Second European multi-disciplinary conference of national strategies for Chlamydia trach. and human papillomavirus NSCP conf. in Berlin, 2013 enhanced detection, management and surveillance of sexually transmitted infections in Europe are essential!

There is a need for updated guidance on detection, management and surveillance of sexually transmitted infections (STIs). Chlamydia, gonorrhoea and syphilisreporting needs to be mandatory in more European countries to aid collection of data. More widespread Chlamydia screening is needed in many countries as this is the only way to reduce complications. The role of Human Papillomavirus (HPV) screening in a situation where the prevalence of HPV infection has dropped significantly was also discussed in the context of the high cost of screening, the need for a relatively complex infrastructure, particularly in developing countries, and falling vaccination costs. An integrated HPV vaccination and screening policy could be the most appropriate with vaccination at 9-13 years as recommended by WHO and a single HPV screen at 35-39 years, possibly repeated thereafter every 10 years. Female and male HPV vaccination programmes could lead to near elimination of genital warts in both females and males. Surveillance of STIsshould be intensified where needed; additional or better quality data should be collected including reasons for testing, denominator data to estimate positivity rates, diagnostic methods, concurrent STIs, sexual orientation and country of acquisition; more analytical rather than descriptive epidemiology is needed.

Experiences with the new genetic variant of Chlamydia trachomatis in Orebro county, Sweden - proportion, characteristics and effective diagnostic solution in an emergent situation.

A Chlamydia trachomatis variant that contains a 377 bp deletion in the cryptic plasmid was recently reported in Sweden. This deletion includes the targets for Cobas Amplicor, Cobas TaqMan48, and Abbott m2000. We examined the proportion and characteristics of this variant in Orebro county, Sweden and developed an effective diagnostic solution. In total, 2,401 consecutive C. trachomatis culture samples and 536 PCR samples from symptomatic and asymptomatic patients and screened females were included. Culture, Cobas Amplicor, and LightMix 480HT were used for diagnosis. A mutant-specific PCR, plasmid sequencing, omp1 sequencing and multilocus sequence typing (MLST) were used to identify and characterise mutants. In total, 162 (6.7%) of the cultured samples were positive for C. trachomatis. However, 61 (38%) of those were negative when using Cobas Amplicor, and 60 of these were subsequently confirmed as the new variant. 13 of these mutant isolates were further characterised genetically, and all were of identical genotype E and the unique MLST sequence type: 21, 19, 1, 2, 1. Of all culture-positive samples, 161 of 162 were positive in the LightMix 480HT assay. The single negative sample was only weakly positive in culture, and negative in all PCRs. Of the 536 PCR samples, 37 were positive in both Cobas Amplicor and LightMix 480HT, 13 were only positive in LightMix 480HT (mutants), and two were only positive in Cobas Amplicor. Mutated C. trachomatis were prevalent in Orebro county in the period from October 2006 to February 2007, and it appeared to be a single clone. LightMix 480HT seemed sensitive, specific, and enabled high throughput diagnostics. However, rare low positive samples may be false-negative. Frequent surveillance and evaluations of diagnostic methods worldwide are crucial.

Detection of human coronavirus NL63, human metapneumovirus and respiratory syncytial virus in children with respiratory tract infections in south-west Sweden.

Two recently detected viruses, human metapneumovirus (hMPV) and coronavirus NL63 (HCoV-NL63), have been associated with acute respiratory tract infections, particularly in young children. This study investigated the frequency of hMPV and HCoV-NL63 infections in Swedish children by screening 221 nasopharyngeal aspirates, collected between November 2003 and May 2005, from 212 children attending the paediatric department of a county hospital in Sweden or submitted from local general practitioners. The samples were originally submitted to be tested for respiratory syncytial virus (RSV), and were examined retrospectively for hMPV and HCoV-NL63 by RT-PCR. Of the 212 patients, 101 were positive for RSV (48%), 22 (10%) were positive for hMPV, and 12 (6%) were positive for HCoV-NL63. The frequency of HCoV-NL63 infection increased from 1% in 2003-2004 to 10% in 2004-2005. Sequence analysis of parts of the coronavirus genomes showed considerable similarity to the HCoV-NL63 prototype sequence. The study demonstrated that HCoV-NL63 and hMPV occur in south-west Sweden with essentially the same frequency, seasonal distribution and clinical characteristics as have been reported in other countries.

Use of broth enrichment and real-time PCR to exclude the presence of methicillin-resistant Staphylococcus aureus in clinical samples: a sensitive screening approach.

A rapid and sensitive method for excluding the presence of methicillin-resistant Staphylococcus aureus (MRSA) in clinical samples was developed and evaluated. The method utilised an MRSA-selective enrichment broth for 16 h, followed by PCR quantification of the nuc gene. Samples below a quantitative PCR threshold were reported as MRSA-negative. Broths from PCR-positive samples were subcultured for MRSA isolation. Clinical samples (n = 334) in a constructed high prevalence population were analysed in parallel with a selective plating method. The new broth-PCR assay increased the number of positive samples by 35% (49 vs. 66), and 94% of negative samples were reported within 24 h. To reduce costs and workload, 665 clinical samples were grown separately in enrichment broth and then pooled in the PCR step. The broth-PCR assay increased the number of MRSA positive samples from 11 to 15 compared with selective plating. Most (89%) of the culture-negative samples were also PCR-negative and could be reported within 24 h. The growth of 25 European EMRSA strains was tested in the selective enrichment broth. On average, the MRSA strains showed a 300 000-fold increase in CFU, compared with 30-fold for the eight methicillin-sensitive Staphylococcus aureus strains tested.

Serotypes and clinical manifestations of invasive group B streptococcal infections in western Sweden 1998-2001.

This study monitored the serotypes of Streptococcus agalactiae (group B streptococcus; GBS) isolated from invasive infections in western Sweden and investigated possible relationships between serotype, age and clinical manifestations. Invasive GBS isolates were collected prospectively during 1998-2001 at six laboratories, covering two counties with a population of 1.8 million, and were serotyped by coagglutination. Clinical data were obtained from hospital notes. In total, 161 invasive strains (50 from neonates and infants aged < 3 months, and 111 from adults) were serotyped. The commonest serotypes from neonates and infants were serotypes III (60%), V (22%) and Ia (10%), and from adults were serotypes V (42%) and III (25%). Serotype V had doubled in frequency among both children and adults compared to a previous study from the same area in 1988-1997. Most (80%) of the adults had an underlying medical condition. No relationship was found between serotype and clinical manifestations. However, the study demonstrated the importance of active surveillance of GBS serotypes and the difficulties of formulating a multivalent polysaccharide conjugate vaccine against GBS.

Partner notification as a tool for research in HIV epidemiology: behaviour change, transmission risk and incidence trends.

OBJECTIVE: To assess whether routinely collected data from partner notification for HIV infection could be used to study HIV epidemiology. The issues addressed were measures of contact patterns and behaviour change, variables influencing transmission risks, and indications of HIV incidence. DESIGN: We collected anonymous questionnaire data from all partner notifications performed from seropositive patients diagnosed in Sweden between 1 January 1989 and 30 June 1990. METHOD: A structured questionnaire was completed by the physician or counsellor interviewing newly diagnosed seropositive patients and counselling their reported partners. The questions focused on temporal and behavioural aspects of all contacts between index patients and partners. RESULTS: Questionnaires were completed for 365 of the 403 (91%) index patients diagnosed during the study period, for 350 of the 390 (90%) located partners, and for 274 of the 297 (92%) relationships where results of HIV testing were known for index patient and partner. Seropositive individuals diagnosed in 1989 or later reported less risk behaviour than those diagnosed earlier. Risk of transmission in sexual contact increased when the infectious partner developed symptoms of HIV infection. Anal intercourse was found to be approximately twice as infectious as vaginal, and transmission risk from a seropositive insertive partner approximately twice as high as from a receptive. The total HIV incidence in Sweden appears to be declining, as does the number of newly diagnosed infected homosexual men. CONCLUSION: Carefully collected data acquired from a partner notification programme are well suited to describe and follow the epidemiology of HIV infection.

Efficacy of partner notification for HIV infection.

Since 1985, partner notification has been part of Swedish policy to prevent the spread of human immunodeficiency virus (HIV) infection. Potentially infected partners of a newly diagnosed seropositive patient are notified either by the index patient or by the physician and referred for counselling. The efficacy of this strategy was assessed over 18 months in 1989-90. 365 HIV-seropositive index patients (91% of the 403 patients diagnosed in Sweden during the study period) reported 564 sexual or needle-sharing contacts. 390 contacts were located and counselled and HIV test results are known for 350 of them. In 53 of the 350 cases, previously unknown seropositivity was diagnosed. Partner notification for HIV should be viewed as a strategy to offer counselling and testing to a high-prevalence group of people. In a country where general HIV prevalence is low, the strategy is cost-effective for location and counselling of unknowingly seropositive individuals.

Bacillus cereus: a significant pathogen in postoperative and post-traumatic wounds on orthopaedic wards.

Over a period of 19 months, Bacillus species, most frequently B. cereus, were isolated from postoperative and post-traumatic wounds in 24 patients on orthopaedic wards in a Swedish hospital. Clinical signs of infection were found in all but 3 patients: in 9 patients, mild signs with increased secretion from the wounds; in 10 patients, moderate signs with fever and/or significant local reaction around the wounds; and in 2 patients, severe signs with necrotic infections. Bacillus spp. were isolated from one-fourth of all patients with wound complications following total hip arthroplasty. Their hospitalization was significantly prolonged, compared with a control group (p = 0.0042). Isolates of B. cereus from wounds should not be dismissed as contaminants or as non-pathogenic, but must be assessed in the light of the clinical situation.

Outbreaks of infections with erythromycin-resistant group A streptococci in child day care centres.

Erythromycin-resistant group A streptococci (ERGAS) are considered rare in Sweden. In the county of Halland (240,000 inhabitants) in southern Sweden, we had 294 isolates of ERGAS between January 1984 and June 1985. Almost all strains were of T-type 12 and only resistant to erythromycin (MIC values approximately 8 g/l). Seven child day care centres (DCC) were involved in the outbreaks and on average 49% of all children were infected in each outbreak. Employees were seldom infected (8%), but parents and siblings more often (23% and 36%). One course of phenoxymethylpenicillin succeeded in eradicating ERGAS from 75% of those infected. The ERGAS strains are now established in southern Sweden and account for about 2% of all group A streptococcal infections in the county of Halland.

Epidemiologic control of genital Chlamydia trachomatis infections.

Sexually transmitted diseases (STD), whether old or new, impose a heavy economic burden on the public health service. Behavioural changes that could reduce the incidence of STD in the general population take time to make their effects felt. Common and treatable diseases such as genital chlamydial infections can and should be tackled by the old familiar strategy for combatting STD, viz. case finding, diagnosis, contact tracing and treatment, parallel with counselling in sexual behaviour. The incidence of infection is largely dependent on the number of asymptomatic individuals with a chlamydial infection in the population. Case finding programs devised chiefly for young, sexually active people will thus directly influence the natural life of Chlamydia trachomatis in our society. One such program, involving the sampling of women below the age of 30 when they come to the family planning clinic (FPC) for contraceptive advice, when applying for legal abortion, or when receiving prenatal care has been running in Halmstad, with increasing effect, since 1982. Contact tracing is an important part of the program. The prevalence of infected women has been halved since 1984 in the age interval 15-29 years. 10% of infected females, 15-24 years old, evidence repeated infection during 1 year. This program, carried out at a FPC, has proved cost-effective, achieving a 44% reduction in calculated expenditure. Chlamydial infections in Sweden are changing in character from being an untreated hyperendemic disease up to the late 1970s, to become a treated hyperendemic disease, until at last a declining prevalence can now be discerned.

Effective sampling device and mucopurulent cervicitis in women with chlamydial cervical infection.

Brushes (Cytobrush, Medscand) are superior to swabs for the collection of endocervical cells for cytologic examination. In the present randomized study, Cytobrush was compared with ENT-swabs and with white, cotton-tipped swabs to obtain samples for the diagnosis of chlamydial cervicitis. The women were examined for the presence of mucopurulent cervicitis (MPC). The subjects comprised 126 women, most of whom had been referred because of asymptomatic chlamydial infection. Specimens obtained with brushes were culture-positive in 83 women and positive in a direct fluorescent antibody test (FA-test) in 78 women. The corresponding figures for samples obtained with swabs were 80 and 74, respectively. The mean number of inclusions was significantly higher in samples obtained with brushes (4,999), compared with swabs (3,155), as was the mean number of elementary bodies (3,000 vs 2,481). MPC was detected in 65% of the women with asymptomatic chlamydial cervicitis, and in 93% of those with symptomatic infection. The corresponding figures for a pathologic wet smear were 62% and 80%, respectively. The specificity and predictive values of a positive and negative MPC-test was 21%, 39%, and 86%, respectively, and for a pathologic wet smear 53%, 44%, and 85%, respectively. We conclude that brushes are superior to swabs for sampling material, both for culture and for direct FA-tests. The MPC and the wet smear tests could be of value in the diagnosis of chlamydial cervicitis, providing confirmatory laboratory tests are used.