites (Cryptosporidium species) in accordance with standard procedures. Escherichia coli were isolated in 94.7%, Enterococcus species in 92.9%, Yersinia species in 4.8% of the samples and Campylobacter species in one sample only (0.04%). Analysis for virulence factors in E. coli and Yersinia species revealed no pathogenic strains. Neither Salmonella species nor Cryptosporidium oocysts were detected. The public health risk due to reindeer husbandry concerning zoonotic diseases included in this study has to be considered as very low at present but a putative epidemiological threat may arise when herding conditions are changed with respect to intensification and crowding.

Healthcare-associated outbreaks and community-acquired infections due to MRSA carrying the Panton-Valentine leucocidin gene in southeastern Germany.

In response to several isolations of methicillin-resistant Staphylococcus aureus carrying the Panton-Valentine leucocidin gene (PVL-MRSA), the present study was conducted to document the spread of infection in a small region of southeastern Germany. During a 9-month period, two healthcare-associated outbreaks with PVL-MRSA occurred, affecting 83 patients, personnel and contacts of personnel, and 34 additional cases were detected in the community. The clinical spectrum ranged from colonization to skin infection and necrotizing pneumonia. The findings represent the largest number of PVL-MRSA cases detected in Germany so far, and demonstrate the potential of this emerging pathogen to spread within the community and in healthcare institutions.