Rise In Notifications Research Articles

Epidemiological trends of notified human brucellosis in Germany, 2006–2018

ObjectiveWe describe epidemiological trends of human brucellosis in Germany over a 13 year period based on national surveillance data. MethodsWe analyzed demographic, clinical, laboratory and exposure information of symptomatic laboratory-confirmed brucellosis cases notified 2006–18. Using official population data, we calculated incidences and risk ratios (RR). ResultsFrom 2006 to 2018, 408 brucellosis cases were notified in Germany (mean annual incidence: 0.38/1,000,000 population), of which 75% were travel-associated. Yearly notifications peaked in 2014 (n = 47) and remained elevated compared to 2006–2013 (mean: n = 25). Asylum seekers (AS) arriving in Germany accounted for 9/44 (2015) and 15/36 (2016) cases, respectively. RR AS/non-AS 2015–2016: 28, 95% CI: 17–45. Unpasteurized milk products were most frequently notified as source of infection. Imported food and occupational exposure played a role in autochthonous cases. ConclusionsThe incidence of human brucellosis has markedly increased in recent years. Most of the observed rise in notifications can be explained by infections in AS. Exposure still predominantly occurs abroad. Risk factors for autochthonous infections need to be investigated further, though imported dairy products seem to play a role. Physicians should consider brucellosis as differential diagnosis in AS and people with travel to endemic regions with compatible symptoms.

Increasing HIV diagnoses in Australia among men who have sex with men correlated with the growing number not taking antiretroviral therapy

Australia has experienced rising notifications of HIV diagnoses despite widely available combination antiretroviral therapy (CART). New HIV diagnoses have also been younger than the average age of those living with HIV. We investigated the degree to which several risk factors could explain this rise in notifications and the younger age profile. Numbers and ages of men who have sex with men (MSM) living with HIV in Australia from 1983 to 2007 were calculated from notifications of HIV diagnoses and deaths. We compared the trend over time as well as the average ages of MSM newly diagnosed with HIV infection from 1998 to 2007 with those for: notifications of gonorrhoea and syphilis, total MSM living with HIV infection, and the component not on CART. The percentage of younger MSM not taking CART has increased since 1998 (aged <30 years P<0.001; 30-39 years P=0.004). The trend of new HIV diagnoses was most significantly correlated with the total number of MSM living with HIV infection and the sector not taking CART (P<0.0001). Based on similarity of average ages, MSM living with HIV infection and not taking CART was the best predictor of the increasing trend in new HIV diagnoses (99.9999% probability, Akaike information criterion). Our analyses suggest MSM living with HIV infection and not taking CART could be the source of the increase in HIV infections. Consequently, greater CART enrolment should decrease HIV incidence, especially in younger MSM.

Where are we going with chlamydia?

Chlamydia continues to perplex us. Throughout much of the industrialised world, notifications have been relentlessly rising for a decade. Several countries have launched national screening programs. Chlamydia infection is a generalised epidemic: while there are well recognised risk factors for individuals, no major segment of the population is spared.1 Even among the minority of the public that know what it is, in its own right chlamydia represents an insufficient threat to drive most people to abstinence, life-long exclusive relationships, or the consistent use of condoms. By the time chlamydia results in infertility or an ectopic pregnancy the organism has usually moved on. Thus, the true culprit is rarely implicated and is almost never publicly singled out as causing major disease in an individual. Only high profile and ‘incurable’ conditions like HIV infection are capable of achieving sustained behaviour change, however patchy. Nevertheless, many Australian jurisdictions and New Zealand have launched targeted education programs with goals that include encouraging condom use, raising awareness of chlamydia among the public and health professionals and recommending screening. A consensus has emerged thatmore intensive and focussed population screening is needed, along with improved partner management strategies. With only 7 to 8% of women under the age of 25 years tested for chlamydia each year,1 Australia clearly has a lot more case finding to do. From 2006, with a program budget of AU$12.5 million, the Australian Government has begun to fund a series of pilot screening projects involving a wide range of clinical services and a variety of priority populations, and with geographical diversity. This program is also funding national projects that are investigating chlamydia reinfection rates; education packages for general practitioners, rural and remote health workers, teachers, parents and young people; and a system of enhanced sentinel surveillance.2 A particularly encouraging feature of the program is that over 100 applications for project funding were received, indicating a high level of enthusiasm among many organisations. In this context, it is timely for Sexual Health to contribute to a growing body of literature exploring enhanced chlamydia surveillance and screening strategies in various populations,3−8including barriers to testing5,6,9 and contact tracing.10,11 In Canberra, no significant difference was found in chlamydia prevalence among men who have sex with men between clinical and community settings, from which a need for more screening of anal swabs was concluded.4 As suggested by the work of Gaydos et al.6 in Baltimore, momentary embarrassment and confidentiality concernsmay be among the foremost barriers to chlamydia testing. Perhaps we need to adjust our clinical model so that the process is less intimidating for our patients. ‘Simple and inexpensive’ online resources can then be made available to the family doctor to facilitate partner management.11 An interesting hypothesis – that chlamydia prevalence may be suppressed at a population level by antibiotics given mainly for other purposes – also warrants further research.12 UsingAustralian cost parameters and a traditional methodology, screening women annually up to the age of 25years is shown to be cost effective.13 Itwould be interesting to also examine cost effectiveness using a dynamic model. In such amodel, the possibility that widespread screening could lower the population prevalence of chlamydia, thus averting incident infections could be examined. This ongoing benefit would be in addition to the prevention of complications in those women who are already infected. Alternative screening models, including screeningmen, also need to be assessed for cost effectiveness. Almost certainly, with increasing testing, chlamydia notifications will continue to rise. Because it is a largely asymptomatic condition, chlamydia statistics are vulnerable to testing artefact,14,15 making notification data very difficult to interpret. A rise in notifications could be plausibly interpreted as either success (because more asymptomatic cases are being detected and treated) or failure (because more transmission is occurring) of a more widespread testing campaign. Clearly, we need surveillance strategies that can differentiate these outcomes. Repeated cross-sectional chlamydia prevalence surveys of the same populations are one option. Enhanced sentinel surveillance in a range of

Tuberculosis: the silent epidemic.

Tuberculosis (TB) used to be a common cause of death in the UK, accounting for a quarter of all annual deaths in the 19th century. While the poor were most vulnerable to the disease, every stratum of society was affected, as witnessed by the suffering of the Brontë sisters and Keats among others. Improved social conditions and better nutrition helped to reduce the prevalence of TB, and the introduction of the BCG vaccine and successful antibiotic therapy reduced the incidence further. Indeed, in the 1970s some thought that there would be no TB at the millennium. However, following a steady decline in recent decades, there are now an increasing number of TB notifications in England and Wales. While most of the rise is accounted for by notifications in the London area, there has also been a significant rise in notifications in the South East and Trent. Three quarters of notifications relate to males, of whom the vast majority are aged 25–64 years. It is perhaps not surprising, therefore, that TB is ranked the fifth most important communicable disease by professionals and the fifth most important disease requiring further work (Horby et al, 2001).