Excess mortality in Europe coincides with peaks of COVID-19, influenza and respiratory syncytial virus (RSV), November 2023 to February 2024

Since the end of November 2023, the European Mortality Monitoring Network (EuroMOMO) has observed excess mortality in Europe. During weeks 48 2023-6 2024, preliminary results show a substantially increased rate of 95.3 (95% CI:  91.7-98.9) excess all-cause deaths per 100,000 person-years for all ages. This excess mortality is seen in adults aged 45 years and older, and coincides with widespread presence of COVID-19, influenza and respiratory syncytial virus (RSV) observed in many European countries during the 2023/24 winter season.

Estimated number of reported vaccine-preventable disease cases averted following the introduction of routine vaccination programs in Sweden, 1910-2019

BACKGROUND

Routine childhood vaccination programs have had enormous positive public health impacts worldwide. However, in some areas, these benefits may be impeded by vaccine hesitancy and undervaccination. We estimated the number of reported cases of measles, pertussis, mumps and poliomyelitis averted in Sweden after the introduction of routine childhood vaccination programs.

METHODS

We used annual national data on population size and the number of reported cases of measles (1911-2019), pertussis (1911-2019), mumps (1914-2019) and poliomyelitis (1910-2019) for Sweden. For each disease, we calculated the median and 95% confidence interval of the annual pre-vaccination incidence to estimate the number of counterfactual cases; that is, the estimated number of cases that would have been observed in the post-vaccination period had no vaccine been introduced (median incidence × average annual population). For the post-vaccination periods, we calculated reported cases averted and assumed all decreases were due to vaccines.

RESULTS

In total, for all four diseases combined, over 2.1 million cases were reported over the respective surveillance periods. Since the introduction of vaccinations, we estimate that over 1.5 million reported cases of these four diseases combined have been averted: measles (633 091), pertussis (608 670), mumps (262 951) and poliomyelitis (58 240). However, due to underreporting, especially during pre-vaccination years, these are likely underestimates.

CONCLUSIONS

Since the introduction of these routine childhood vaccination programs in Sweden, a substantial number of reported cases of vaccine-preventable diseases have been averted. Vigilance against both failure to vaccinate and undervaccination is necessary to prevent future increases of these vaccine-preventable diseases.

High Prevalence of SARS-CoV-2 Omicron Infection Despite High Seroprevalence, Sweden, 2022

We performed 2 surveys during 2022 to estimate point prevalences of SARS-CoV-2 infection compared with overall viral seroprevalence in Sweden. Point prevalence was 1.4% in March and 1.5% in September. Estimated seroprevalence was >80%, including among unvaccinated children. Continued SARS-CoV-2 surveillance is necessary for detecting emerging, possibly more pathogenic variants.

Splenic Injury After Colonoscopy in a 55-Year-Old Female Patient

Colonoscopy is, in general, a relatively safe procedure with a low complication rate. Splenic injury related to this procedure is very rare, ranging from one in 100,000 to one in 6,387 colonoscopies, but a possibly lethal complication. For its diagnosis, a high degree of clinical suspicion is needed as many physicians are not aware of its existence. Clinical symptoms and signs are observed 1-10 days after the procedure. The imaging modality of choice is contrast-enhanced computed tomography (CECT). However, contrast-enhanced ultrasound (CEUS) may also be used to detect abdominal fluid and the injured area of the spleen. We present a case of a 55-year-old female with splenic rupture after a colonoscopy, diagnosed with CEUS and CECT. Splenectomy was performed, and the patient's recovery was uneventful.

A Rare Case of Synchronous Primary Gallbladder and Sigmoid Colon Neoplasms

Colorectal cancer is considered the third most common cancer worldwide. On the other hand, gallbladder cancer is rare. Synchronous tumors in both the colon and the gallbladder are extremely infrequent. Herein, we report the case of a female patient with sigmoid colon cancer and incidental detection of synchronous gallbladder cancer on histopathological examination of the surgical specimen. As synchronous gallbladder and colonic carcinomas are rare, physicians should be aware of these so that an optimal course of treatment can be chosen.

Point prevalence of SARS-CoV-2 infection in Sweden at six time points during 2020

Background

In order to estimate the prevalence and understand the spread of SARS-CoV-2 in Sweden, the Public Health Agency of Sweden, with support from the Swedish Armed Forces, conducted a series of point prevalence surveys between March and December 2020.

Methods

Sampling material and instructions on how to perform self-sampling of the upper respiratory tract were delivered to the homes of the participants. Samples were analysed by real-time PCR, and the participants completed questionnaires regarding symptoms.

Findings

The first survey in the Stockholm region in March 2020 included 707 participants and showed a SARS-CoV-2 prevalence of 2.5%. The following five surveys, performed on a national level, with between 2461 and 2983 participants, showed SARS-CoV-2 prevalences of 0.9% (April), 0.3% (May), 0.0% (August), 0.0% (September), and 0.7% (December). All positive cases who responded to questionnaires reported experiencing symptoms that occurred from 2 weeks before the date of sampling up to and including the date of sampling.

Interpretation

None of the individuals shown to be PCR-positive were asymptomatic at the time of sampling or in the 14 days prior to sampling. This is in contrast to many other surveys in which a substantial proportion of positive cases have been reported to be asymptomatic. Our surveys demonstrate a decreasing ratio between notified cases and the observed prevalence throughout the year, in line with increasing testing capacity and the consecutive inclusion of all symptomatic individuals in the case definition for testing.

Seroprevalence of SARS-CoV-2 in Sweden, April 26 to May 9, 2021

A national point seroprevalence study of SARS-CoV-2 was conducted in Sweden in April-May 2021. In total, 2860 individuals 3 to 90 years old from a probability-based web panel were included. Results showed that an estimated 32.6% of the population in Sweden had detectable levels of antibodies, and among non-vaccinated 20.1% had detectable levels of antibodies. We tested for differences in seroprevalence between age groups and by sex and estimated seroprevalence among previously infected participants by time since reporting.

An Extremely Rare Case of a Primary Pancreatic Yolk Sac Tumor

Yolk sac tumor (YST) is a rare malignant type of germ cell tumor (GCT). Extragonadal yolk sac tumor is a very rare entity. We report the case of a 33-year-old male with a pancreatic mass, which proved to be a primary yolk sac tumor, arising in the pancreas.

Thromboprophylaxis in surgically treated colorectal cancer patients with tinzaparin: Intermediate results from the Onco-CAST trial

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Background: The incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) after colorectal surgery is approximately 29% and 1.6% respectively. The incidence of asymptomatic postoperative DVT in colorectal cancer (CRC) patients has been reported as high as 20%, even under thromboprophylaxis. Thus, thromboprophylaxis after surgical treatment for CRC is crucial. Latest guidelines from International Initiative on Thrombosis and Cancer (ITAC 2019) recommend use of highest prophylactic dose of Low Molecular Weight Heparin (LMWH). Methods: Onco-CAST is a prospective, phase IV, observational, non-interventional cohort study evaluating a) current management approach for CRC surgical prophylaxis and b) efficacy and safety of tinzaparin at 8.000 Anti-Xa IU, once daily (OD), for at least one month post hospital discharge. Patients enrolled after signing informed consent. Onco-CAST was conducted by the Hellenic Society of Coloproctology. Results: Results from 175 CRC patients from 9 Onco Surgical Clinics are reported. Participation completed 79% of patients at report time: 66% males, 67±12 years, BMI: 27.4±5.5. Histology: adenocarcinomas NOS 81%, mucinous adenocarcinomas 9%, small cell neuroendocrine carcinomas 2%, and others. High grade differentiation indicated: 26% and 5% metastatic. 32% treated with right hemicolectomy, 20% with low anterior resection, 12% with sigmoid colectomy, 9% with abdominal-perineal resection, 9% with left hemicolectomy and other methods. 67% treated open and 33% laparoscopic while the median number of lymph nodes dissected for left and right hemicolectomy was 32.5 (Q1-Q3:26-38) and 24 (Q1-Q3: 14.5-32), p = 0.0253. Factors related to thrombosis risk are presented in table, notably, 95% of patients accumulated ≥3 risk factors. Median thromboprophylaxis duration with tinzaparin 8.000 Anti-Xa IU, OD, was: 37 days (1st-3rd quartile: 33-45 days). Three thrombotic events occurred (efficacy 98.3%, 95% CI: 95.1-99.4%), one DVT+PE, one DVT and one due to Central Venous Catheter (CVC). Eight patients experienced bleeding events (4.6%, 95%CI: 2.3-8.8%), 3 minor, 3 major and 2 CNMB, 2 had a possible relation to thromboprophylaxis (1.1%, 95%CI: 0.3-4.1%). Conclusions: Thromboprophylaxis in Surgically Treated Colorectal Cancer Patients with Tinzaparin intermediate dose seems safe and efficient approach.[Table: see text]

A Rare Case of an Adrenal Mass Proved to Be a Benign Cellular Schwannoma

Adrenal schwannomas are extremely uncommon tumors. We report the case of a 39-year-old male with a right adrenal mass. Laboratory tests were normal and radiological exams revealed the adrenal tumor. Open surgical adrenalectomy was performed. The postoperative course was uneventful. Microscopy and immunohistochemistry revealed a cellular schwannoma. Adrenal schwannomas are rare tumors, very difficult to diagnose in preoperative evaluation. Surgical excision of the tumor, histological and immunohistochemical examination of the specimen provide a definitive diagnosis. Prognosis is generally very good. Recurrence rates are related to positive surgical margins.

Large-Cell Esophageal Neuroendocrine Carcinoma: Report of a Rare Case

Neuroendocrine tumors (NETs) are neoplasms with neuroendocrine characteristics such as secretion of neuropeptides, large secretory vesicles, and a lack of neural structures. Neuroendocrine carcinoma (NEC) of the esophagus is a very rare malignancy. We present the case of a 58-year-old male with a pure large cell NEC of the esophagus.

Chronic disease and immunosuppression increase the risk for non-vaccine serotype pneumococcal disease - a nationwide population-based study

Background

Demography is changing, with people living longer with comorbidities. In this nationwide population-based study, we investigated the serotype-specific invasive pneumococcal disease (IPD) risk in individuals with comorbidities, and effects of the pneumococcal conjugated vaccine (PCV) child immunization program.

Methods

Cases included 14 096 IPD episodes in Sweden during 2006–2015. Controls (n = 137 289), matched to cases by age, sex, region, and calendar time, were selected from the general population. Comorbidity data was obtained through health registers and grouped as immunocompromising (IC) or chronic medical conditions (CMC).

Results

The prevalence of CMC and IC among elderly cases was 33.9% and 39.4%. New risks identified for IPD were sarcoidosis, inflammatory polyarthropathies, systemic connective tissue, and neurological diseases. The odds ratio (OR) for IPD caused by non-PCV13 compared with PCV13 serotypes was higher in individuals with CMC/IC. Serotypes associated with the highest risk were 16F, 15C, 35F, 19F, and 23A (OR 3–5 for CMC, >10 for IC). Most comorbidities increased post-vaccination, and absolute increases of IPD caused by non-PCV13, PPV23–non-PCV13, and non-PCV13/non-PPV23 serotypes were higher in individuals with IC/CMC compared with healthy persons. Non-PCV13 serotypes 6C, 9N, 11A, 22F, 23A and 35F increased more in those with comorbidities. Mortality due to non-PCV13 serotypes increased in individuals with IC/CMC, while remaining stable in persons without comorbidities.

Conclusions

The PCV child immunization program associates with an increased disease burden of non-vaccine serotypes in individuals with comorbidities. These data are important for vaccine design and optimization of current vaccination strategies.

Pertussis seroprevalence among adults of reproductive age (20-39 years) in fourteen European countries

The reported incidence of pertussis in European countries varies considerably. We aimed to study specific Bordetella pertussis seroprevalence in Europe by measuring serum IgG antibody levels to pertussis toxin (anti-PT IgG). Fourteen national laboratories participated in this study including Belgium, Denmark, Finland, Greece, Hungary, Italy, Lithuania, Malta, Norway, Poland, Portugal, Romania, Spain, and Sweden. Each country collected approximately 250 samples (N = 7903) from the age groups 20-29 years (N = 3976) and 30-39 years (N = 3927) during 2010-2013. Samples were anonymous residual sera from diagnostic laboratories and were analyzed at the national laboratories by a Swedish reference method, a commercial ELISA kit, or were sent to Sweden for analysis. The median anti-PT IgG concentrations ranged from 4 to 13.6 IU/mL. The proportion of samples with anti-PT IgG ≥100 IU/mL, indicating a recent infection ranged from 0.2% (Hungary) to 5.7% (Portugal). The highest proportion of sera with anti-PT IgG levels between 50 and <100 IU/mL, indicating an infection within the last few years, was found in Portugal (12.3%) and Italy (13.9%). This study shows that the circulation of B. pertussis is quite extensive in adults, aged 20-39 years, despite well-established vaccination programs in Europe.

An outbreak investigation of Legionella non-pneumophila Legionnaires’ disease in Sweden, April to August 2018: Gardening and use of commercial bagged soil associated with infections

In early June 2018, an increase in non-travel-related cases of Legionella non-pneumophila Legionnaires’ disease (LD) was observed in Sweden and a national outbreak investigation was started. Outbreak cases were defined as notified confirmed or probable cases of L. non-pneumophila LD, with symptom onset after 1 April 2018. From April to August 2018, 41 cases were reported, 30 of whom were identified as L. longbeachae. We conducted a case–control study with 27 cases and 182 matched controls. Results from the case–control study indicated that gardening and handling commercial bagged soil, especially dusty dry soil, were associated with disease. L. longbeachae was isolated in soils from cases’ homes or gardens, but joint analysis of soil and human specimens did not identify any genetic clonality. Substantial polyclonality was noted between and within soil samples, which made finding a genetic match between soil and human specimens unlikely. Therefore, whole genome sequencing may be of limited use to confirm a specific soil as a vehicle of transmission for L. longbeachae. Handling soil for residential gardening was associated with disease and the isolation of L. longbeachae in different soils provided further evidence for Legionella non-pneumophila infection from soil.

Real-time monitoring shows substantial excess all-cause mortality during second wave of COVID-19 in Europe, October to December 2020

The European monitoring of excess mortality for public health action (EuroMOMO) network monitors weekly excess all-cause mortality in 27 European countries or subnational areas. During the first wave of the coronavirus disease (COVID-19) pandemic in Europe in spring 2020, several countries experienced extraordinarily high levels of excess mortality. Europe is currently seeing another upsurge in COVID-19 cases, and EuroMOMO is again witnessing a substantial excess all-cause mortality attributable to COVID-19.

Outbreak of unusual H2S-negative monophasic Salmonella Typhimurium strain likely associated with small tomatoes, Sweden, August to October 2019

Sweden is investigating an outbreak of monophasic Salmonella Typhimurium. Eighty-two nationally-distributed cases have been confirmed, with date of symptom onset between 28 August and 29 October. Cases were 51 years of age on average (range: 0–89) and the majority of cases were female (62%). A case–control study was conducted and suggested small tomatoes as source of the outbreak (adjusted odds ratio (OR): 10.8, 95% confidence interval (CI): 4.15-112.68, p value < 0.001), and a trace-back investigation led to a single, non-Swedish producer in Europe. Both the Salmonella strain and the source of the outbreak are rarely encountered in Europe. Results from investigation at the producer are pending.

Excess all-cause mortality during the COVID-19 pandemic in Europe - preliminary pooled estimates from the EuroMOMO network, March to April 2020

A remarkable excess mortality has coincided with the COVID-19 pandemic in Europe. We present preliminary pooled estimates of all-cause mortality for 24 European countries/federal states participating in the European monitoring of excess mortality for public health action (EuroMOMO) network, for the period March–April 2020. Excess mortality particularly affected  ≥ 65 year olds (91% of all excess deaths), but also 45–64 (8%) and 15–44 year olds (1%). No excess mortality was observed in 0–14 year olds.

The changing epidemiology of community-acquired pneumonia: nationwide register-based study in Sweden

BACKGROUND

There is limited evidence on the impact of pneumococcal conjugate vaccine childhood immunization programmes (PCV-CIP) on community-acquired pneumonia (CAP) in individuals with underlying diseases.

METHODS

A nationwide cohort study using Swedish health registers to assess the incidence of hospitalization with all-cause (AC-CAP) and pneumococcal or lobar (PL-CAP) CAP between 2005 and 2015, in relation to PCV-CIP introduction in 2007-09.

RESULTS

In total, 303 691 episodes of AC-CAP occurred, of which 14 225 were PL-CAP. Comparing before (2005-06) with after (2014-15) PCV-CIP, relative incidence reductions were 36% (95% Confidence Interval 32-40), 20% (14-25) and 16% (11-22) of AC-CAP for age groups < 2, 2-4 and 5-17 years, respectively, with similar reductions in young children with and without comorbidities. The reductions were more pronounced for PL-CAP. In the age groups 40-64, 65-74, 75-84 and ≥85 years there were relative increases of 11% (8-14), 18% (15-22), 15% (12-17) and 30% (27-34) of AC-CAP, respectively, but these increases were attenuated after adjustment for admittance practices using four control conditions. In adults with comorbidities, there was an increase in incidence of AC-CAP, and PL-CAP, in contrast to adults without reported underlying diseases where the incidence was stable or diminished for some age groups. Over the study period, there was an increased proportion of pneumonia patients with underlying diseases in all ages.

CONCLUSION

This emphasizes that direct preventive interventions should be targeted towards individuals with underlying diseases. Future studies should investigate reasons for the observed increased risk in adults with comorbidities, for example due to pneumococcal nonvaccine serotypes, or other pathogens, preferentially affecting subjects with underlying diseases.

Socioeconomic disparities associated with 29 common infectious diseases in Sweden, 2005-14: an individually matched case-control study

BACKGROUND

Although the association between low socioeconomic status and non-communicable diseases is well established, the effect of socioeconomic factors on many infectious diseases is less clear, particularly in high-income countries. We examined the associations between socioeconomic characteristics and 29 infections in Sweden.

METHODS

We did an individually matched case-control study in Sweden. We defined a case as a person aged 18-65 years who was notified with one of 29 infections between 2005 and 2014, in Sweden. Cases were individually matched with respect to sex, age, and county of residence with five randomly selected controls. We extracted the data on the 29 infectious diseases from the electronic national register of notified infections and infectious diseases (SmiNet). We extracted information on country of birth, educational and employment status, and income of cases and controls from Statistics Sweden's population registers. We calculated adjusted matched odds ratios (amOR) using conditional logistic regression to examine the association between infections or groups of infections and place of birth, education, employment, and income.

FINDINGS

We included 173 729 cases notified between Jan 1, 2005, and Dec 31, 2014 and 868 645 controls. Patients with invasive bacterial diseases, blood-borne infectious diseases, tuberculosis, and antibiotic-resistant infections were more likely to be unemployed (amOR 1·59, 95% CI 1·49-1·70; amOR 3·62, 3·48-3·76; amOR 1·88, 1·65-2·14; and amOR 1·73, 1·67-1·79, respectively), to have a lower educational attainment (amOR 1·24, 1·15-1·34; amOR 3·63, 3·45-3·81; amOR 2·14, 1·85-2·47; and amOR 1·07, 1·03-1·12, respectively), and to have a lowest income (amOR 1·52, 1·39-1·66; amOR 3·64, 3·41-3·89; amOR 3·17, 2·49-4·04; and amOR 1·2, 1·14-1·25, respectively). By contrast, patients with food-borne and water-borne infections were less likely than controls to be unemployed (amOR 0·74, 95% CI 0·72-0·76), to have lower education (amOR 0·75, 0·73-0·77), and lowest income (amOR 0·59, 0·58-0·61).

INTERPRETATION

These findings indicate persistent socioeconomic inequalities in infectious diseases in an egalitarian high-income country with universal health care. We recommend using these findings to identify priority interventions and as a baseline to monitor programmes addressing socioeconomic inequalities in health.

FUNDING

The Public Health Agency of Sweden.

Comparison of the Impact of Pneumococcal Conjugate Vaccine 10 or Pneumococcal Conjugate Vaccine 13 on Invasive Pneumococcal Disease in Equivalent Populations

Background

Pneumococcal conjugate vaccine 10 (PCV10) and pneumococcal conjugate vaccine 13 (PCV13), are used in childhood immunization programs worldwide, but direct comparisons of impacts against invasive pneumococcal disease (IPD) in equivalent populations have not been performed. We compared the vaccines (prevaccination 2007-2009 vs postvaccination 2013-2016) in Sweden, where the 21 counties use either PCV10 or PCV13 (introduced 2009-2010).

Methods

All IPD episodes (n = 16992) were recorded in Sweden during 2005-2016. Of 14 186 isolates from 2007-2016, 13 468 (94.9%) were characterized with serotyping and 12 235 (86.2%) with antibiotic susceptibility. Poisson models assessed changes in incidence over time.

Results

Invasive pneumococcal disease incidences decreased between 2005 and 2016 in vaccinated children (by 68.5%), and in the whole population (by 13.5%), but not among the elderly (increased by 2%) due to a substantial increase in nonvaccine types (NVTs). In 2016, NVTs constituted 72% of IPD cases in the elderly. Serotype 6A declined in PCV10 and PCV13 counties, whereas serotype 19A increased in PCV10 counties. There was no effect against serotype 3. Cross-protection was found between 6B and 6A but not between 19F and 19A. Serotype 6C increased in PCV10 counties, but not in PCV13 counties, suggesting cross-protection with 6A, which is included in PCV13. In the elderly, the increase in NVTs, excluding 6C, was more pronounced in PCV13 counties.

Conclusions

The overall impact of IPD incidences was not statistically different irrespective of vaccine used. The incidence of serotypes, where the effect of the vaccines differed, will influence the cost-effectiveness of which vaccine to use in immunization programs. The dominance of NVTs suggests a limited effect of current pediatric PCVs against IPD in the elderly.

Unaltered pneumococcal carriage prevalence due to expansion of non-vaccine types of low invasive potential 8years after vaccine introduction in Stockholm, Sweden

OBJECTIVE

To evaluate the carriage prevalence, serotype distribution, and antibiotic resistance for pneumococcal carriage isolates collected 4-8years after introduction of pneumococcal conjugate vaccines (PCVs) in Stockholm, Sweden, and to identify risk factors for carriage and calculate the invasive disease potential for emerging serotypes.

METHODS

Nasopharyngeal aspirates were collected from 3024 children aged 0-<5years at regular visits at 23 Child Health Centers in Stockholm County in 2011-2015, and from 787 parents in 2014-2015. The invasive disease potential was calculated for serotypes using invasive disease isolates from 824 patients of all ages identified in the Stockholm County during the same time period as the carriage isolates.

RESULTS

A total carriage prevalence of 30% did not change during the study period. Non-vaccine types (NVT) dominated (94% by 2015) and the most common serotypes in descending order were 11A, 23B, 35F and 21. Risk factors for carriage were: age ⩾3months-<3years, having siblings, attending day-care and having travelled abroad the last 3months. Antibiotic resistance remained low. The invasive disease potential was high for NVT 8, 9N, 12F, and 22F, while low for a majority of emerging NVTs in carriage.

CONCLUSION

The carriage prevalence remained the same 4-8years after vaccine introduction, but serotype replacement became almost complete. A majority of emerging NVTs in carriage showed a low invasive disease potential. Carriage studies are an important complement to invasive disease surveillance to understand the full effect of PCV vaccine programs.

Effects of PCV7 and PCV13 on invasive pneumococcal disease and carriage in Stockholm, Sweden

The effects of pneumococcal conjugated vaccines (PCVs) need to be investigated. In Stockholm County, Sweden, PCV7 was introduced in the childhood immunisation programme in 2007 and changed to PCV13 in 2010.Over 90% of all invasive isolates during 2005-2014 (n=2336) and carriage isolates, 260 before and 647 after vaccine introduction, were characterised by serotyping, molecular typing and antibiotic susceptibility, and serotype diversity was calculated. Clinical information was collected for children and adults with invasive pneumococcal disease (IPD).The IPD incidence decreased post-PCV7, but not post-PCV13, in vaccinated children. Beneficial herd effects were seen in older children and adults, but not in the elderly. The herd protection was more pronounced post-PCV7 than post-PCV13. PCV7 serotypes decreased. IPD caused by PCV13 serotypes 3 and 19A increased post-PCV7. Post-PCV13, serotypes 6A and 19A, but not serotype 3, decreased. The serotype distribution changed in carriage and IPD to nonvaccine types, also in nonvaccinated populations. Expansion of non-PCV13 serotypes was largest following PCV13 introduction. Serotype diversity increased and nonvaccine clones emerged, such as CC433 (serotype 22F) in IPD and CC62 (serotype 11A) in carriage. In young children, meningitis, septicaemia and severe rhinosinusitis, but not bacteraemic pneumonia, decreased.Pneumococcal vaccination leads to expansion of new or minor serotypes/clones, also in nonvaccinated populations.

Sinusitis and pneumonia hospitalization after introduction of pneumococcal conjugate vaccine

BACKGROUND AND OBJECTIVE

Streptococcus pneumoniae is a major cause of pneumonia and sinusitis. Pneumonia kills >1 million children annually, and sinusitis is a potentially serious pediatric disease that increases the risk of orbital and intracranial complications. Although pneumococcal conjugate vaccine (PCV) is effective against invasive pneumococcal disease, its effectiveness against pneumonia is less consistent, and its effect on sinusitis is not known. We compared hospitalization rates due to sinusitis, pneumonia, and empyema before and after sequential introduction of PCV7 and PCV13.

METHOD

All children 0 to <18 years old hospitalized for sinusitis, pneumonia, or empyema in Stockholm County, Sweden, from 2003 to 2012 were included in a population-based study of hospital registry data on hospitalizations due to sinusitis, pneumonia, or empyema. Trend analysis, incidence rates, and rate ratios (RRs) were calculated comparing July 2003 to June 2007 with July 2008 to June 2012, excluding the year of PCV7 introduction.

RESULTS

Hospitalizations for sinusitis decreased significantly in children aged 0 to <2 years, from 70 to 24 cases per 100 000 population (RR = 0.34, P < .001). Hospitalizations for pneumonia decreased significantly in children aged 0 to <2 years, from 450 to 366 per 100 000 population (RR = 0.81, P < .001) and in those aged 2 to <5 years from 250 to 212 per 100 000 population (RR = 0.85, P = .002). Hospitalization for empyema increased nonsignificantly. Trend analyses showed increasing hospitalization for pneumonia in children 0 to <2 years before intervention and confirmed a decrease in hospitalizations for sinusitis and pneumonia in children aged 0 to <5 years after intervention.

CONCLUSIONS

PCV7 and PCV13 vaccination led to a 66% lower risk of hospitalization for sinusitis and 19% lower risk of hospitalization for pneumonia in children aged 0 to <2 years, in a comparison of 4 years before and 4 years after vaccine introduction.

Clinical manifestations of invasive pneumococcal disease by vaccine and non-vaccine types

Pneumococcal conjugated vaccines (PCVs) have shown protection against invasive pneumococcal disease by vaccine serotypes, but an increase in non-vaccine serotype disease has been observed. Type-specific effects on clinical manifestation need to be explored. Clinical data from 2096 adults and 192 children with invasive pneumococcal disease were correlated to pneumococcal molecular serotypes. Invasive disease potential for pneumococcal serotypes were calculated using 165 invasive and 550 carriage isolates from children. The invasive disease potential was lower for non-PCV13 compared to vaccine-type strains. Patients infected with non-PCV13 strains had more underlying diseases, were less likely to have pneumonia and, in adults, tended to have a higher mortality. Furthermore, patients infected with pneumococci belonging to clonal serotypes only expressing non-PCV13 capsules had a higher risk for septicaemia and mortality. PCV vaccination will probably lead to a decrease in invasive pneumococcal disease but an alteration in the clinical manifestation of invasive pneumococcal disease. Genetic lineages causing invasive pneumococcal disease in adults often express non-vaccine serotypes, which can expand after vaccination with an increased risk of infection in patients with underlying diseases.

Evaluation of an Internet-based monitoring system for influenza-like illness in Sweden

To complement traditional influenza surveillance with data on disease occurrence not only among care-seeking individuals, the Swedish Institute for Communicable Disease Control (SMI) has tested an Internet-based monitoring system (IMS) with self-recruited volunteers submitting weekly on-line reports about their health in the preceding week, upon weekly reminders. We evaluated IMS acceptability and to which extent participants represented the Swedish population. We also studied the agreement of data on influenza-like illness (ILI) occurrence from IMS with data from a previously evaluated population-based system (PBS) with an actively recruited random sample of the population who spontaneously report disease onsets in real-time via telephone/Internet, and with traditional general practitioner based sentinel and virological influenza surveillance, in the 2011-2012 and 2012-2013 influenza seasons. We assessed acceptability by calculating the participation proportion in an invited IMS-sample and the weekly reporting proportion of enrolled self-recruited IMS participants. We compared distributions of socio-demographic indicators of self-recruited IMS participants to the general Swedish population using chi-square tests. Finally, we assessed the agreement of weekly incidence proportions (%) of ILI in IMS and PBS with cross-correlation analyses. Among 2,511 invited persons, 166 (6.6%) agreed to participate in the IMS. In each season, 2,552 and 2,486 self-recruited persons participated in the IMS respectively. The weekly reporting proportion among self-recruited participants decreased from 87% to 23% (2011-2012) and 82% to 45% (2012-2013). Women, highly educated, and middle-aged persons were overrepresented among self-recruited IMS participants (p<0.01). IMS (invited and self-recruited) and PBS weekly incidence proportions correlated strongest when no lags were applied (r = 0.71 and r = 0.69, p<0.05). This evaluation revealed socio-demographic misrepresentation and limited compliance among the self-recruited IMS participants. Yet, IMS offered a reasonable representation of the temporal ILI pattern in the community overall during the 2011-2012 and 2012-2013 influenza seasons and could be a simple tool for collecting community-based ILI data.

Intraclonal variations among Streptococcus pneumoniae isolates influence the likelihood of invasive disease in children

Background. Pneumococcal serotypes are represented by a varying number of clonal lineages with different genetic contents, potentially affecting invasiveness. However, genetic variation within the same genetic lineage may be larger than anticipated.

Methods. A total of 715 invasive and carriage isolates from children in the same region and during the same period were compared using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing. Bacterial genome sequencing, functional assays, and in vivo virulence mice studies were performed.

Results. Clonal types of the same serotype but also intraclonal variants within clonal complexes (CCs) showed differences in invasive-disease potential. CC138, a common CC, was divided into several PFGE patterns, partly explained by number, location, and type of temperate bacteriophages. Whole-genome sequencing of 4 CC138 isolates representing PFGE clones with different invasive-disease potentials revealed intraclonal sequence variations of the virulence-associated proteins pneumococcal surface protein A (PspA) and pneumococcal choline-binding protein C (PspC). A carrier isolate lacking PcpA exhibited decreased virulence in mice, and there was a differential binding of human factor H, depending on invasiveness.

Conclusions. Pneumococcal clonal types but also intraclonal variants exhibited different invasive-disease potentials in children. Intraclonal variants, reflecting different prophage contents, showed differences in major surface antigens. This suggests ongoing immune selection, such as that due to PspC-mediated complement resistance through varied human factor H binding, that may affect invasiveness in children.

Detection of tract formation for prevention of bile peritonitis after T-tube removal. Case report

Bile leakage after removal of T-tube is a relatively rare complication caused by inadequate tract formation around the tube. We report a case of bile peritonitis after removal of a latex T-tube. The patient underwent reoperation and a new T-tube was introduced. The T-tube was removed six weeks later. Immediately after removal of the tube, the cutaneous ostium of the tube was catheterized with a thin Nelaton catheter. The administration of gastrographin showed the presence of an intact tract. The removal of the t-tube was uneventful. We would propose this method for detecting the tract after removal of the T-tube in order to prevent severe bile leakage after inadequate tract formation.

Dieulafoy-like lesion of the colon presenting with massive lower gastrointestinal bleeding

The Dieulafoys lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. We describe an elderly patient who presented with severe lower gastrointestinal bleeding caused by a colonic Dieulafoy-like lesion. This is the third report of colonic Dieulafoys lesion treated successfully with endoscopic hemoclipping. We review the pathophysiology, clinical presentation, diagnosis, and treatment of this rare disease.

Endoscopic snare resection of an intrapapillary pedunculated villous adenoma presenting as acute recurrent pancreatitis

Tumors of the papillary region are an unusual and heterogeneous group of neoplasms that arise from the major papilla, the ampulla of Vater, and the peripapillary duodenum. Benign adenomas of the papilla of Vater are an increasingly recognized condition in those with familial adenomatous polyposis syndromes as well as sporadic cases. Papillary adenoma is a recognized but rare cause of acute pancreatitis. We describe a patient who presented with acute recurrent pancreatitis that was attributed to an intrapapillary pedunculated villous adenoma. Following diagnosis by endoscopic needle knife sphincterotomy and endoscopic retrograde cholangiopancreatography, endoscopic snare resection of the adenoma resulted in symptomatic improvement.

Pyogenic cholangitis after inadvertent submucosal contrast injection in the papilla of Vater in a patient with cholestatic hepatitis

Common bile duct stones and tumors constitute the leading cause of acute biliary tract obstruction and cholangitis. Septic complications after diagnostic endoscopic retrograde cholangiopancreatography (ERCP) are very unusual in unobstructed bile ducts. There are only three reported cases of patients without evidence of biliary tract disease who developed cholangitis and liver abscesses due to Pseudomonas aeruginosa. Biliary endoscopists believe that the inadvertent submucosal injection of contrast into the papilla of Vater is an innocent accident that has no serious consequences other than increasing the percentage of unsuccessful catheterizations of the common bile duct. Herein we describe a patient with drug-induced cholestatic hepatitis who developed pyogenic cholangitis after the inadvertent injection of submucosal contrast in the papilla of Vater.

The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones

BACKGROUND

Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting.

METHODS

Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients.

RESULTS

In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced.

CONCLUSIONS

These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.

Endoscopic sphincterotomy for cholangitis after recent coronary artery bypass graft surgery

It is particularly attractive to perform endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy for cholangitis due to common bile duct stone because of the increased morbidity and mortality of the alternative therapy of choledochal exploration. The safety of therapeutic ERCP after recent myocardial injury is unknown since there are only five previously reported cases. Three patients underwent therapeutic ERCP after recent coronary artery bypass graft surgery for indication of recent cholangitis due to choledochal stones. Initially, the cholangitis was managed medically in all patients. Endoscopic sphincterotomy (ES) was performed 11, 17, and 14 days after coronary artery bypass graft surgery. The calculi were successfully extracted by sweeping the choledochus with a balloon-tipped catheter or basket in all cases. During ERCP the vital signs remained stable; no cardiac arrhythmias, hemorrhage, or pulmonary complications occurred. Our study demonstrates that therapeutic ERCP is not absolutely contraindicated after recent myocardial injury and suggests that ES is preferable to surgery for cholangitis due to common bile duct stones.

Hemolysis caused by G-6PD deficiency after a difficult and prolonged therapeutic endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP), together with its substantial therapeutic capabilities, carries a higher potential for complications than other endoscopic procedures. Common major complications specific to pancreaticobiliary instrumentation include pancreatitis, post-sphincterotomy hemorrhage, perforation, and cholangitis with or without systemic sepsis. Two patients underwent therapeutic ERCP for recurrent episodes of abdominal pain and elevation of hepatobiliary enzymes. Endoscopic sphincterotomy was difficult and prolonged. The calculi were successfully extracted by sweeping the choledochus with a balloon-tipped catheter or basket in both cases. The patients experienced postprocedure diffuse abdominal pain unassociated with nausea or vomiting. Laboratory data showed normal serum amylase and lipase 2, 6, and 18 h after the end of procedure, a fall in hematocrit level, and an increase of indirect bilirubin and lactic dehydrogenase. The abdominal pain subsided in 4 to 6 h. The hematocrit level remained stable during the next 3 days, and the patients were very well when discharged. Examination of glucose-6-phosphate dehydrogenase (G-6PD) enzyme levels in red cells 20 days later showed complete enzyme deficiency. This report highlights the importance of examining G-6PD deficiency in patients with post-ERCP abdominal pain, normal serum amylase and lipase, and laboratory findings of hemolysis.

Hypoplasia of the right hepatic lobe combined with a floating gallbladder

Agenesis or hypoplasia of the right hepatic lobe combined with a floating gallbladder is an extremely rare condition. We report a case of hypoplasia of the right hepatic lobe, discovered in a 65-year old female. This was an incidental finding at CT scan for staging of a right colonic cancer. The CT evidenced the presence of a hypoplastic right lobe, while the left lobe was diffusely enlarged. Furthermore, the gallbladder was described as floating with partially calcified walls. The diagnosis of this rare anomaly was confirmed intraoperatively. The patient underwent right hemicolectomy and cholecystectomy. Biopsies were taken from both right and left hepatic lobes, revealing the presence of normal hepatic parenchyma. Since all causes of acquired atrophy of the liver had been ruled out, we considered this case to be of congenital origin.

Intrahepatic lithiasis as a late complication of hepaticojejunostomy

The development of intrahepatic lithiasis proximal to a bilodigestive anastomosis is rare. We report a case of intrahepatic lithiasis of the right hepatic duct, which developed almost 6 years after a hepaticojejunostomy performed for an iatrogenic lesion of the common hepatic duct. The patient experienced repeated episodes of acute cholangitis and was treated with intracorporeal lithotripsy and dilation of the stenosis.

Needle-knife sphincterotomy

Choledochocele, now classified as choledochal cyst type III, is a rare anomaly of the terminal biliary tree causing abdominal pain, pancreatitis, and obstructive cholestasis. Traditionally, the therapy for this malformation has been surgery. Recently, endoscopic therapy has been used alternatively for the treatment of choledochocele mainly in adults. We report two patients with recurrent episodes of acute pancreatitis found to be caused by a large choledochocele; both patients were treated by needle-knife sphincterotomy without complications. They remained asymptomatic at 1 and 2 years' follow-up, respectively. Despite the fact that the risk of bleeding seems to be higher using needle-knife sphincterotomy, when the Choledochocele is large, our experience suggests that needle-knife sphincterotomy can be performed accurately and safely. Further studies are necessary to confirm the safety and effectiveness of needle-knife sphincterotomy in large choledochocles.

Acute recurrent pancreatitis associated with anomalous pancreaticobiliary ductal union and choledochal cyst of mixed type I plus II

Anomalous pancreatobiliary ductal union (APBDU) has a variety of presentations. We report the case of a 72-year-old woman who presented with recurrent episodes of acute pancreatitis that were found to be caused by the presence of an APBDU associated with an unusual choledochal cyst of mixed type I plus II. She underwent endoscopic sphincterotomy and has remained asymptomatic to the present time, 2 years after sphincterotomy. A discussion of the possible etiologies of choledochal cyst and pancreatitis due to APBDU is presented.

Pseudomonas aeruginosa liver abscesses after diagnostic endoscopic retrograde cholangiography in two patients with sphincter of Oddi dysfunction type 2

Patients with sphincter of Oddi dysfunction have a significantly increased rate of pancreatitis after manometry or sphincterotomy, but septic complications after diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients with sphincter of Oddi dysfunction type 2 have not been reported. We describe two patients with sphincter of Oddi dysfunction type 2 in whom Pseudomonas aeruginosa serotype 10 septicemia and multiple small hepatic abscesses developed, all within 48 h after they underwent diagnostic ERCP. The sepsis and hepatic abscesses resolved after successful intravenous antibiotic administration. Despite scrupulous examination of the duodenoscope washing machine and the bottle of water, the bacteria responsible for the sepsis could not be isolated. It is possible that despite disinfection, a nondetectable colony of P. aeruginosa remained in a part of duodenoscope and proliferated to reach a potentially hazardous level the following day. This report highlights the importance administering antibiotic prophylaxis to patients with sphincter Oddi dysfunction type 2 who undergo ERCP, despite the functional nature of the disease.

Biliary stricture due to neuroma after an innocent blunt abdominal trauma

A traumatic neuroma of the biliary tract is rarely associated with biliary obstruction. However, when it arises in the common bile duct (CBD) and is associated with obstructive jaundice, it is difficult to distinguish it from bile duct cancer. We describe a patient who developed obstructive jaundice and itching, due to CBD stricture, 8 years after innocent blunt abdominal trauma. The stricture was resected and hepatico-jejunal anastomosis was performed. Histological examination revealed a traumatic neuroma and a fibrous scar around the common bile duct. Symptoms disappeared following surgical removal of the lesion. Blunt abdominal injury may cause the late onset of a fibrous scar and traumatic neuroma in the common bile duct. To our knowledge, a traumatic neuroma of the biliary tract after blunt abdominal trauma has not been reported previously. We review the clinical picture of this relatively rare problem, along with its diagnosis, pathogenesis and treatment.

Successful treatment of duodenal bulb obstruction caused by a gallstone (Bouveret's syndrome) after endoscopic mechanical lithotripsy

Because of acute symptoms in the upper abdomen, upper gastrointestinal endoscopy was performed in a 68-year-old man. A large perforated gallstone was embedded in the duodenum, causing complete obstruction of the duodenal bulb. The stone was crushed successfully by endoscopic mechanical lithotripsy. The patient was referred for surgery, and was discharged after a successful and uneventful cholecystectomy.

Osteotomy for osteoarthritis of the hip. A clinical and radiological survey

The authors have reviewed the clinical and radiological results of 70 intertrochanteric osteotomies in 65 patients. The mean follow-up was 8 years and most of the patients (53 osteotomies) were examined from 6 to 15 years after operation. The mean age at operation was 47 years. In almost two-thirds of patients the osteoarthritis was secondary to congenital disorders of the hip. The technique was usually a rotational osteotomy with slight medial displacement. The clinical results were satisfactory in 49 osteotomies and unsatisfactory in 21. The radiological results were less encouraging, but an impression was gained that a poor radiological appearance does not necessarily preclude a good clinical outcome. There was no significant statistical difference in the results between primary and secondary osteoarthritis. No clear patterns could be established to explain why the operation succeeded in some patients and failed in others.